Geriatric Trauma Research Articles

Impact of concomitant injuries in geriatric patients with proximal femur fracture : an analysis of the Registry for Geriatric Trauma.

The impact of concomitant injuries in patients with proximal femoral fractures has rarely been studied. To date, the few studies published have been mostly single-centre research focusing on the influence of upper limb fractures. A retrospective cohort analysis was, therefore, conducted to identify the impact and distribution of concomitant injuries in patients with proximal femoral fractures. A retrospective, multicentre registry-based study was undertaken. Between 1 January 2016 and 31 December 2019, data for 24,919 patients from 100 hospitals were collected in the Registry for Geriatric Trauma. This information was queried and patient groups with and without concomitant injury were compared using linear and logistic regression models. In addition, we analyzed the influence of the different types of additional injuries. A total of 22,602 patients met the inclusion criteria. The overall prevalence of a concomitant injury was 8.2% with a predominance of female patients (8.7% vs 6.9%; p < 0.001). Most common were fractures of the ipsilateral upper limb. Concomitant injuries resulted in prolonged time-to-surgery (by 3.4 hours (95 confidence interval (CI) 2.14 to 4.69)) and extended length of stay in hospital by 2.2 days (95% CI 1.74 to 2.61). Mortality during the admission was significantly higher in the concomitant injury group (7.4% vs 5.3%; p < 0.001). Additionally, walking ability and quality of life were reduced in these patients at discharge. More patients were discharged to a nursing home instead of their own home compared to patients without additional injuries (25.8% vs 30.3%; p < 0.001). With a prevalence of 8.2%, the appearance of a concomitant injury is common in elderly patients with hip fracture. These patients are at a greater risk for death during the admission, longer hospital stays, and delayed surgery. This knowledge is clinically important for all who are involved in the treatment of proximal femur fractures. Cite this article: Bone Joint J2021;103-B(9):1526-1533.

Open globe injuries in geriatric population in Iran: characteristics and outcomes.

To investigate the patterns and outcomes of open globe injuries in the elderly population in Iran. In this retrospective cross-sectional chart review, medical records of 248 patients (aged 60y and more) with the diagnosis of open globe injury from 2006 to 2016 were reviewed. Demographic features, type, and mechanism of open globe injury, ocular trauma score (OTS), visual acuity before and after treatment, the zone of injuries, and the associated injuries found at the presentation or thereafter were documented. A total of 248 eyes of 248 patients were included. The mean age was 69.2±5.8y (range: 60-90y). Male/ female ratio was about 3:1 (187 vs 61). The three most common causes of injury were falling (25.2%), sharp objects (18.9%), and tree branches (13.9%). Penetrating injury accounted for most of the geriatric ocular trauma (50.4%), followed by globe rupture (40.3%), intraocular foreign body (IOFB; 7.3%), and perforating injury (2.0%). The median raw OTS for the population was 60.5 and the most common OTS class was 3. The injuries tend to affect zone I more than zone II and zone III. The only predictor of final visual acuity was the class of OTS (P<0.001). Geriatric open globe injury should be valued specifically. The most common type of open globe injury in Iran is penetrating injuries but falling remain the main cause. The OTS class must be considered as an important predictor of final visual acuity.

Care of Geriatric Patients with Lumbar Spine, Pelvic, and Acetabular Fractures before and after Certification as a Geriatric Trauma Center DGU®: A Retrospective Cohort Study.

Background: More than 750,000 fragility fractures occur in Germany every year, with an expected increase in the following years. Interdisciplinary care pathways for geriatric patients are increasingly established to improve the treatment process and outcome, but there has been only limited evaluation of their use. Objectives: This study aimed to compare patient care before and after the implementation of a geriatric trauma center (GTC) in conformity with the German Society for Trauma Surgery (DGU®). Patients and Methods: We performed a retrospective single-center cohort study, including 361 patients >70 years old with lumbar spine, pelvic, and acetabular fractures, admitted between January 2012 and September 2019. Patients were divided into a usual care cohort (UC, n = 137) before implementation and an ortho-geriatric care cohort (OGC, n = 224) after implementation of the GTC DGU®. We recorded and compared demographic data, fracture type, geriatric assessment and management, therapy, complications, and various clinical parameters, e.g., length of stay, time to surgery, hours admitted to ICU, and change in walking ability. Results: The geriatric assessment revealed significant geriatric co-morbidities and a need for geriatric intervention in 75% of the patients. With orthogeriatric co-management, a significant increase in the detection of urological complications (UC: 25.5% vs. OGC: 37.5%; p = 0.021), earlier postoperative mobilization (UC: 57.1% vs. OGC: 86.3%; p < 0.001), an increased prescription of anti-osteoporotic treatment at discharge (UC: 13.1% vs. OGC: 46.8%; p < 0.001), and lower rates of revision surgery (UC: 5.8% vs. OGC: 3.1%; p = 0.012) could be seen. Conclusions: Our results emphasize the improvement in patient care and clinical outcome by implementing a GTC DGU® and provide opportunities for future improvement in ortho-geriatric patient care.

