Transcript Kentucky update 2012 - University of Kentucky | Medical Center

ElderTrauma:
2012 Update
Robert D. Barraco, MD, MPH, FACS, FCCP
Chief, Geriatric Trauma
Lehigh Valley Health Network
Allentown, PA
Objectives
■
■
Describe the epidemiology and
physiology of geriatric trauma and its
impact on our system.
Discuss recent literature in the area of
geriatric trauma.
Committee Update
Background
■
Injury rates are
rising
■ 38% of inpatients
were aged 65 years
and over, 43% days
of care
■ Those aged 75
years and over 24%
of all inpatients
Source: NHDS
Epidemiology
■
Trauma is the 5th leading cause of
death in the elderly
– In order of most to least common:
• Falls
• MVC
• Pedestrian struck
• Stab wounds
• Gunshot wounds
• others
Mechanism of Injury
■
Falls
– Most common method of injury in the
elderly
– Most responsible for cause of death
– By 2020, 47.8 billion dollars spent on the
treatment of geriatric falls
Mechanism of Injury
■
Motor Vehicle Crash
– MVC are #1 cause of trauma related
cause of death ages 65-74
– In accidents involving elderly patients
• 80% were found to be at fault
• 18% syncopal episode was the inciting agent
Mecahnism of Injury
■
Pedestrian struck by MV
– Involves the elderly more than any other
age group.
– Cause
• Confusion
• Vision or hearing deficiency
• Poor gait
Bodily Changes:
Sunset or Sunrise?
■
■
■
■
Changes in all body systems
Less reserve
Relatively unable to compensate
Physical exam findings unreliable
Nervous System
■
■
■
■
■
Sensory decline
Motor decline
Memory impairment
Impaired
temperature/ blood
pressure control
Sleep changes
Cardiovascular System
 Stretch of cardiac
muscle
■ Atherosclerosis:
Hardening of the
arteries
■ Can’t compensate
with heart rate
■ Fat in-growth of SA
and AV nodes
■
Respiratory System
■
Stiffening of chest
wall and lung
■  Oxygen
■  amount of air with
maximal breath
■  Work of
respiratory muscles
Urologic System
 Kidney failure
■  Drug clearance
and processing
■  Response to
dehydration
■
GI System
■
Swallowing
problems
■ Reflux
■ Diverticuli
Immune System
 Cancer
■  Autoimmune
disease like
Rheumatoid Arthritis
■  Infections/
complications
■
Endocrine System
■
Reduced ability to
respond to stress
■ Loss of glucose
tolerance leads to
diabetes
Bones, Joints and Muscles
■
■
■
■
■
 Muscle strength,
endurance and size
Osteoporosis
 Fractures
 Joint disease
Osteoarthritis
% Mortality By Year for All State Registry Patients Age 65
and Older
14000
12.0
12000
10.0
10000
8000
6.0
6000
4.0
4000
2.0
2000
0
0.0
2001
2002
2003
2004
2005
Total pts
2006
Percent
2007
2008
2009
2010
% Mortality
Total Patients
8.0
Factors affecting outcome and
mortality in Eldertrauma
2001
■ Triage Issues
■ Parameters (End Points) for
Resuscitation
2010
■ Correction of anti-coagulation
■ Age as indicator for trauma alert
■ Supraphysiologic Resucitation
What is “Elderly”?
Level II
In general, where specific guidance is not otherwise
given for the purposes of determining independent
risk for adverse outcomes following trauma,
patients >65 years of age can be considered as
“elderly”.
Prehospital Triage and
Activation
Level II
■
Injured patients with advanced age (>65) and
pre-existing medical conditions (PEC’s)
should lower the threshold for field triage
directly to a designated/verified trauma
center.
Prehospital Triage and
Activation
Level III
■
A lower threshold for trauma activation should
be utilized for injured patients>70 years age
who are evaluated at trauma centers.
■ Elderly patients with at least one body system
with an AIS>3 should be treated in
designated trauma centers, preferably in
ICU’s staffed by surgeon-intensivists.
