Best Practices in Orthopedic Trauma Care – A TQIP Update

Disclosures

• None

2

1917- 48 y.o. 1918 - 36 y.o. Today- 78.7 y.o.

Life expectancy was increasing

3

Epidemiology: Why are we doing this?

• By 2050, it is expected there will be 90 million adults older than 65 years of age

• Currently, patients older than 65 years of age account for 47% of all trauma admissions

• Falls are the leading cause of trauma in the elderly

71%

25%

4%

Fall

MVC

Other

Epidemiology: Why are we doing this?

Rise in Geriatric Trauma

• 85+ is fastest growing age group

• Greatest amount of healthcare dollars are spent on ages 65+

– Complications

– Longer lengths of stay

– Medications

Epidemiology: What is the Impact on

Outcomes?

• Large burden on Healthcare Resources

– $

– High rates of readmission

– Increased complications

– Increased length of stay

• Only 8.8% of trauma centers in the US incorporate Geriatric Resource Programs

– Extent is unknown

Maxwell, C. et al (2013) Geriatric Resources in acute care hospitals and trauma centers. J of Gerontological Nursing, 39(12), 33-42

Epidemiology: What is the Impact on

Outcomes?

• Trauma is the 5th leading cause of death in the elderly

– Outcomes are worse: up to 1/3 of elderly patients presenting with an ISS >15 are expected to die before discharge

• Mortality/morbidity after trauma is strongly correlated with increasing age

• Consistent under-triage of elderly patients

• Trauma death rate per year (per 100,000)– All age groups- 56

– Age > 65 - 113

VK Shiflette, et al, J of Trauma, 69 (1) July 2010

Evidence

G-60 Trauma Pilot Study

• NTDB data 1999-2008 data queried retrospectively

– 802,211 trauma

– Age >60 y.o. accounted for 21% of all patients

Conclusions

• A relation exists between increased age,

associated pre-existing medical conditions

and poor physiologic reserve with resultant

poorer outcome

• Essential to not under-triage the elderly

• High index of suspicion for injury

The Results:

The Results:

Reduced times for elderly trauma patients

Reduced morbidity and mortality rates

16

American College of Surgeons

Committee on Trauma

“… a well-coordinated, multidisciplinary approach that acknowledges the unique challenges associated with the elderly injured patient is encouraged.”

“Specialized programs for the care and rehabilitation of older patients will need to be developed…”

A brief lesson in the history of the

ACS’s trauma care publications….

If this version says: The next version will say:

Should

Do it.Encouraged

Shall

Consider

ACS TQIP GERIATRIC TRAUMA MANAGEMENT GUIDELINES

Problems

• Triage Criteria– Activation

• Initial Evaluation

• Inpatient Care– Prognostication/Risk Assessment

– Frailty

– Medications/Delirium

• Discharge– Prevention

– Rehab/Late deaths

Geriatric Trauma Service Goals

• Proper triage of the geriatric trauma patient

• Provide the best care across the spectrum

of all subspecialists.

• Expedite the operative management for

better results

• Provide the earliest and best rehabilitation

Geriatric Trauma Service Goals

• Embrace research of this group of patients

to improve outcome

• Provide regional geriatric trauma

prevention and education

• Decrease the cost of healthcare

How to get started

• Identify Key Stakeholders

– Administration

– Trauma Staff

• TMD, TPD, PI Coordinators, Surgeons

– Surgical sub-specialists

– Internal Medicine and sub-specialty Medicine

• Hospitalist and Geriatricians

– Anesthesia

How to get started


– Emergency Department

• Physician and nursing

– Operating room

– ICU Care

• Intensivists and nursing

– Med-surg care

• Nursing

How to get started


– Ancillary Services• Pharmacy

• Rehab Services– Physical Therapy

– Occupational Therapy

– Speech Therapy

• Respiratory Therapy

• Case Management and Social Work

• Pastoral care

Geriatric Specific Unit

• More homelike environment

– Better lighting

– Larger clocks and larger letters

– Warmer colors within the room

– Higher countertops

– Hearing assistance devices available

– Community area


• Patient-centered care

– Plans for preventing disability and iatrogenic

illness

– Comprehensive discharge planning and

management

– Utilization of evidence-based practices

– Interdisciplinary

Interdisciplinary Team Approach

• Integrates disciplines to collaboratively develop patient-centered care rather than multidisciplinary where services practice independently

– Goal is to improve functional status, reduce acute care hospital days, readmissions and lower mortality rates

– 2 models:• Team directs care vs consultative


• Patient-centered care

– Nurses will be Geriatric Trained• NICHE: “Nursing improving Care for Healthsystem

Elders”– Program of the Hartford Institute for Geriatric Nursing

– Over 500 hospitals and healthcare facilities

– Provides Resources, programs and a framework to the hospital

– Embeds evidence-based geriatric knowledge into practice

• Use of a Daily Rounds Checklist

www.nichprogram.org

Problems




– Frailty




• Ensure trauma team activation for all

elderly injured patients meeting trauma

criteria (first or second tier)

• Age?