A retrospective cohort study of 27,049 polytraumatized patients age 60 and above: identifying changes over 16\xa0years

Key summary pointsAimIn this study, we establish an overview of changes we observed in demographics of older severe trauma patients from 2002 to 2017.FindingsTrauma mechanism, as well as injury pattern, changed over time. We found length of stay and mortality decreased despite an increase in patient age.MessageWe ascribe this observation mainly to increased use of diagnostic tools and improved treatment algorithms and underline the importance of the implementation of specialized geriatric trauma centers allowing interdisciplinary care.

Allogeneic Red Blood Cell Transfusion Rate and Risk Factors After Hemiarthroplasty in Elderly Patients With Femoral Neck Fracture.

ObjectiveThis study aimed to determine the rate and risk factors of allogeneic red blood cell transfusions (ABT) after hemiarthroplasty (HA) in elderly patients with femoral neck fracture (FNF).MethodsThe subjects of the study were elderly patients (≥65 years old) who were admitted to the geriatric trauma orthopedics ward of Beijing Jishuitan Hospital between March 2018 and June 2019 for HA treatment due to an FNF. The perioperative data were collected retrospectively, and univariate and multivariate stepwise logistic regression analyses were performed to determine the post-operative ABT rate and its risk factors.ResultsThere were 445 patients in the study, of whom 177 (39.8%) received ABT after surgery. Multivariate stepwise logistic regression analysis showed that preoperative low hemoglobin (Hb), high intraoperative blood loss (IBL), advanced age, and a low body mass index (BMI) are independent risk factors of ABT after HA in elderly FNF patients.ConclusionABT after HA is a common phenomenon in elderly patients with FNF. Their post-operative ABT needs are related to preoperative low Hb, high IBL, advanced age, and low BMI. Therefore, ABT can be reduced by taking these factors into account. When the same patient had three risk factors (preoperative low hemoglobin, advanced age, and low BMI), the risk of ABT was very high (78.3%). Also, when patients have two risk factors of preoperative low hemoglobin and low BMI, the risk of ABT was also high (80.0%).

Marijuana and thromboembolic events in geriatric trauma patients: The cannabinoids clots correlation!

BackgroundTetrahydrocannabinol (THC) can alter the coagulation cascade resulting in hypercoagulability. The aim of our study is to evaluate the impact of THC use on thromboembolic complications (TEC) in geriatric trauma patients (GTP). MethodsThis is a 2017 analysis of the TQIP database including all GTP (age ≥65 years). Patients were stratified based on THC use. Propensity score matching (1:2 ratio) was performed. ResultsA total of 2,835 patients were matched (THC+: 945 and THC-: 1,890). Mean age was 70 ± 6 years, 94% sustained blunt injuries, and median ISS was 22[12–27]. Sixty-two percent of patients received thromboprophylaxis, with median time to initiation of 27 h from admission. Overall, the rate of TEC was 2.1% and mortality was 6.0%. THC + patients had significantly higher rates of TEC compared to THC- patients (3.0% vs. 1.7%; p = 0.01). Rates of DVT (2.2% vs 0.6%, p < 0.01) and PE (1.4% vs 0.4%, p < 0.01) were higher in the THC + group. ConclusionTHC exposure increases the risk of TEC in GTP. Incorporation of THC use into risk assessment protocols merits serious consideration in GTP.