Literature Support:
Trauma Center Triage/Care
Effectiveness of Prehospital
Trauma Triage…
■
■
■
■
Retrospective study
Three NJ counties with Level 1 trauma
centers
18% undertriage in elderly men, 15% in
elderly women
Age cutoff 65 years
J Emerg Nursing 2003; 29:109-15
Old Age as a Criterion for
Trauma Activation
■
Retrospective review 7.5 years
■ Level 1 urban trauma center
■ 25% of age 70 and over met one standard
criteria
– Mortality 50%, ICU 40%, OR 35%
■
75% not meet criteria
– Mortality 16%, ICU 24%, OR 19%
■
Age 70 a stand alone criteria for activation
J Trauma 2001 Oct; 51(4): 754-6
Should Age be a Factor…
■
■
■
■
NTDB review
At all levels of injury, patients older than
60 have 3 fold increased morbidity and
5 fold increased mortality with minor ISS
(0-15), 2- and 4-fold with major ISS.
Minor ISS were often Level II activations
Suggests Level 1 activation age 60 and
over
J Trauma Issue/Volume 69(1), July 2010, pp 88-92
The impact of advanced age on trauma
triage decisions and outcomes:
a statewide analysis
■
■
■
■
13,820 (27%) elderly patients.
Significantly less likely trauma team
activation despite similar severity
More often required urgent craniotomy
and orthopedic procedures
Undertriaged elderly patients had 4
times the mortality rate
Am J Surg. 197(5):571-4; discussion 574-5, 2009 May.
Undertriage of elderly trauma patients to
state-designated trauma centers
■
Even when trauma is recognized and
acknowledged by EMS, providers are
consistently less likely to consider
transporting elderly patients to a trauma
center.
Arch Surg. 143(8):776-81; discussion 782, 2008 Aug.
Elderly Injury: A Profile of Trauma
Experience in the Sunshine (Retirement)
State
■
■
In the moderate and minor injury
categories, TC survival was significantly
better for both groups.
The proportion of NTC fatalities as
potentially preventable is significantly
higher than trauma centers.
Elderly Injury: A Profile of Trauma
Experience in the Sunshine (Retirement)
State
■ When the effects of all reported
diagnoses are considered, potentially
preventable mortality for patients with
noninjury comorbidity is significantly
lower in TC.
■ Moreover, by using “discharge to home”
as an indicator of completeness of
recovery, TCs seem to be significantly
more effective than NTC
The Journal of Trauma: Issue: Volume 48(4), April 2000, pp 581-586
Trauma in the very elderly: a communitybased study of outcomes at trauma and
nontrauma centers
■
Head injury, injury severity, and lack of
TC verification are associated with
hospital mortality in very elderly trauma
patients.
J Trauma. 52(1):79-84, 2002 Jan.
Anticoagulation
Level III
■
■
■
All elderly patients who receive daily therapeutic
anticoagulation should have appropriate assessment
of their coagulation profile as soon as possible after
admission.
All elderly patients with suspected head injury
receiving daily anticoagulation should be evaluated
with head CT as soon as possible after admission.
Patients receiving warfarin with a post-traumatic
intra-cranial hemorrhage should receive initiation of
therapy to correct their INR toward a normal range
within 2 hours of admission.
PTSF Geriatric Trauma Committee
Vision: Pennsylvania’s Trauma System will pioneer and
excel in the care of the injured elderly.
Goals:
■ Evaluate/Examine Best Practices in Geriatric Trauma Care in
■
■
■
■
■
the Commonwealth
Limit variation and improve outcomes through standardization
of care
Discuss and resolve issues of importance to the care of the
Geriatric Trauma Patient
Evidence-Based Reviews as available or create our own to
guide care
Research to provide tools to change practice and provide the
best care to our community
Trauma Systems approach to issues
Definition
■
Geriatric trauma will be defined in the
Commonwealth of Pennsylvania as
injured patients age 65 and over.
