Improved Outcomes Seen among Older Trauma Patients Receiving Geriatric Consultations
Trauma surgeons at Brigham and Women’s Hospital (BWH) implemented mandatory geriatric consultations for all trauma patients 70 years-of-age or older who are admitted to BWH, beginning in September 2013. They recently compared data from 215 patients admitted from June 2011 through June 2012 (preintervention) with data from 191 patients admitted from October 2013 through September 2014 (postintervention) in a study published in the Journal of the American College of Surgeons earlier this year (J Am Coll Surg. 2016 Mar 3. pii: S1072-7515(16)00045-4.).
“Frailty and cognitive impairment are often key contributing factors in falls and accidents that lead to fractures and other injuries among the elderly presenting in our Emergency Department,” said Zara Cooper, MD, FACS, a BWH trauma surgeon and lead author of the study. “We believe that focusing on these underlying conditions is essential to optimizing the care and outcomes of these patients.”
Personalized Assessment and Plan
The geriatric consultation includes a thorough assessment of the patient’s medical conditions, cognition, function, nutrition, and emotional status, as well as risk for delirium. In addition, family members are interviewed to gather information regarding the patient’s social circumstances. Geriatricians collaborate with the trauma team to implement personalized geriatric-based patient care. Patients and their families are counseled on short- and long-term needs and important considerations for care settings. Bedside nursing follow-up and discharge planning within five days are also becoming part of the protocol for elderly trauma patients.
In the study, the researchers found significant benefits in the postintervention group, including:
Decrease in in-hospital mortality from 9.3 percent to 5.24 percent;
Decrease in 30-day mortality from 11.63 percent to 6.81 percent;
Decrease in intensive care unit readmission from 8.26 percent to 1.96 percent;
Increase in delirium documentation from 31.16 percent to 38.22 percent;
Increase in advanced directives from 10.23 percent to 38.22 percent.
Striving to continue to improve care and outcomes for geriatric patients, the team’s current initiatives include:
Preoperative geriatric assessment for elective orthopaedic procedures, such as spine and shoulder procedures and hip and knee replacements;
Prospective study using an oral liquid supplement to provide calories for geriatric patients up to two hours before their scheduled procedures. The study is designed to address compromised nutritional status in geriatric patients and possibly decrease the incidence of postoperative delirium. The current standard is “nothing by mouth” for six to eight hours before surgery.
“We have found that preoperative geriatric assessment, including use of the Mini-Cog test for dementia, has resulted in better prediction of patients at high risk for complications and dramatic improvement in the outcomes of hip fracture patients, as well as other fragility related injuries,” said Mitchel B. Harris, MD, Chief of the Orthopaedic Trauma Service.
Additionally, in early 2016, the Frailty Identification and Care Pathway was implemented in the Trauma Center. Upon admission, all trauma patients 65 years and older are screened for frailty.
Dr. Cooper explained, “Once they have been identified as pre-frail or frail, patients are enrolled into this multidisciplinary pathway and receive specialized order sets and consults including a comprehensive geriatrics assessment, early mobilization, delirium prevention, and fall prevention education.”
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