Geriatric Recovery and Enhancement Alliance in Trauma (GREAT) multidisciplinary quality improvement initiative: improving rates of successful resuscitation, rehabilitation and reintegration of geriatric trauma patients across the trauma spectrum of care

Geriatric Recovery and Enhancement Alliance in Trauma (GREAT) multidisciplinary quality improvement initiative: improving rates of successful resuscitation, rehabilitation and reintegration of geriatric trauma patients across the trauma spectrum of care. Sandy Widder, Kristin E. Morch, Nori L Bradley, Lauren Ternan, Ni Thuyen Lam Background: Traumatic injuries are a significant cause of morbidity and mortality in the elderly, with the risk of poor outcomes increasing with advanced age. Using a multidisciplinary geriatric trauma care approach, led by a dedicated nursing coordinator, standardized order sets were implemented to reduce in-hospital complications and screening tools applied early to identify patient specific care needs. Specifically, early trauma consult, identification of injuries, appropriate opioid ordering, polypharmacy avoidance, delirium prevention, mental health issues, and mobility needs were addressed The goal was to improve geriatric trauma awareness, decrease in-hospital complications and improve the likelihood of return to home and baseline function Implementation: Through stakeholder consultation process, it was recognized that the hospital needed a coordinated, geriatric trauma team process. The geriatric trauma navigator (GTN) role was created to lead these quality improvement initiatives. This included the development of educational strategies for frontline staff and physicians to highlight the unique challenges of trauma patient management and to introduce the GREAT study for optimized patient care. Patients 65 years of age or older with a traumatic mechanism were enrolled. GREAT patients then followed a protocol designed for tracking and implementing standardized processes, including early ED and in-patient order sets, engagement of trauma services, and the application of screening tools and specialty consultations. Screening tools (Identification of Seniors At Risk (ISAR), Confusion Assessment Method (CAM), Mini-Cog, Patient Health Questionnaire (PHQ-2), Geriatric Depression Scale (GDS-15), Alcohol Use Disorders Identification Test- Concise (AUDIT-C), Canadian Nutrition Screening Tool (CNST), Clinical Frailty Scale, ADL/IDLs) were administered to identify at-risk patients and to inform consultation with geriatrics and psychiatry, and allied health services (occupation therapy, physical therapy, nutrition services, pharmacy). The study team evaluated data on a monthly basis and met quarterly to evaluate and implement changes. Evaluation Methods: Data was prospectively collected and compared to control data from the Alberta Trauma Registry and Trauma Quality Improvement Program (American College of Surgeons). Data tabulation and statistical analysis was performed using Stat59 (STAT59 Services Ltd, Edmonton, AB, Canada). Outcome measures-provision of timely and comprehensive care: rates of trauma team activations, emergencydepartment and in-hospital length of stay-reduction of hospital complications: UTI, DVT/PE, pneumonia, pressure ulcers, ICUadmission, unexpected readmission to hospital-improvement of functionality upon discharge: in-hospital and 30 day mortality rates,return to function, disposition (home versus long term care) Process measures-time to diet and ambulation-tracking of number of days of urinary catheter in situ-compliance with GOC discussions-use of assessment screening tools-spinal clearance &lt;24 hours Results: Enrollment of patients into GREAT based on study criteria lowered the threshold for triggering a trauma team consult, improving the recognition rate of geriatric trauma. This was reflected in the decreased average ISS scores and higher rate of trauma consults. Ground level falls, which previously did not typically activate a trauma consult, are now be recognized as major trauma. With the GTN, we determined that gaps exist in the current monitoring of key performance measures. Through the GREAT data collection process, we were able to establish baseline data and target PDSA changes to address these gaps. Advice and Lessons Learned: This quality initiative was designed as a proof of concept model for early identification of the geriatric trauma patient and a collaborative team approach to optimize care processes, and in turn minimize complications. The GTN role was vital to identify patients, implement screening tools, and coordinate care. With limited resources and increasing work loads for all programs, the additional GTN role required site leadership and stakeholder support. Ideally, a protocolized geriatric trauma team activation and admission process would ensure all patients receive screening tools as part of their in-patient orders for early assessments and interventions. Further educational campaigns will need to be developed to increase awareness of the importance of geriatric trauma. Additionally, processes need to be streamlined for data gathering and monitoring of performance measures. Access to screening tools and order sets need to be user friendly, built into currently existing workflows, and evaluated for optimization.