PTSF Geriatric Trauma Committee
On the agenda:
■ Best practices/usable protocols
■ Interfacility standard work:
– Common protocols for clinical situations
• Anticoagulant reversal
• Syncope
■
■
Triage
Prevention Initiatives
Coumadin and CHI protocol:
Non-trauma vs. Level 3/4
Mechanism for Head Injury and
taking Coumadin:
GCS < 14?
Mechanism for Head Injury and
taking Coumadin:
Able to obtain stat head CT
and read it?
Yes
No
Stat PT/INR/PTT
Type and Cross
Obtain stat head CT with stat
read
Injury on CT?
Stat PT/INR/PTT
Type and Cross
Stat head CT with stat read
See Level 3-4 algorithm
Transfer to Level 1 or 2 trauma
center
Yes
No
Transfer to Level 1 or 2 trauma
center
Begin correction as able
Yes
No
Admit, observe
Consider CT in AM
Geriatric Triage Research
■
■
■
■
■
No denominator
Need to see if numbers would
overwhelm resources
Rich database of PCRs with PEHSC
Will look at data points for answers at
state level
Will use locoregional EMS if needed
Geriatric Issues in
Trauma Care
Frailty
AAST 2011
■ PREDICTORS OF CRITICAL CARE RELATED
COMPLICATIONS IN COLECTOMY PATIENTS USING
THE NATIONAL SURGICAL QUALITY IMPROVEMENT
PROGRAM: EXPLORING FRAILTY AND AGGRESSIVE
LAPAROSCOPIC APPROACHES.
■ ARE THE FRAIL DESTINED TO FAIL?: FRAILTY INDEX
AS A PREDICTOR OF SURGICAL MORBIDITY AND
MORTALITY IN THE ELDERLY
Surgery in the Elderly
■
21% of those over age 60 will undergo
surgery and anesthesia as compared
with only 12 percent of those aged 45 to
60 years by 2030
■
20% of all open heart surgery >70
Surgery in the Elderly
■
■
■
■
■
Overall risk steadily
declining
Heart disease
mortality 3-5%
Heart attack 1-4%
CHF 4-10%
Lungs most
common: 15-45%
Frailty
■
■
■
■
■
Unintentional weight loss
(10 pounds or more in a year)
General feeling of exhaustion
Weakness (as measured by grip strength)
Slow walking speed
Low levels of physical activity.
Trauma in the Elderly: Frailty
■
■
Frailty Scales: Measure thinking,
functionality and general health status.
Higher scores were associated in
increased complications and decreased
chance of being discharged to home.
VES-13
■
The VES-13 relies on patient self-report.
■ VES-13 is function-based.
■ In the national sample of elders, a score of 3+
identified 32% of individuals as vulnerable.
■ This vulnerable group had four times the risk
of death or functional decline when compared
to elders scoring 3 or less.
Frailty Outcomes
■
Increasing frailty was associated with
postoperative complications, increased length
of hospitalization and inability to be
discharged home independent of age.
■ EFS scores of 3 or less were associated with
a lower risk of having a complication and a
higher chance of being discharged home.
■ EFS scores exceeding 7 were associated
with increased complications and a lower
chance of being discharged home.
Cardiac evaluation
■
■
■
■
Diagnostic testing in at risk patients
EKG, Stress, Cath
Assign risk, NOT CLEAR
Recommendations
– Statins, Beta blockers
– Perioperative monitoring
Putting it all together…
Preoperative Risk Assessment
■
What is missing?
