Tag Archives: prevention

Best of EAST #5: Elderly Falls And Vision Problems

January 6, 2021 The Trauma Pro Leave a comment

Elderly falls have become a huge problem. There isn’t a night that goes by that we don’t admit at least two or three at our trauma center. There are at least a dozen factors that have been identified that are associated with falls, including:

Medications
Bone and muscle loss
Underlying medical conditions
Gait problems
Throw rugs and other environmental hazards
Visual problems

And many more! But let’s focus on that last one. Vision problems can be due to primary disease, such as glaucoma, or from lack of adequate correction of those problems, such as decreased visual acuity.

The group at West Virginia University is presenting a prevention paper next week. They prospectively studied patients older than 60 years who were admitted to their trauma service over a one year period. They wanted to determine the prevalence of undertreated or undiagnosed eye disease in the population, and to find out if using readily available screening tests could detect this and assist in prevention efforts.

A dilated ophthalmic exam was performed and used as the gold standard. The results were compared to a screening app administered by a trauma provider via an iPad (the eyeTests Easy app). This app can be used to test for visual acuity, macular degeneration, near vision, and astigmatism.

Here are the factoids:

A total of 96 patients were enrolled, with an average age of 75 and a predominant mechanism of fall in 79%
Significant abnormal vision was undiagnosed in 39% of patients and undertreated in 14%
The trauma provider app exam was 94% sensitive and 92% specific
Correlation was best on pupil exam (86%), visual fields (58%), and the macular degeneration test (52%)
A combination of visual fields and the Amsler grid were associated with significant abnormal vision

The authors concluded that unrecognized visual problems are common, and are present in 53% of their elderly trauma admissions. They also state the the trauma provider exam can identify abnormalities in “most cases” and can identify those who should be screened by an ophthalmologist.

My comments: This is an interesting study that compares a simple, app-based screen with a more sophisticated ophthalmology exam. However, it is not clear what “significant abnormal vision (SAV)” really is. The sensitivity and specificity numbers cited depend on this definition. Is it a positive answer to one of the screening questions? Evidence of macular degeneration? If so, how much? I’m sure that a lot of the elderly (and younger) population have some small irregularities in their vision, but what makes it significant?

The study does show that the app can be used as a screening tool due to the congruence with the “gold standard” ophthalmologic exam. And given that vision is one of the major factors associated with falls risk, it may be a cost-effective tool for reducing it.

Here are my questions for the authors and presenter:

What is you exact definition of “significant abnormal vision?” This is critical, because it determines the significance of the rest of your results. If the threshold is set too low, you will detect many anomalies but they may not be clinically significant. This definition needs to be as objective as possible so others can duplicate and take advantage of your work.
What do you recommend for workflow to incorporate this tool? Who should do it and when? Should the user focus on particular portions of the app (e.g. Amsler and visual fields, acuity)?
Describe your future plans for the longitudinal study mentioned in the abstract.

This is very interesting prevention work. I look forward to the nitty gritty details next week!

Reference: Stop the fall: identifying the 50% of geriatric trauma patients with significant vision loss. EAST 2021, Paper 11.

Abstracts

EAST 2019 #6: Trauma Prevention and Your Trauma Registry

January 3, 2019 The Trauma Pro Leave a comment

Trauma centers verified by the American College of Surgeons (ACS) (and most states who perform their own designation visits) are required to engage in trauma prevention activities. Furthermore, ACS centers are required to provide prevention programs based on identified local needs. Frequently, trauma professionals see a pattern of injury in the patients they treat. This generally stimulates a search through their trauma registry. Reviewing registry data is the most direct way of identifying and confirming injury patters specific to the local population.

The next abstract for review describes the process and outcomes of such a project from a Level II center in Fort Walton Beach, Florida. They noted a pattern of diving injury and high cervical fractures. This was confirmed using 2016 registry data. Admitted patients were intensive resource users, with 71% requiring ICU admission and operative fixation, and nearly half requiring rehab admission upon discharge.

Based on this, they developed a “Think Before You Dive” program with posters, signs, swag (a custom koozie), a trifold brochure, and magnets with diving and water safety tips. Posters and flyers were provided to local business, and magnets were placed in hotel rooms in the area. One time-share company even placed a hard stop in their registration process so that visitors had to acknowledge the safety message.

What’s a koozie, you ask? I didn’t know the technical term for this, but here’s a picture:

Here are the factoids:

There was a reduction of 100% in cervical spine injuries, and 24% of all water-related incidents in the targeted area
All remaining diving/high-cord injuries came from outside the target area
It was estimated that costs were reduced by $1.2 million

As you can see, this is not the typical hard research paper usually provided at most scientific meetings. However, it is very important that this kind of information is presented, as it has the potential for impact on the other clinical research.

Here are some questions for the authors and presenter to consider in advance to help them prepare for audience questions:

How did you recognize the problem initially? Was it a pattern picked up by humans? Which ones (nurses, trauma physicians, therapists/rehab, others)?
Why did you think that your prevention approach would be effective?
Provide some details on how you convinced businesses to carry your message. Was there any resistance, and what were their arguments? How did you overcome it?
Show us the numbers. Although it may be difficult to show statistical differences in patient numbers, cost savings is important as well. Show the patient numbers pre- and post-intervention for the cluster area and outside of it.
Define how you arrived at your cost savings numbers. How do the previously published economic numbers relate to costs at your own center and those reported in this study?

I believe that this is important information, and will help many other centers properly design their own trauma prevention programs!

Reference: Using the trauma registry to guide your injury prevention programs. EAST 2019 Paper #18.

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