Geriatric traumatology (e. g. "Alterstraumatologie") is more than orthogeriatrics-Experiences of aphysician in advanced training.

This article reporting the view of an early career physician focuses on the diverse components of orthogeriatric co-management in aclinical setting. Geriatric trauma patients require amultimodal and interdisciplinary management, which includes individual and age-specific aspects, such as intensified physiotherapy, trauma surgery and geriatric expertise as well as social support. In Germany this surgical and geriatric co-treatment is provided by the program geriatric traumatology (Alterstraumatologie), which is implemented and certified at special institutions called geriatric trauma centers (Alters-Trauma-Zentrum). This special care is accomplished by an orthogeriatric co-management, which combines the efforts of both modern state of the art trauma surgery and geriatric medicine, preferable by using the procedure of the so-called geriatric early rehabilitative complex treatment (geriatrische frührehabilitative Komplexbehandlung) according to the diagnosis-related group (DRG) procedure OPS 8550. This is administered in 3periods: the preoperative period, perioperative period and postoperative period and if indicated followed and completed by ageriatric rehabilitation. According to recent studies this approach has proved to be beneficial especially with respect to a reduction of posttraumatic morbidity rates and avoiding loss of function.

Critical care ultrasound in geriatric trauma resuscitation leads to decreased fluid administration and ventilator days.

Geriatric trauma populations respond differently than younger trauma populations. Critical care ultrasound (CCUS) can guide resuscitation, and it has been shown to decrease intravenous fluid (IVF), lower time until operation, and lower mortality in trauma. Critical care ultrasound-guided resuscitation has not yet been studied in geriatric trauma. We hypothesized that incorporation of CCUS would decrease amount of IVF administered, decrease time to initiation of vasopressors, and decrease end organ dysfunction. A PRE-CCUS geriatric trauma group between January 2015 and October 2016 was resuscitated per standard practice. A POST-CCUS group between January 2017 and December 2018 was resuscitated based on CCUS performed by trained intensivist upon admission to the intensive care unit and 6 hours after initial ultrasound. The PRE-CCUS and POST-CCUS groups underwent propensity score matching, yielding 60 enrollees in each arm. Retrospective review was conducted for demographics, clinical outcomes, and primary endpoints, including amount of IVF in the first 48 hours, duration to initiation of vasopressor use, and end organ dysfunction. Wilcoxon two-sample, χ2 tests, and κ statistics were performed to check associations between groups. There was no statistical difference between PRE-CCUS and POST-CCUS demographics and Injury Severity Scores. Intravenous fluid within 48 hours decreased from median [interquartile range] of 4941 mL [4019 mL] in the PRE-CCUS to 2633 mL [3671 mL] in the POST-CCUS (p = 0.0003). There was no significant difference between the two groups in time to initiation of vasopressors, vasopressor duration, lactate clearance, intensive care unit length of stay, or hospital length of stay. There was a significant decrease in ventilator days, with 26.7% PRE-CCUS with ventilation longer than 2 days, and only 6.7% POST-CCUS requiring ventilation longer than 2 days (p = 0.0033). Critical care ultrasound can be a useful addition to geriatric resuscitation. The POST-CCUS received less IV fluid and had decreased ventilator days. While mortality, lactate clearance, complications, and hospital stay were not statistically different, there was a perception that CCUS was a useful adjunct for assessing volume status and cardiac function. Therapeutic, level II.

The DEPARTS Score: A Novel Tool for Predicting Discharge Disposition in Geriatric Trauma Patients.

Geriatric trauma patients (GTPs) represent a high-risk population for needing post-acute care, such as skilled nursing facilities (SNFs) and long-term acute care hospitals (LTACs), due to a combination of traumatic injuries and baseline functional health. As there is currently no well-established tool for predicting these needs, we aimed to create a scoring tool that predicts disposition to SNFs/LTACs in GTPs. The adult 2017 Trauma Quality Improvement Program database was divided at random into two equal sized sets (derivation and validation sets) of GTPs >65years old. First, multiple logistic regression models were created to determine risk factors for discharge to a SNF/LTAC in admitted GTPs. Second, the weighted average and relative impact of each independent predictor was used to derive a DEPARTS (Discharge of Elderly Patients After Recent Trauma to SNF/LTAC) score. We then validated the score using the area under the receiver-operating curve (AROC). Of 66479 patients in the derivation set, 36944 (55.6%) were discharged to a SNF/LTAC. Number of comorbidities, fall mechanism, spinal cord injury, long bone fracture, and major surgery were each independent predictors for discharge to SNF/LTAC, and a DEPARTS score was derived with scores ranging from 0 to 19. The AROC for this was .74. In the validation set, 66477 patients also had a SNF/LTAC discharge rate of 55.7%, and the AROC was .74. The DEPARTS score is a good predictor of SNF/LTAC discharge for GTPs. Future prospective studies are warranted to validate its accuracy and clinical utility in preventing delays in discharge.