– 60: VK Shiflette, et al J Trauma 69(1), July

2010, pp 88-92

– 65: NSQIP, EAST and PTSF definition

– 70: D Demetriades, et al, J Trauma 2001 Oct;

51(4): 754-6

Trauma Team Activation

Prehospital Triage and Activation

Level II

• Injured patients with advanced age (>65) and pre-existing medical conditions (PEC’s) should lower the threshold for field triage directly to a designated/verified trauma center.

Level III

• A lower threshold for trauma activation should be used for injured patients aged 65 years or older who are evaluated at trauma centers.

Calland JF, et al Evaluation and Management of geriatric trauma: An EAST PMG. J Trauma Acute Care Surg 2012. 73(5) supplement 4 345-350

Triage and Activation Criteria

• Hemodynamics in the elderly are different

and need alternate criteria.*

• Triage criteria involving medications,

comorbidities, mechanisms and injuries are

different from standard adult criteria in

states that have implemented such.**

• Under-triage associated with a two-fold

increase in the risk of death

*Am Surg 2010 Oct; 76(10): 1035-8 **Prehosp Disaster Med 2011 Jun;26(3): 170-9*Am Surg 2010 Oct; 76(10): 1035-8 **Prehosp Disaster Med 2011 Jun;26(3): 170-9

Problems




– Frailty




Initial Evaluation

• Secondary survey should focus on:

– Determine medications that affect initial evaluation

and care.

• Blood thinners, B blockers, ACE inhibitors

– Consider common, acute, non-traumatic events that

could complicate the patient’s presentation.

• UTI, Syncope, MI, CVA, AKI, Pneumonia

– Labs

• Hypoperfusion underappreciated- check BD or lactate

• Routine labs, BAL

Initial Evaluation

• Secondary survey should focus on:

– Imaging: Occult injuries are common

• CT scans

– Anticoagulation assessment and reversal

Problems




– Frailty




Admission

• Admission Orders should include

– Clinical management guidelines

• Beers criteria

• Geriatric Screening Tools

• Frailty

• Delirium Evaluation Tools

– Nutrition

– Mobility

Admission

• Admission Orders should include (cont’)

– Pain management

– Rehab Services

– Case Management

Admission

• American Geriatrics Society 2015 updated Beers

Criteria for potentially inappropriate medication

use in older adults.

– www.guideline.gov/summaries/summary/49933

• Inappropriate Medications in the Elderly• 30% of hospital admissions

• 177,000 emergency department visits

• 7 times more likely to be hospitalized

• 33% involve warfarin *

*www.cdc.gov

http://www.guideline.gov/summaries/summary/49933

• Before you were injured, did you need someone to help you on a regular basis?

• Since the injury, have you needed more help than usual to take care of yourself?

• Have you been hospitalized for one or more nights during the past six months?

• In general, do you have problems seeing well?

• In general, do you have serious problems with your memory?

• Do you take more than three different medications every day?

Geriatric Consultation ScreenTwo or more indicate consult recommended

ACS TQIP guidelines

• Discuss and document (72 hours):

– Patient’s priorities and preferences regarding treatment plans

– Post-injury risks of complications, mortality, and temporary/permanent functional decline

– Advance directives or living will

– Identify surrogate decision maker

– In appropriate setting, present hospice as a positive active treatment

Patient Decision: Making Capacity and

Care Preferences

• Discuss and document (72 hours):

– Hold a family meeting

– Evaluate and address delirium risk factors

and reversible causes

– Monitor fluid status

– Prevent iatrogenic complications

Patient Decision: Making Capacity and

Care Preferences

Problems



• Prognostication/Risk Assessment– Frailty

• Inpatient Care– Medications/Delirium



Discharge

• Majority (up to 88%) of injured older adults

fail to return to their prior level of

independence and function

• Many issues complicate the post discharge

of these patients

ACS TQIP Guideline

Discharge

• Begin developing a plan for transition to post hospital care

• Asses home environment, social support and equipment needs

• Provide a thorough discharge document

• Communicate with the patient’s PCP

• Arrange for a home health visit or phone call within several days of discharge

Metrics

• Hospital and ICU LOS

• Ventilator days

• Morbidity Rates

– Cardiac arrest / ARDS / MI / Decubitus /

Pneumonia / UTI / Sepsis / Re-intubations /

Transfers back to higher level of care

• Mortality Rates

Evidence Based Guidelines

• Geriatric Pain management

• Nutritional screening

• Gait and Mobility screening

• Geriatric Rib Fracture management

• General Geriatric management

Keys to Success

• Identify Key stakeholders

• Show the benefit through evidence

• Geriatric specific unit

• Interdisciplinary care

• Initiate PMG’s

• Track your metrics

“Age is strictly a case of

mind over matter. If you

don’t mind then it

doesn’t matter.”Jack Benny

Questions?

Department of Surgery

References

Best Practices in Orthopedic Trauma Care – A TQIP Update

Documents

Transcript of Best Practices in Orthopedic Trauma Care – A TQIP Update