An Evaluation of a Proactive Geriatric Trauma Consultation Service
*Department of Medicine, University of Saskatchewan, Saskatchewan, Canada †Division of Trauma, St. Michael's Hospital ‡Department of Surgery, St. Michael's Hospital §Division of Geriatric Medicine, Li Ka Shing Knowledge Institute, St. Michael's Hospital ‖Department of Surgery, Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Ontario, Canada.Annals of surgery (Impact Factor: 8.33). 10/2012; 256(6). DOI: 10.1097/SLA.0b013e318270f27a
OBJECTIVE:: To describe and evaluate an inpatient geriatric trauma consultation service (GTCS). BACKGROUND:: Delays in recognizing the special needs of older trauma patients may result in suboptimal care. The GTCS is a proactive geriatric consultation model aimed at preventing and managing age-specific complications and discharge planning for all patients 60 years or older admitted to the St Michael's Hospital Trauma Service. METHODS:: This was a before and after case series of patients admitted pre-GTCS (March 2005-August 2007) and post-GTCS (September 2007-March 2010). Study data were derived from a review of the medical records and from the St Michael's Hospital trauma registry. Abstracted data included demographics, type of geriatric issues addressed, rate of adherence to recommendations made by the GTCS, geriatric-specific clinical outcomes, trauma quality indicators, consultation requests, and discharge destinations. RESULTS:: A total of 238 pre-GTCS patients and 248 post-GTCS patients were identified. The rate of adherence to recommendations made by the GTCS team was 93.2%. There were fewer consultation requests made to Internal Medicine and Psychiatry in the post-GTCS group (N = 31 vs N = 18, P = 0.04; and N = 33 vs N = 18, P = 0.02; respectively). There were no differences in any of the prespecified complications except delirium (50.5% pre-GTCS vs 40.9% post- GTCS, P = 0.05). Among patients admitted from home, fewer were discharged to long-term care facilities among the post-GTCS group (6.5% pre-GTCS vs 1.7% post-GTCS, P = 0.03). CONCLUSIONS:: A proactive geriatric consultation model for elderly trauma patients may decrease delirium and discharges to long-term care facilities. Future studies should include a multicenter randomized trial of this model of care.
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ABSTRACT: IMPORTANCE In trauma populations, improvements in outcome are documented in institutions with higher case volumes. However, it is not known whether improved outcomes are attributable to the case volume within specific higher-risk groups, such as the elderly, or to the case volume among all trauma patients treated by an institution. OBJECTIVE To test the hypothesis that outcomes of trauma care for geriatric patients are affected differently by the volume of geriatric cases and nongeriatric cases of an institution. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study using a statewide trauma registry was set in state-designated levels 1 and 2 trauma centers in Pennsylvania. It included 39 431 eligible geriatric trauma patients (aged >65 years) in the Pennsylvania Trauma Outcomes Study. MAIN OUTCOMES AND MEASURES In-hospital mortality, major complications, and mortality after major complications (failure to rescue). RESULTS Between 2001 and 2010, 39 431 geriatric trauma patients and 105 046 nongeriatric patients were captured in a review of outcomes in 20 state-designated levels 1 and 2 trauma centers. Larger volumes of geriatric trauma patients were significantly associated with lower odds of in-hospital mortality, major complications, and failure to rescue. In contrast, larger nongeriatric trauma volumes were significantly associated with higher odds of major complications in geriatric patients. CONCLUSIONS AND RELEVANCE Higher rates of in-hospital mortality, major complications, and failure to rescue were associated with lower volumes of geriatric trauma care and paradoxically with higher volumes of trauma care for younger patients. These findings offer the possibility that outcomes might be improved with differentiated pathways of care for geriatric trauma patients.JAMA SURGERY 01/2014; 149(4). DOI:10.1001/jamasurg.2013.4834 · 3.94 Impact Factor
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ABSTRACT: Background: Care in a trauma centre is associated with significant reductions in mortality after severe injury. However, emerging evidence suggests that outcomes across similarly accredited trauma centres are not equivalent, even after adjusting for case-mix. The primary objective of this analysis was to evaluate secular trends in overall mortality at trauma centres. Secondarily, we explored trauma centre-specific mortality to determine the extent of variation between centres. Methods: Data on 26 421 adults (≥□18 yr) admitted to a trauma centre between 2005 and 2011 were derived from the Ontario Trauma Registry. We used generalized estimating equations to calculate in-hospital mortality over time and hierarchical models to estimate trauma-centre-specific mortality. To quantify variability between centres, we calculated median odds ratios. Adjusted odds of death were calculated for each trauma centre to identify those with higher than expected, average and lower than expected mortality. Results: Overall mortality at trauma centres decreased from 13.2% in 2005 to 11.2% in 2009. After adjusting for case mix, the odds of death decreased by approximately 3% a year (95% confidence interval 0%-5%). Trauma centre-specific mortality ranged from 11.4% to 13.1%. After adjusting for case mix, differences in trauma centre-specific mortality were observed (median odds ratio = 1.25), suggesting that the odds of dying could be 1.25-fold greater if the same patient was admitted to 1 randomly selected trauma centre as opposed to another. Differences were most pronounced for patients with isolated head injuries and among older patients as evidenced by higher median odds ratios and the number of outliers. Interpretation: We observed a significant improvement over time in the mortality of severely injured patients cared for at Ontario's trauma centres. However, considerable differences in trauma centre-specific mortality were observed. Differences were most pronounced among older injured patients and those with isolated traumatic brain injury. System-wide performance improvement initiatives should target these subgroups.07/2014; 2(3):E176-82. DOI:10.9778/cmajo.20140007
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ABSTRACT: Background Due to parallel advances in health care and an aging population, geriatric injury has become an increasing burden to trauma systems, suggesting that specific clinical pathways may improve the care of this cohort. We created a dedicated geriatric trauma institute (GTI), with multidisciplinary support, as a part of our existing trauma program, theorizing that the Geriatric Trauma Institute would promote quality care, reduce length of stay, and reduce hospital charges. Methods We performed a retrospective analysis of the prospective database of our level 1 trauma center. Patients greater than or equal to 65 years were identified over 12 month, representing 5 months prior and also after implementation of the new program. Results The mean length of stay was reduced for admissions to a non-trauma vs. Geriatric Trauma Service (5.64 vs.4.43 days, p=.03) generating a charge reduction of 21.4% in only the first 5 months after program implementation. Conclusion Our preliminary findings, which require longer term analysis, suggest that a dedicated geriatric trauma multidisciplinary system promotes quality patient care, improves throughput, and results in significant cost savings via reduced length of stay and concomitant hospital charges.The American Journal of Surgery 09/2014; 208(6). DOI:10.1016/j.amjsurg.2014.08.007 · 2.29 Impact Factor
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