Advanced Trauma Care for Nurses (ATCN): A Single-Center Analysis of Trauma Nurses Knowledge Gaps.

Trauma is a global cause of death and disability, and trauma systems are not well developed in low- and middle-income countries. Training of nurses in trauma care is of utmost importance to improve the organization and delivery of trauma care. This study aimed to identify common knowledge gaps and develop study aids to improve nurses' performance taking the Advanced Trauma Care for Nurses (ATCN) course. This is a descriptive, single-center study of the multiple-choice final examinations of the ATCN course conducted over 1 year in the All India Institute of Medical Sciences, Rishikesh, Level I trauma center. The questions missed by candidates were compiled, and the wrong options were tabulated. The most commonly missed questions were identified, and the most commonly marked wrong option was analyzed vis-a-vis the correct answer. Each error was classified into either a theoretical error or a practice-based error. Ninety-six nurses attended 6 courses from June 2019 to June 2020. Of the theoretical-based questions, the top 3 categories of most missed questions were geriatric trauma (n = 13; 81.2%), massive transfusion (n = 35; 72.9%), and traumatic brain injury (n = 35; 72.9%). Of the practice-based questions, the top 3 categories of most missed questions were dislocated extremity management (n = 54; 79.4%), basic airway (n = 31; 64.5%), and shock management (n = 30; 62.5%). Periodic identification and categorization of the ATCN course examination's most frequent knowledge gaps allow instructors to develop teaching aids to enhance instructor teaching and improve trauma nurses' knowledge.

Changing pattern of trauma during the COVID-19 Pandemic

BackgroundThe COVID-19 pandemic compelled the Indian government to enforce a complete nationwide lockdown on 24th March 2020. MethodsThis retrospective study was done to analyse the profile of trauma patients presenting to the emergency department (ED) from January to August 2020. Data from 69 days of lockdown and 83 days of pre-lockdown periods were used to calculate the 30-day incidence rates. ResultsDuring the 7-month study period, 5220 patients presented to our ED with trauma; 2296 in the prelockdown phase (83 days), 1205 during the lockdown phase (69 days), and 1719 during the postlockdown phase (92 days). There was a significant decrease (36.7%) in the 30-day incidence rate of trauma victims presenting to the ED during the lockdown phase (525) compared with the prelockdown phase (830). The 30-day incidence of road traffic accidents (RTA), fall from height, fall on level ground and other trauma decreased by 53.2%, 26%, 23.2% and 12.9%, respectively, while assault cases increased by 8.3% during the lockdown period as compared with the prelockdown period. During the lockdown period, the 30-day incidence of trauma victims with a positive blood alcohol content decreased by 39.6% with a significant drop in the strict lockdown month of April 2020. ConclusionsA significant reduction in the incidence rate of trauma victims, especially RTA and geriatric trauma was seen during the gruelling lockdown period of the COVID 19 pandemic.

The Burden of Geriatric Trauma at the University College Hospital, Ibadan, Nigeria.

