Older adults make up a growing percentage of trauma patients. In response, trauma centers worldwide are seeking ways to improve care for injured elders. At this year’s Annual Scientific Assembly of the Eastern Association for the Surgery of Trauma (EAST), five teams presented research on geriatric trauma. Their findings point out several opportunities to improve geriatric care — by identifying injuries more accurately, making better-informed care decisions and providing more timely interventions.
1. Make better observe-versus-admit decisions for geriatric fall patients
A 68-year-old woman on anticoagulation has fallen and struck her head. CT scans are negative, but you’re concerned about delayed intracranial hemorrhage. Should you hold the patient for observation or go ahead and admit her as an inpatient? A group from Yale New Haven Health has identified several factors that predict length of stay (LOS) for these patients.
The research group looked at 231 fall patients treated over a period of nearly 4 years. Patients were older than 65 and on anticoagulation, and they presented with one of the following — history of head strike, Glasgow Coma Scale (GCS) < 14, external signs of head or face trauma, INR > 3.5 or focal neuro deficits. Among the patients who met these criteria, 19% had LOS ≤ 2 days and 81% had LOS > 2 days.
- Factors associated with LOS ≤ 2 days (observation status) included the ability to walk more than 100 feet (OR=2.90), a fall that took place at a care facility (OR=2.08) and injuries isolated to the head and face (OR=2.71).
- Factors associated with LOS > 2 days (inpatient status) included use of an ambulatory assistive device (OR=3.52) and injuries to areas other than the head or face (OR=7.7).
- Risk factors that were not significant were falls that took place at home, direct thrombin inhibitors, age of 75 or greater, more than 10 presenting medications, weight loss or gain greater than 5 pounds, and ground level falls versus falls from a height.
“Predicting shorter hospital stays for this population can be valuable for resource utilization,” the research group concludes. “Functional ability, fall location, and anatomic location of injuries should be considered when deciding to admit as observation or inpatient status.”
(Source: Gregg SC, O’Neill K, Cholewczynski W, et al. Factors Predicting Length of Stay of Anticoagulated Geriatric Fall Victims With Negative Head CTs: Observation vs. Inpatient Admission? EAST 2017, Poster #13.)
2. Use CT liberally to clear older patients for cervical spine fracture
Under current guidelines, awake and alert blunt trauma patients who report no pain can be safely cleared for cervical spine fracture. But according to a group of researchers from Iowa Methodist Medical Center, these guidelines may be inadequate for older trauma patients.
The investigators looked retrospectively at four years of data on older patients (age 55 plus) with c-spine fracture. “Patients were considered asymptomatic or pain-free if they did not complain of neck pain on initial presentation and denied tenderness to palpation of the c-spine on exam,” according to the paper. More than one-fifth (22%) of patients with cervical spine fracture were pain-free upon presentation and during clinical exam.
“Current guidelines state that radiological assessment is unnecessary for safe clearance of the asymptomatic c-spine in awake and alert blunt trauma patients, but this may not be the case for older patients,” the researchers conclude. “We recommend liberal CT imaging of the c-spine for all older trauma patients, even with low probability of injury or normal clinical exam.”
(Source: Healey CD, Pelaez C, Spilman SK. Asymptomatic Neck Fractures: Current Guidelines Can Fail Older Patients. EAST 2017, Paper #8.)
3. Adopt a third triage level to expedite care for geriatric patients
Some geriatric patients with occult trauma may not meet trauma team activation (TTA) criteria. Can trauma centers improve care for these patients without overextending trauma team resources? A group from Reading Hospital (Pennsylvania) examined geriatric trauma outcomes before and after implementation of “Tier 3” (T3) — a triage criteria designed to identify geriatric patients with occult blunt head and torso trauma who do not meet conventional TTA requirements.
The research group compared 1,715 patients treated before the new triage level was created to 3,688 patients treated after the implementation of T3. All patients were 65 years or older, and each cohort represented nearly 4 years of data. The group controlled for age, injury severity score (ISS), GCS, systolic blood pressure and heart rate. Odds of death were 39% lower for geriatric patients treated after the new triage level was implemented.
“The addition of an EM physician-driven protocol for evaluation of geriatric patients who did not meet trauma activation criteria provided efficient identification of serious injuries, lowered mortality and improved utilization of EM and trauma team resources,” the researchers conclude.
(Source: Fernandez F, Ong AW, Butts C, et al. “Tier 3”: Long Term Experience With a Novel Addition to a Two-Tiered Triage System to Expedite Care of Geriatric Trauma Patients. EAST 2017, Poster #34.)
4. Understand how a geriatric trauma service can improve hip fracture outcomes
In recent years, several hospitals have developed special services focused on geriatric trauma. Do these services improve outcomes for older trauma patients? A group from Washington University in St. Louis has demonstrated that a geriatric trauma service (GTS) has led to improved care and outcomes for geriatric patients with isolated hip fracture.
The research group used their center’s trauma registry to identify patients older than 55 who were admitted for an isolated hip fracture before the creation of the specialized service (500 patients) and after full implementation of the GTS (271 patients). In comparison to the pre-implementation group, patients seen by the GTS had decreased time to OR (1.30.9 days versus 1.71.4 days) and decreased overall LOS (5.02.1 days versus 6.49.0 days).
“Although the patient populations are comparable in terms of age, ISS, and ASA, the institution of GTS has resulted in improved outcomes as well as cost-saving from faster time to OR and decreased length of hospitalizations,” the group concludes.
(Source: Choi PM, Tan WH, Tian D, Ricci W, Bochicchio GV, Schuerer DJE. Outcomes After the Implementation of Geriatric Trauma Service in Patients With Isolated Hip Fractures. EAST 2017, Quick Shot #10.)
5. Consider using a more manageable formula for predicting geriatric mortality
The PALLIATE Consortium published a paper last year validating the Geriatric Trauma Outcome Score (GTOS) as a tool for predicting in-hospital mortality after injury for older patients. How does GTOS compare to the Trauma Injury Severity Score (TRISS) in terms of usability?
The GTOS formula is [age]+ [ISS × 2.5] + [22 if transfused any packed red blood cells (PRBCs) by 24 hours after admission]. In comparison, the TRISS model uses multiple variables and requires separate formulas for blunt and penetrating injury.
In this study, the PALLIATE researchers applied both models to 10,894 patients with a mean age of 78.3 years and a mean ISS of 10.9. They found that both GTOS and TRISS accurately predict probability of death for injured elders. The GTOS formula, however, is more user-friendly. “GTOS has the advantages of fewer variables to be collected, no reliance on data collected in the Emergency Room or by other observers, and a single formula for all mechanisms of injury,” the researchers conclude.
(Source: Madni T, Ekeh AP, Brakenridge SC, et al. A Comparison of Prognosis Calculators for Geriatric Trauma: A P.A.L.Li.A.T.E. Consortium Study. EAST 2017, Paper #6.)