Framing the issue:
• As Americans age, today’s trauma patient is more likely to have suffered a fall than a motor vehicle- or gun-related injury.
• Some studies indicate that older patients may be slower to recover from even relatively minor traumatic injuries.
• Setting up a geriatric trauma program, or at least a protocol, can ideally get the patient to surgery faster and better support their physical therapy, pharmacy and other age-related needs.
• Hospitals that have developed these programs, which are still relatively new, report a reduction in time to surgery, and a shorter hospital stay.
Trauma surgeons at Conemaugh Memorial Medical Center in Johnstown, Pa., had begun to notice an increasing influx of older faces, many suffering the aftereffects of some type of fall. By 2012, 43 percent of trauma patients were 65 or older.
The surgeons worried that primary care providers weren’t sufficiently fast-tracking those patients given their age and vulnerability to complications. “We said, ‘This is ridiculous. They’re waiting two and three days for an operation; if the same patient were on the trauma service, we would have him or her operated on by the next day,’ ” says Russell Dumire, M.D., medical director of trauma services at the Level 1 trauma center, located about 60 miles east of Pittsburgh.
In 2013, Dumire and his colleagues started the hospital’s Geriatric Trauma Institute, assuming the initial care of any injured patient 65 or older, even those with such relatively minor injuries as a few broken ribs or a cut to the head. One of their primary objectives has been to streamline any medical clearances needed to qualify for surgery. “If they come in now at 8 or 9 o’clock in the evening and they need a cardiology consult, they get it at 8 or 9 o’clock in the evening,” Dumire says.
As the vast generation of baby boomers grows older, Conemaugh Memorial is among the hospitals striving to make sure trauma care can meet their needs. The emerging cadre of programs is described as geriatric trauma although the “geriatric” patient involved might be as young as 55 [see sidebar “Geriatric at what age?” Page 56]. While these programs vary somewhat in their approach, they share certain overarching goals: to reduce the time these patients spend in the emergency department; to push for timely medical consults and clearances needed for surgery; and to activate a specialized team that addresses pharmacy, nutrition and other age-related needs.
Studies in recent years underscore the heightened need for trauma care specially geared to older individuals. One analysis, published in 2010 in the Journal of Trauma and Acute Care Surgery, found that patients older than 60 were five times more likely to die and three times more likely to develop complications from a minor trauma, compared with their younger counterparts. For major trauma, the mortality risk was four times greater and the complications were twice as high, according to the findings, based on a decade’s worth of injury data from the American College of Surgeons’ National Trauma Data Bank.
In 2013, the ACS issued a set of geriatric trauma-management guidelines. Proponents say that’s a step toward understanding that treating similar conditions should be modified according to the patient’s age. It was only a few decades ago that clinicians recognized that a child with appendicitis shouldn’t be treated the same as an adult, says Alicia Mangram, M.D., an author of the 2010 study and medical director of trauma and surgical critical care at John C. Lincoln Health Network in Phoenix.
“Maybe we haven’t reached the point of geriatric hospitals,” she says. “But we shouldn’t treat identical injuries in a 20-year-old in the same way we treat them in a 70-year-old and expect the same results.”
Age and trauma fragility
A decade ago, motor vehicle accidents were still the leading cause of trauma in the United States. They comprised nearly 41 percent of incidents in 2003 compared with 24.1 percent for falls, according to the NTDB. By 2012, those numbers were reversed; falls comprised nearly 41 percent vs. 28.1 percent for motor vehicle injuries.
Age is a big factor. Once people reach late middle age, 55 to 64, falls outnumber motor vehicle injuries — 42,195 vs. 26,739 — and that gap widens with the years. A so-called simple fall later in life can be complicated by other factors. For instance, many seniors are on blood thinners, Mangram says. “Now, a fall can result in blood in the brain and broken ribs.”
Moreover, she says, today’s senior citizens aren’t retreating to their recliners. “Sixty-year-olds, 70-year-olds — they ride motorcycles, they hike, they bike.”