– Medications
– Frailty evaluation
– Optimization beyond Cardiac
■
■
Utilizing VES-13 as part of preop screen
to undergo Comprehensive Geriatric
Assessment, more accurate
prognostication and optimization
Journal of the American College of
Surgeons Recommendations
Models of Care: CGA
■
Geriatrics-focused interdisciplinary
management of older adults can be grouped
into 2 models of care:
– Geriatric evaluation and management (GEM), in
which the interdisciplinary team actively follows
up on the patient and directs medical care
– Comprehensive geriatric assessment (CGA), in
which the consultative interdisciplinary team
makes specific recommendations to the patient’s
primary care provider rather than directly
implementing care
Using nurse practitioners to implement
best practice care for the elderly during
hospitalization: the NICHE journey at the
University of Virginia Medical Center
■
■
Nurses Improving Care for Hospitalized
Elders
These include the Geriatric Resource
Nurse model, the Acute Care of the
Elderly model, and, most recently, the
Geriatric Consultation Service model.
Critical Care Nursing Clinics of North America. 19(3):321-37, vii, 2007 Sep.
NICHE Models at UVA
■
■
Nurse practitioners (NPs) with geriatric
expertise have provided the leadership
in implementing these initiatives to
achieve the goal of improving geriatric
care delivery within the health system.
Each NP functions in a broad role that is
tailored to meet the needs of the
patients and staff and includes the role
components of clinician, educator, team
leader, and care coordinator.
Models of Care: ACE
■
Geriatrician-led interdisciplinary team
approach
– Improve functional status, reduce acute care
hospital days and readmission, and lower
mortality rate in hospitalized acutely ill frail older
patients
■
Acute Care of the Elderly (ACE) unit
– More homelike environment
– Patient-centered care that includes plans for
preventing disability and iatrogenic illness, and
comprehensive discharge planning and
management
Models of Care: ACE
■
ACE Units bring evidence-based
practices to hospital care
– Better patient outcomes
– Better staff retention
■
Geriatric Resource Nurses are a
relatively low-cost option for putting
aging knowledge across units and
clinics.
Models of Care: ACE
■
Geriatrics expertise, when coupled with
high-margin procedures can lead to
better patient outcomes and shorter
stays in hospital.
– Better margins
– Better downstream revenues
– Competitive edge in recruiting patients
Treatment
■
Exercise and geriatric interdisciplinary
assessment and treatment models
improve outcomes
Delirium
Delirium: History
■
■
First century AD - mental disorders
during fever or head trauma
Current - transient, reversible syndrome
that is acute and fluctuating, and which
occurs in the setting of a medical
condition
Delirium: Epidemiology
■
■
■
■
Incidence - 14–56% of all hospitalized
elderly patients.
Postoperative delirium - in 15–53% of
surgical patients over the age of 65
70–87% of elderly in the ICU
At least 20% of the hospitalized patients
over 65 each year in the US experience
complications due to delirium
Delirium: Factors
Potentially modifiable risk
factors
■ Sensory impairment (hearing
or vision)
■ Immobilization (catheters or
restraints)
■ Medications
■ Acute neurological diseases
■ Intercurrent illness
■ Metabolic derangement
■ Surgery
■ Environment
■ Pain
■ Emotional distress
■ Sustained sleep deprivation
Nonmodifiable risk factors
■
■
■
■
■
■
Dementia or cognitive
impairment
Advancing age (>65 years)
History of delirium, stroke,
neurological disease, falls or
gait disorder
Multiple comorbidities
Male sex
Chronic renal or hepatic
disease
Diagnosing Delirium
CAM and CAM-ICU
■
■
■
■
Form
Algorithm
Video
Website: icudelirium.org
Delirium: Imaging
■
■
CT scan: marked cortical atrophy in the
prefrontal cortex, temporoparietal
cortex, and fusiform and lingual gyri in
the nondominant hemisphere, and
atrophy of deep structures,
Reflect a state of increased vulnerability
of the brain to any insult
Delirium: Prevention
■
30–40% of cases of delirium are preventable
■ Beers Criteria drugs should be avoided
■ The Hospital Elder Life Program (HELP)
uses tested delirium prevention strategies to
improve overall quality of hospital care.