Background:Geriatric populations presently account for 9% of the world population and this is expected to increase. Injuries to the elderly accounted for 5.8 million accident and emergency visits in the USA as well as 4% of patients treated for traumatic injuries in Abuja, Nigeria. Traumatic injury is therefore a major cause of morbidity in the elderly as such the need for the study in our environment.Aims and Objectives:The aim(s) of this article is to review the incidence and types of traumatic injury among elderly population who presented at the University College Hospital, Ibadan, Nigeria and to determine the causes of traumatic injury involving the geriatric age group in our environment.Materials and Methods:A retrospective hospital-based study involving the records of geriatric patients who presented with traumatic injuries between January 2014 and June 2021 at the geriatric center and the accident and emergency department of the hospital. The record was retrieved from the Total Quality Management Unit of the hospital.Results:About 7.61% of the traumatic injury that presented at the accident and emergency department within the study period involved geriatric patients with a male-to-female ratio of 1:1.08, whereas 0.3% of the patients for inpatient care at the geriatric center had traumatic injury. Fall was the most common cause of traumatic injury observed and fracture the most common traumatic injury observed.Conclusion:Less than 10% of the patients with traumatic injury who presented at the University College Hospital, Ibadan, Nigeria are in the geriatric age group. Most of the traumatic injury involving geriatric patients in our environment is due to low energy falls, and fracture is the most common injury observed, with the femur being the most affected bone. Therefore, interventions directed at reducing the incidence of falls in our environment will hopefully help in reducing the incidence of traumatic injuries in the older population.

Impact of COVID-19 pandemic on hip fractures: the central London experience COVID-related urgent geriatric hip trauma (COUGH) study COVERT ( COVid Emergency-Related Trauma and orthopaedics) collaborative

IntroductionCOVID-19 has been recognized as the unprecedented global health crisis in modern times. The purpose of this study was to assess the impact of COVID-19 on treatment of neck of femur fractures (NOFF) against the current guidelines and meeting best practice key performance indicators (KPIs) according to the National Hip Fracture Database (NHFD) in two large central London hospitals.Materials and methodsA multi-center, longitudinal, retrospective, observational study of NOFF patients was performed for the first ‘golden’ month following the lockdown measures introduced in mid-March 2020. This was compared to the same time period in 2019.ResultsA total of 78 cases were observed. NOFFs accounted for 11% more of all acute referrals during the COVID era. There were fewer overall breaches in KPIs in time to theatre in 2020 and also for those awaiting an orthogeriatric review. Time to discharge from the trust during the pandemic was improved by 54% (p < 0.00001) but patients were 51% less likely to return to their usual residence (p = 0.007). The odds ratio was significantly higher for consultant surgeon-led operations and consultant orthogeriatric-led review in the post-COVID era. There was no significant difference in using aerosol-generating anaesthetic procedures or immortality rates between both years.ConclusionThe impact of COVID-19 pandemic has not adversely affected the KPIs for the treatment of NOFF patients with significant improvement in numerous care domains. These findings may represent the efforts to ensure that these vulnerable patients are treated promptly to minimize their risks from the coronavirus.

Open Reduction in Subtrochanteric Femur Fractures Is Not Accompanied by a Higher Rate of Complications.

Backgroundand Objectives: Hip fractures are among the most typical geriatric fractures. Subtrochanteric fractures are considered difficult to treat, and, to date, there is no consensus on the optimal surgical treatment. Materialisand Methods: We analyzed data from the Registry for Geriatric Trauma, which includes patients ≥ 70 years old with hip fractures or periprosthetic fractures requiring surgery (21,734 patients in 2017–2019). For this study, we analyzed only the subgroup of patients with a subtrochanteric fracture. We analyzed the difference between closed and open surgical methods on a range of outcomes, including mortality, mobility, length of acute hospital stay, and the need for surgical revisions. Results: A total of 506 patients with subtrochanteric fractures were analyzed in this study. The median age was 85 years (interquartile range of 81–89). About 21.1% (n = 107) were operated on with a closed technique, 73.3% (n = 371) with open reduction without using a cerclage, and 5.53% (n = 28) with open reduction with the additional use of one or more cerclage wires. A total of 3.56% (n = 18) of the patients had complications requiring operative revision, most commonly soft tissue interventions (open vs. closed reduction—3.26% vs. 4.67%) (p = 0.687). Patients treated with open reduction were significantly more mobile 7 days after surgery (p = 0.008), while no significant effects on mortality (p = 0.312), length of hospital stay (p = 0.968), or surgical complications (p = 0.687) were found. Conclusion: Proper reduction is the gold standard practice for successful union in subtrochanteric fractures. This study shows that open reduction is not associated with a higher complication rate but does lead to increased mobility 7 days after operation. Therefore, in case of doubt, a good reduction should be aimed for, even using open techniques.

Impact of a geriatric consultation service on outcomes in older trauma patients: a before-after study.