Mangram helped to start the geriatric trauma program at Methodist Dallas Medical Center before launching a similar one in Phoenix. She argues that clinicians traditionally put a misplaced emphasis on younger patients. If a 70- or 80-year-old told the physical therapist to get out of the room, “the therapist would say, ‘Yes, Ma’am’ and leave. If it were a 20-year-old, the therapist would say, ‘No, you’re going to get up. You have to walk,’” she says. “But the person who really needs to get up is the 70- or 80-year-old. The 20-year-old will be just fine.”
An elderly trauma patient confined too long in bed risks developing pneumonia and other complications that will prolong recovery. One analysis looking at the triage of elderly trauma patients, published last year in the Journal of the American College of Surgeons, illustrates how minor injuries can have major ramifications. The analysis, which looked at deaths within 60 days, identified a pattern: 80 percent occurred in patients older than 75 who had fallen and whose injury was relatively minor, with an injury severity score of less than 15.
The sticky question — one that makes some clinicians a bit uncomfortable — is whether these patients should get more expedited care than their younger counterparts. Clinically speaking, there’s no wiggle room, says Matthew Indeck, M.D., a trauma surgeon based at Penn State Milton S. Hershey Medical Center in Hershey, Pa. “You really can’t afford to make an error with them, because they won’t tolerate it,” he says.
Indeck authored a study published this year in JAMA Surgery, which found that hospitals that treated a higher proportion of older trauma patients reported lower rates of in-hospital mortality. It’s unclear precisely why, but it might be that those facilities have developed a comfort level and approach in treating this age group, he says.
“Elderly patients, in general, are basically going day to day with very minimal reserve capacity,” he says. “A lot of these individuals are living independently, but they are on the fence. It doesn’t take much to throw them off, and they’ll never get back to that independent living.”
Mobilizing the G-team
A 64-year-old woman who arrived by ambulance this spring, after falling at home, is typical of the sort of geriatric patient seen at Methodist Dallas, says Darryl Amos, M.D., who directs the hospital’s geriatric trauma program. The patient had broken several ribs as well as her shin bone. The G-60 team was activated, and in short order she was scheduled for several consults, including with a geriatric trauma specialist, orthopedics and the medicine service.
Her leg was repaired within 48 hours. But then she experienced some breathing difficulties related to the broken ribs as well as the anesthesia during surgery, and needed to go on a ventilator for a stretch. The team’s geriatric trauma expertise helped, Amos says, explaining, “Had somebody with a few rib fractures and a broken leg just been admitted to the hospital and an orthopedic consult, they might not have picked up on the pulmonary issues that developed later.”
At Methodist Dallas, which started its geriatric trauma program in 2009, patients admitted to the unit received faster care, according to the first year of data published in 2012 in the Journal of Trauma and Acute Care Surgery. The researchers reported that the time from the ED to surgery was much faster — 52.9 hours in the control group vs. 37.6 hours for the G-60 patients. Hospital length of stay declined from 7 days to 4.8 days, as did in-hospital mortality, from 5.7 to 3.8 percent, although the difference didn’t reach statistical significance.
Methodist and other hospitals with such programs describe the importance of setting rigorous treatment targets. Clinicians at Fort Worth, Texas-based John Peter Smith Hospital, which began its program in January, strive to get geriatric trauma patients — defined at JPS Hospital as 55 or older — to the operating room within 36 hours, says Raj Gandhi, M.D., trauma medical director at JPS. Discharge planning is begun on Day 1, with the goal of sending the patient home or to another care facility, such as rehabilitation, within four days.
Another key component of geriatric trauma programs is addressing patients’ nutritional, rehabilitation and other non-trauma needs. As one example, a pharmacist can check a patient’s medications to see if any boost his or her fall risk, triggering a sudden drop in blood pressure, says Elizabeth Price, R.N., coordinator of trauma advanced practice at JPS. “There are many times we send them home on two or three medications fewer than what they came in on,” she says.
Geriatric trauma 2.0
The research jury is still out, though, regarding whether older patients fare better at trauma vs. non-trauma facilities, says Richard Mullins, M.D., a professor of surgery and trauma surgeon at Portland’s Oregon Health & Science University. Mullins, who has researched trauma trends, cites a 2006 New England Journal of Medicine study that followed patients up to one year after leaving the hospital. It found that those 55 and older didn’t enjoy superior survival when treated at a trauma facility, he says.
