Transcript Old and Injured: Geriatric Trauma - wcrtac-wi

Developing a “Sentinel
Event” Geriatric Falls
Program
Michael D. McGonigal MD
Director of Trauma Services
Regions Hospital
Objectives
 List risk factors for falls in the elderly
 Discuss construction of a
multidisciplinary team to evaluate a
“sentinel event” fall
 Review results of recent studies
Facts About Falls
 The risk of falling increases with age and is greater for
women than for men
 Two-thirds of those who experience a fall will fall again
within six months
 A decrease in bone density contributes to falls and
resultant injuries
 Failure to exercise regularly results in poor muscle
tone, decreased strength, and loss of bone mass and
flexibility
 At least one-third of all falls in the elderly involve
environmental hazards in the home
Facts About Falls
 Polk, Pierce, St. Croix counties
 N=36, Average LOS = 5 days
Type of Fall
Slip, trip, stumble
Count
11
Not specified
Ladder
Stairs
8
7
5
To another level
Wheelchair
Other
2
1
2
Fall Prevention
 Risk factors are known
 More risk factors = greater chance of fall
that threatens independence
 Most factors can be prevented or
ameliorated
Fall Factors
 Osteoporosis
 Multiple causes
 Hormones
 Nutrition
 Activity level
Fall Factors
 Lack of physical activity
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Poor muscle tone
Decreased muscle strength
Accelerates osteoporosis
Increases severity of injury
from falls
Fall Factors
 Vision problems
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Acuity
Cataracts
Glaucoma
Decreased peripheral vision
Fall Factors
 Medication
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Wide variety of drug classes, Rx and OTC
Drug interactions
Nutritional supplements
Alcohol
Fall Factors
 Medical conditions
 Arrhythmias
 Atherosclerotic disease
 Dementia
Solution
 Identify a fall as a “sentinel event”
 Select age threshold
 Modify definition to suit the community
 Falls seen in ED
 Falls requiring admission
 Conduct further investigation prior to
discharge
Assemble The Puzzle Pieces
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Medical evaluation
Medication review
Chemical dependence evaluation
Osteoporosis screen
Nutritional evaluation
Home evaluation
Exercise programs
Monitoring
Public Relations / Publication
Grant writing
Teamwork
 Multidisciplinary team
 Lead physician – coordinates team
 Consultation with patient’s primary
physician
 Comprehensive H&P
 Vision screen – involve OPH if needed
 Directs appropriate medical workup
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Screening bloodwork
EKG
Syncope evaluation
Osteoporosis screen
Teamwork
 EMS
 Home evaluation during initial encounter
 Physical / Occupational Therapy
 Evaluate motor strength, coordination, stability
 Cognitive evaluation to detect dementia
 Nutritionist
 Evaluates overall nutritional state
 Reviews lab results
Teamwork
 Pharmacist
 Reviews all medications for interactions
 Needs expertise in supplements
 Works with Lead MD and PMD to determine appropriateness
and necessity
 Social Worker
 Evaluates social and family situation
 Arranges Chemical Dependence resources
 Uses community resources as needed / available
 Exercise Program
 Enroll at-risk seniors at community programs / Y
Teamwork
 Final recommendations / action
 Team arrives at final recommendations
 Lead MD reviews and implements
recommendations with assistance from
Social Work and support staff
Other Components
 Monitoring
 Followup mechanisms are mandatory!
 Need feedback regarding repeat falls
 Compare to historical controls
 Grant Writing
 Defray costs of services selected
 Can provide funds for home adaptations / repairs
 Grant writing costs included in grant
 Public Relations
 Bragging rights
 Local business can assist with costs
 Before, during and after!
Results
 Randomized, prospective cohort trial
 Evaluation of 300 patients presenting to
the ED with a fall
 Physical exam
 Home OT visit
 Monitored for recurrent falls for 1 year
Prevention of Falls in the Elderly Trial (PROFET), 1999
Results
 Principle causes of falls were found to be
hazards about the home, and CV disease
 Intervention group: 183 additional falls
in 141 patients
 Control group: 510 additional falls in 163
patients*
Prevention of Falls in the Elderly Trial (PROFET), 1999
Benefits
 Addresses serious problem in the elderly
 Decreases cost to community
 Maintains independence for the elderly
 Excellent prevention activity for RTAC /
Trauma Centers of any level
What Do We Do Next?
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Consider grant funding
Select components
Select lead physician(s)
Design protocol
 Select hospital(s)
 Include additional personnel
 EMS
 Pharmacist
 Nutritionist
 Therapists
 Social Worker
Summary
 The elderly are at risk of falls due to a
finite number of risk factors
 The risk from most of these factors can
be reduced or eliminated
 A multidisciplinary team is best suited to
address recurrent falls in the elderly