Early geriatric involvement is recommended for older trauma patients. We wished to determine the impact of geriatric consultation on mortality, hospital length of stay and discharge disposition in older patients who were admitted to our Level 1 trauma unit. We completed a health records review of trauma unit patients, age ≥ 75years old with Injury Severity Score (ISS) ≥ 12, before (11/2015-10/2017) and after (11/2017-10/2019) implementation of a geriatric trauma consultation initiative. Primary outcomes were mortality, hospital length of stay and discharge destination. Secondary objectives were adherence to the geriatric trauma consult process and identification of geriatric-specific issues. A multivariable analysis controlling for age, gender, multi-morbidity and ISS was undertaken. 157 patients pre-implementation and 172 post-implementation with mean age 83.8years and 53.8% females were included. Geriatric consultation had no impact on in-hospital mortality [OR 0.70 (95% CI 0.31-1.58)] or length of stay [ß 0.68 (95%CI - 1.35-2.72)]. Patients who received a geriatric consultation were more likely to be discharged home (OR 2.01 (95% CI 1.24-3.24). The adherence to consultation process was 99.4%. Mobility, pain and cognitive impairment were the most common geriatric concerns, identified in 76.6, 61.1 and 50.0% of older trauma patients, respectively. Older trauma patients that receive geriatric trauma consultation are more likely to be discharged home. Collaboration between trauma and geriatric specialists is beneficial and may lead to meaningful improvements in outcomes for older trauma patients.

Best case/worst case for the trauma ICU: Development and pilot testing of a communication tool for older adults with traumatic injury.

"Best Case/Worst Case" (BC/WC) is a communication tool to support shared decision making in older adults with surgical illness. We aimed to adapt and test BC/WC for use with critically ill older adult trauma patients. We conducted focus groups with 48 trauma clinicians in Wisconsin, Texas, and Oregon. We used qualitative content analysis to characterize feedback and adapted the tool to fit this setting. Using rapid sequence iterative design, we developed an implementation tool kit. We pilot tested this intervention at two trauma centers using a pre-post study design with older trauma patients in the intensive care unit (ICU). Main outcome measures included study feasibility, intervention acceptability, quality of communication, and clinician moral distress. BC/WC for trauma patients uses a graphic aid to document major events over time, illustrate plausible scenarios, and convey uncertainty. We enrolled 86 of 116 eligible patients and their surrogates (48 pre/38 postintervention). The median patient age was 72 years (51-95 years) and mean Geriatric Trauma Outcome Score was 126.1 (±30.6). We trained 43 trauma attendings and trauma fellows to use the intervention. Ninety-four percent could perform essential tool elements after training. The median end-of-life communication score (scale 0-10) improved from 4.5 to 6.6 (p = 0.006) after intervention as reported by family and from 4.1 to 6.0 (p = 0.03) as reported by nurses. Moral distress did not change. However, there was improvement (less distress) reported by physicians regarding "witnessing providers giving false hope" from 7.34 to 5.03 (p = 0.022). Surgeons reported the tool put multiple clinicians on the same page and was useful for families, but tedious to incorporate into rounds. BC/WC trauma ICU is acceptable to clinicians and may support improved communication in the ICU. Future efficacy testing is threatened by enrollment challenges for severely injured older adults and their family members. Therapeutic, level III.

Trends in Geriatric Ground-Level Falls: Report from the National Trauma Data Bank

Ground-level falls (GLF) are typically reported as a minor mechanism of injury; however, they represent a significant portion of hospitalized geriatric trauma patients as they can result in multisystem injury in this subset of the population. Our study aimed to analyze trends in geriatric trauma falls on the national level. We performed a 5-y (2011-2015) analysis of the American College of Surgeons National Trauma Data Bank (ACS-NTDB) and included all geriatric trauma patients (age ≥ 65 y) who presented with GLF. GLF was identified using ICD-9 E CODES. Our outcome measures were national incidence of GLF, and overall discharge disposition and trauma center level discharge disposition following GLF. We used Cochran Armitage test and multivariate regression analysis. We analyzed a total of 1,017,326 geriatric trauma patients, of which 39% had had a fall as a mechanism of injury. Among those who fell, mean age was 78 ± 7, 63% were females, and 85% were whites. The incidence of falls significantly increased over the study period, and was noted to be proportional to age, with a plateau beyond age 85 y old. The rate of discharge to SNF and/or Rehab significantly increased over the study period; however, discharge to home and mortality rates trended downwards over the study period. Discharge to SNF and/or Rehab was significantly lower among level I trauma centers compared to other level trauma centers. Conversely, discharge to home was higher in level I trauma centers compared to other level trauma centers. Around one in three elderly trauma patients were admitted following a GLF with an overall increased incidence of falls over time. Although overall mortality rates decreased, there was an increase in adverse discharge disposition and loss of functional independence over the study period, mostly among those admitted to non-level I trauma centers.