To determine the relative success of their approach, Mullins says, programs should track mortality rates for at least 60 days, because some elderly patients might not survive long after leaving the hospital. While he supports the geriatric trauma concept, Mullins cautions that for some older patients, the definition of success might be more than sheer survival.
“If you are young and you’re injured, you almost always want to survive,” he says. “That’s your No. 1 goal. In my experience, there are elderly patients for which their No. 1 goal is to recover to a full level of independence. And if they’re unable to do that, then we have failed them in terms of enabling them to recover from their injuries.”
Dumire, the trauma director at Conemaugh Memorial, says palliative care is part of the hospital’s initial assessment, along with nutritional, pharmaceutical and other clinical areas. “It’s not unusual for us in the first 12 hours to stabilize the patient and then get the palliative care process going, if that’s the patient’s wishes,” he says.
The first year of the institute’s data, tracking care through this past April, showed that time to surgery was shortened from two to one days, when compared with data from the year prior to the institute’s formation. The hospital length of stay declined from 6.8 days to 4.1 days, and Conemaugh saved $3.6 million in room charges alone, according to hospital officials.
Developing the program wasn’t easy, Dumire says. He and his fellow surgeons had to navigate some internal hospital politics. “At the time, the primary care doctors thought that we were trying to take bread off their table by taking their patients,” he says. So they gathered data showing that surgery occurred more quickly for trauma patients, and spent some time presenting their case both to hospital administrators and to the primary care doctors.
At John Peter Smith Hospital, signs already indicate that a heightened attention to geriatric needs won’t start and stop at the Level 1 trauma center’s doors. Clinicians there want to develop a follow-up initiative, ideally by year’s end, in which the home of the fall patient is visited following discharge. During that homebound exam, hospital staff could recommend exercises and other steps, such as securing loose carpets and installing safety bars in the bathroom.
— Charlotte Huff, a writer in Fort Worth, Texas, primarily writes about medicine and business.
‘Geriatric’ at what age?
he very term “geriatric trauma” can be jarring to those in late middle age who feel as though they’re just hitting their stride, and the programs themselves disagree on the precise age group involved.
When John Peter Smith Hospital rolled out its program this year, clinicians selected their target population as 55 and older. “That’s shocking to a lot of people, and a lot of people get insulted by that number,” says Raj Gandhi, M.D., trauma medical director at the county taxpayer-funded hospital in Fort Worth, Texas.
But data from the American College of Surgeons’ National Trauma Data Bank shows that fall-related fatalities begin to pick up in the 60s and beyond, clinicians say. Plus, as a safety net facility, JPS patients already may have other medical conditions that might prolong their recovery.
Another Texas facility, Methodist Dallas Medical Center, set the age bar slightly higher, activating their G-60 team for patients 60 and older. That cutoff was selected because a 2010 study had determined that the risk of death or complications was significantly higher in that age group, according to Alicia Mangram, M.D., one of that study’s authors who helped to launch the Methodist program.
Meanwhile, Johnstown, Pa.-based Conemaugh Memorial Medical Center focuses its Geriatric Trauma Institute on patients 65 and older because that’s how the Pennsylvania trauma system defines a geriatric patient, says Russell Dumire, M.D., the hospital’s medical director of trauma services.
What should hospital leaders consider, as they develop a geriatric trauma program?
Evaluate the system’s patient mix
Before determining which patients the hospital should serve, take a close look at the region’s demographic trends. Regardless of how young and spry a patient may seem, research data show that age 60-plus is a critical dividing line in terms of trauma recovery, says Alicia Mangram, M.D., medical director of trauma and surgical critical care at John C. Lincoln Health Network in Phoenix.
Navigate the internal politics
Administrative backing is crucial because some non-trauma physicians might feel as though a program is diverting away their patients. Establishing a program in a smaller hospital or system might be easier, with fewer bureaucratic hurdles, says Russell Dumire, M.D., medical director of trauma services at Conemaugh Memorial Medical Center in Johnstown, Pa.
Be sure to track results
Along with measuring in-hospital mortality, follow what happens to patients after they are discharged. Also, survey patients to determine if the program meets their quality-of-life desires, which might extend beyond survival, says Richard Mullins, M.D., a professor of surgery and trauma surgeon at Portland’s Oregon Health & Science University.