Inappropriate Medications
in the Elderly
■
■
■
■
30 percent of hospital admissions in elderly patients
may be linked to drug-related problems or toxicity
Overall human and economic consequences of
medication-related problems vastly exceed the
findings of the Institute of Medicine (IOM) on deaths
from medical errors
In 2000, it is estimated that medication-related
problems caused 106 000 deaths annually at a cost
of $85 billion.
Fifth leading cause of death in the United States
Beers Criteria
■
■
The Beers List: Potentially Inappropriate
Medications for the Elderly
CBC News In Depth: Drugs seniors
should avoid - The Beers criteria
Delirium: Prevention
■
In a controlled trial that evaluated HELP,
delirium developed in 9.9% of the intervention
group, compared with 15.0% of the usualcare group
■ The HELP interventions can also effectively
reduce the total number of episodes and days
of delirium
■ Proactive geriatric consultation reduces risk
of delirium after acute hip fracture by 40%
Delirium: Treatment
■
Reorientation and behavioral intervention.
■ Caregivers should use clear instructions and
make frequent eye contact with patients.
■ Sensory impairments, such as vision and
hearing loss, should be minimized
■ Physical restraints should be avoided
because they lead to greater risk of injury and
prolongation of delirium
Delirium: Treatment
■
■
An environment with minimal noise at night
Nonpharmacological sleep protocol
– First, a glass of warm milk or herbal tea
– Second, relaxation tapes or relaxing music
– Third, back massage
■
Reduced the use of sleeping medications
from 54% to 31%
Fong TG et al. (2009) Delirium in elderly adults: diagnosis, prevention and
treatment Nat Rev Neurol doi:10.1038/nrneurol.2009.24
Summary
■
Delirium is a serious cause and complication
of hospitalization in elderly patients and
should be considered to be a medical
emergency until proven otherwise.
■ Potential to markedly affect the overall
outcome and prognosis of severely ill
patients, as well as substantially increasing
health-care utilization and costs.
“ The alleviation of suffering is the
warrant of medicine and its test of
adequacy…it is a test that
contemporary medicine fails despite
the brilliance of its science and its
awesome technical power”
Eric J. Cassell, J Clin Ethics. 1991; 2(2): 81-82
What is Palliative Care?
■
■
■
Good patient care
Caring for terminally-ill patients and
their families
Aggressive symptom management
– Primary goal
■
■
Communication
Spirituality
Curative vs. Palliative Models
■
Primary goal is cure
■
■
■
Object is disease
Symptoms treated as
clues
Measurable data
Devalue subjective
Therapy indicated if cures
or slows
Patient’s body different
from mind
Death is failure
■
■
■
■
■
■
■
■
■
■
■
Primary goal relief of
suffering
Object is patient/family
Symptoms treated as
entities in themselves
Subjective is valued;
patient’s experience
Therapy if relieve
suffering
Patient a complex of
physical, emotional,
social and spiritual
Live fully and comfortably
till death a success
What Palliative Care is Not…
■
■
■
■
End-of-Life Care
Withdrawal of
Care
Do not Treat
Giving up
“ A medicine that embodies an acceptance
of death would represent a great change
in the common conception, and might set
the stage for viewing the care of dying
people not as an afterthought when all
else has failed but as one part of the ends
of medicine.”
Daniel Callahan, from The Troubled Dream of Life
Five Basic Palliative Care
Interventions
■
■
■
■
■
Control Pain and other Distressing
Physical Symptoms
Alleviate Psychosocial Problems
Communicate Effectively
Empathic Presence
Foster Hope
“We are a culture that denies
death…therefore we are all
walking towards death backwards!
It is better to turn around.”