Early Surgery Does Not Improve Outcomes for Patients with Periprosthetic Femoral Fractures-Results from the Registry for Geriatric Trauma of the German Trauma Society.

Background and Objectives: Appropriate timing of surgery for periprosthetic femoral fractures (PFFs) in geriatric patients remains unclear. Data from a large international geriatric trauma register were analyzed to examine the outcome of patients with PFF with respect to the timing of surgical stabilization. Materials and Methods: The Registry for Geriatric Trauma of the German Trauma Society (Deutsche Gesellschaft für Unfallchirurgie (DGU)) (ATR-DGU) was analyzed. Patients treated surgically for PFF were included in this analysis. As outcome parameters, in-house mortality rate and mortality at the 120-day follow-up as well as mobility, the EQ5D index score and reoperation rate were analyzed in relation to early (<48 h) or delayed (≥48 h) surgical stabilization. Results: A total of 1178 datasets met the inclusion criteria; 665 fractures were treated with osteosynthesis (56.4%), and 513 fractures were treated by implant change (43.5%). In contrast to the osteosynthesis group, the group with implant changes underwent delayed surgical treatment more often. Multivariate logistic regression analysis of mortality rate (p = 0.310), walking ability (p = 0.239) and EQ5D index after seven days (p = 0.812) revealed no significant differences between early (<48 h) and delayed (≥48 h) surgical stabilization. These items remained insignificant at the follow-up as well. However, the odds of requiring a reoperation within 120 days were significantly higher for delayed surgical treatment (OR: 1.86; p = 0.003). Conclusions: Early surgical treatment did not lead to decreased mortality rates in the acute phase or in the midterm. Except for the rate of reoperation, all other outcome parameters remained unaffected. Nevertheless, for most patients, early surgical treatment should be the goal, so as to achieve early mobilization and avoid secondary nonsurgical complications. If early stabilization is not possible, it can be assumed that orthogeriatric co-management will help protect these patients from further harm.

Quality of life, walking ability and change of living situation after trochanteric femur fracture in geriatric patients–Comparison between sliding hip screw and cephalomedullary nails from the registry for geriatric trauma

BackgroundThere is no well-established gold standard for treating trochanteric femur fractures in the elderly. The two common treatment options are cephalomedullary nails (CMN) and sliding hip screws (SHS). In this study, treatment using CMN and SHS were compared for a cohort of patients older than 70 years of age: The main outcomes were quality of life and main residence after surgery. MethodsIn this retrospective study we analyzed 24,919 patients from 100 hospitals, treated between 2016 and 2019 and documented in the Registry for Geriatric Trauma. The impact of CMN vs. SHS on the walking ability, quality of life (QoL), living situation, mortality, and revision rate were analyzed. To analyze the change of the living situation, the main residence 120 days after surgery for patients, who lived in their own home before fracture, was described for both groups. FindingsA total of 10,995 patients could be included of which 10,436 patients were treated with CMN and 369 patients with SHS. 120 days postoperative the QoL differed significantly (p = 0.020) in favor of treatment using CMN. 26% of the SHS group who lived at home prior to surgery had to reside in a nursing home after surgery, whereas the rate was only 18% in the CMN group (p < 0.001). No significant difference in the mortality rate nor a difference in the walking ability 120 days postoperative were found. CMN were implanted more promptly (median: 13.9 vs. 18.4 hours; p < 0,001). No differences were found concerning the revision rate between the two groups, neither during inpatient treatment (p = 0.723) nor during the 120 day follow-up period (p = 0.524). InterpretationThere might be a benefit for geriatric patients with trochanteric femur fractures to be treated with a proximal femur nail in regard to a higher QoL and a reduced institutionalization rate. Mortality or revision rate was not affected by the chosen implant.