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.
- [Show abstract] [Hide abstract]
ABSTRACT: The traumatically injured geriatric patient presents a challenge to the practitioner. Increased morbidity and mortality can result in unique requirements for the treatment of elderly patients. The principles of surgical management of genitourinary injuries remain largely unchanged in the geriatric population. Reconstructive techniques to repair these injuries generally require appropriate evaluation and timing of repair. Fortunately, the treatment of genitourinary injuries in the geriatric population remains largely successful. © 2014 Springer Science+Business Media New York. All rights reserved.
- [Show abstract] [Hide abstract]
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.
- [Show abstract] [Hide abstract]
ABSTRACT: Psychiatric consultation services in general medical hospitals typically operate on a consultation-as-requested basis: medical teams determine that a patient requires a consultation, place an order for a consultation, and the patient is then seen by a psychiatrist for a standard consultation. This system may fail to detect patients who could benefit from consultation or may detect such patients after a delay, and conversely may generate consult requests for patients who will not benefit from inpatient consultation. We argue that psychiatric consultation services must become “proactive,” organized to seek out cases that require and will benefit from consultation, and to provide the services actually needed in each case. We argue that such services can improve health care and decrease length of stay (LOS). LOS has been widely studied as an indicator of the timely delivery of appropriate care. Studies used many different models and research designs. We analyze the characteristics of the few studies that had a significant effect on LOS. There are ten studies of increased psychiatric consultation, with four showing a significant improvement in LOS. Twelve studies have analyzed the effects of increased geriatric consultation, with three showing significant improvement in LOS. Three studies have focused on delirium in geriatric patients without showing LOS benefit, but one study in geriatric trauma patients did demonstrate a notable trend towards LOS improvement. Eight studies have investigated increased geriatric consultation for elderly patients with hip fracture, two with statistically significant benefit, and an additional four with trend towards improvement. Additionally, we note that three studies on clinical pathways including comprehensive geriatric consultation all show clear evidence of LOS benefit, as do six studies with dedicated ortho-geriatric unit care. Finally, we describe two models of proactive psychiatric consultation implemented in our hospital that have demonstrated reductions in LOS. Successful studies do share certain elements in common: screening for and selection of appropriate target population who can benefit, focus on improving LOS, and close integration of consult care into medical team operation. We argue that the data thus far show that simply doing more consultations is not efficient, but that appropriately targeted and integrated care does provide timely services and reduce LOS. We conclude with suggestions about the design of successful proactive psychiatric consultation services, and with suggestions about appropriate research designs for further work in the field.
Data provided are for informational purposes only. Although carefully collected, accuracy cannot be guaranteed. The impact factor represents a rough estimation of the journal's impact factor and does not reflect the actual current impact factor. Publisher conditions are provided by RoMEO. Differing provisions from the publisher's actual policy or licence agreement may be applicable.