Michael Meade
Geriatric Trauma Data:
LVH CC
1400
1200
1000
800
65 & up
600
400
200
0
2003
2004
2005
2006
2007
2008
2009
Beers’ Criteria Medications
■
■
■
■
Preliminary data
Compared one year prior to
implementation to 4 and 6 years after
7.6% reduction in patients discharged
on Beers’ meds
20.8% increase in patients taken off
Beers’ meds
Geriatric Trauma Data
LVH CC
9
8
11
7
10.4
13.7
10.6
ISS
11.3
6
5
ICULOS
LOS (mean)
Mortality
4
3
2
1
0
2003
2005
2006
2007
2008
2009
Geriatric Mortality Comparison
2006-2009
Alive
Dead
LVHN
ISS 13.7
3811
212 (5.6%)
State
(adjusted)
ISS 12.5
32047
1931 (8.5%)
Contact Information:
[email protected]
610-402-1350
Fong TG et al. (2009) Delirium in elderly adults: diagnosis, prevention and treatment
Nat Rev Neurol doi:10.1038/nrneurol.2009.24
R
E
F
S
Not Frail
0–5
Apparently
Vulnerable
6–7
Mild Frailty
8–9
Moderate
Frailty
10–11
Severe
Frailty
12–18
Frailty domain
Item
0 Point
1 Point
2 Points
Cognition
Please imagine that this pre-drawn circle is a
clock. I would like you to place the
numbers in the correct positions then
place the hands to indicate a time of
‘ten after eleven’
No errors
Minor spacing errors
Other errors
In the past year, how many times have you
been admitted to a hospital?
0
1–2
≥2
In general, how would you describe your
health?
Excellent/Very
good/G
ood
Fair
Poor
Functional independence
With how many of the following activities do
you require help? (meal preparation,
shopping, transportation, telephone,
housekeeping, laundry, managing
money, taking medications)
0–1
2–4
5–8
Social support
When you need help, can you count on
someone who is willing and able to
meet your needs?
Always
Sometimes
Never
Do you use five or more different
prescription medications on a regular
basis?
No
Yes
At times, do you forget to take your
prescription medications?
No
Yes
Nutrition
Have you recently lost weight such that your
clothing has become looser?
No
Yes
Mood
Do you often feel sad or depressed?
No
Yes
Continence
Do you have a problem with losing control of
urine when you don't want to?
No
Yes
(1) Do heavy work around the house like
washing windows, walls or floors
without help?
Yes
No
(2) Walk up and down stairs to the second
floor without help?
Yes
No
(3) Walk 1 km without help?
Yes
No
General health status
Medication use
Two weeks ago were you able to:
Self-reported performance
Importance of a Comprehensive Geriatric
Assessment in Prediction of Complications
Following Thoracic Surgery in Elderly Patients
■
Dependence for the performance of ADLs
and impaired cognitive conditions are
important predictors of postoperative
complications, especially when the operation
time is long. CGA is necessary in addition to
the conventional cardiopulmonary functional
assessment in elderly patients.
January 1, 2011- July 30, 2011

Queried EMS patient care reports for patients
age 65 and older with the following reported
causes of injury:
◦ Fall
◦ Pedestrian Struck
◦ Motor Vehicle Accident

27,009 Records Returned
15
81.16
14
12.31
GCS Score
13
2.17
12
1.20
11
0.82
10
0.40
9
0.40
8
0.27
7
0.14
6
0.26
5
0.09
4
0.09
3
0.72
0
5
10
15
20
25
30
35
40
45
50
55
60
Percentage of Total Reported
65
70
75
80
85
90
Geriatric Standards
Requirement
Level 1
Level 2
Level 3
Interdisciplinary care
E
E
D
Geriatrician as liaison
Internist/family
medicine/rehab
medicine interested
in geriatrics as
liaison
D
D
D
Geriatric Resource Nurse
(1 FTE if >1000/yr)
D
D
D
Geriatric PI
E
E
D
Palliative Care program
D
D
D
Geriatric Education
E (may be internal)
E (may be internal)
E
Geriatric prevention
E
E
D
Geriatric Trauma Chief
E
E
D
Relationships between various
etiological factors in delirium
Fong TG et al. (2009) Delirium in elderly adults: diagnosis, prevention and treatment
Nat Rev Neurol doi:10.1038/nrneurol.2009.24
Symptom Management
Patient Centered Goals
Concordance between patient, caregiver,
Healthcare team