INTRODUCTION

Traumatic injury in adults older than 65 is associated with high morbidity and mortality. There are conflicting data regarding the benefit of incorporating a geriatrician into routine care of trauma patients with some evidence showing that mandatory geriatric consultation does not change patients' mortality or hospital length of stay (LOS).1 Other research has demonstrated decreased rates of delirium,2 increased adherence to quality guidelines,3 improved functional recovery,4 and a significant impact on mortality rate.5

We initiated a quality improvement (QI) protocol at Maine Medical Center's (MMC) Level 1 trauma center in which all patients aged 75 years and older admitted to the trauma service received a geriatric consultation with a primary focus on falls, cognition, and polypharmacy. We evaluated the protocol's impact on clinical outcomes in older fall-related trauma patients when compared to a pre-implementation sample retrospectively.

METHODS

Retrospective chart review of patients' electronic medical records and our institution's Trauma Registry was performed. Patients eligible for inclusion were aged 75 years or older, and admitted to the trauma service at MMC in Portland, Maine, from March 2017 to September 2017 (pre-protocol) and from March 2018 to September 2018 (post-protocol) with fall as their primary mechanism of injury. Delirium occurrence was calculated based on the addition of a new diagnosis of delirium or encephalopathy to a patient's problem list during their hospital course. The CAM was tracked separately. All medications were tracked using EpicCare software (EPIC, Verona, WI). Differences between the two groups were evaluated using chi-square, Student t tests, odds ratio (OR), or 95% confidence intervals (CIs), as appropriate with statistical significance of p ≤ 0.05.

RESULTS

Our analysis included 441 patients; 217 in the pre-protocol group and 224 in the post-protocol group. The mean age in both groups was 84 and predominantly female (57% in the pre-protocol group vs. 68% in the post-protocol group). Both cohorts had similar injury severities with a mean Glasgow coma scale (GCS) of 14, injury severity score (ISS) of 10, and similar body region injuries.

Geriatric consultation increased from 39% to 85% post-protocol implementation. There was a significant increase in the number of patients enrolled in the HELP delirium prevention program (OR = 2.2; 95% CI 1.5–3.2; p = 0.001; Figure 1). There was no statistically significant difference in delirium occurrence (16.6% vs. 11.2%, p = 0.09) or percentage of patients who were CAM positive.

Comparison of HELP enrollment, delirium diagnosis, anticholinergic and Beer's medications prescribed at discharge, and code status orders on discharge of geriatric patients' pre- and post-implementation of an automatic geriatric consultation protocol. Percent of geriatric patients ± 95% confidence interval

Patients in the post-protocol group had significantly fewer anticholinergic medications (OR = 0.65; 95% CI 0.45–0.95; p = 0.03) and Beers list medications (OR = 0.63; 95% CI 0.41–0.98; p = 0.04) prescribed at discharge. Overall antipsychotic use was unaffected (35.6% vs. 33.5%; OR = 1.0; 95% CI 0.71–1.56; p = 0.81). Code status was more likely to be addressed in the post-protocol group as fewer patients remained Full Code Default at the time of discharge (OR = 26.4; 95% CI 5.7–14.96; p < 0.001; Figure 1).

There were no other statistically significant differences noted, including in-hospital LOS, hospital mortality, hospital charges, or 30-day readmission rates. Outcomes were not affected when controlling for age, gender, anticoagulant therapy use, alcohol use, dementia, history of myocardial infarction, and hypertension.

DISCUSSION

Older adults represent an increasing percentage of trauma patients, which impels us to develop models of care that incorporate geriatrics expertise into trauma care.4 Our study adds to the literature demonstrating benefit from a protocoled comprehensive geriatric consultation for older adults admitted after traumatic injury.2-8 Each consultation provides an in-depth, individualized, patient-centered assessment that promotes adherence to best practices recommended in the Trauma Quality Improvement Program (TQIP) guidelines, such as appropriate prescribing and discussions of goals of care.9 Despite these efforts, there was no significant difference in delirium occurrence or CAM scores after the implementation of routine geriatric consultation.

Some of this may be secondary to confounding as delirium may have been identified and documented more frequently with the addition of a geriatric consultation; this was not formally assessed.

At our institution, this work has dovetailed nicely into several other QI initiatives, including a system-wide project dedicated to CAM adherence and accuracy, efforts at reducing polypharmacy and associated fall risk during admission, and expanding the relationship between geriatrics and other subspecialties. The collaboration between geriatrics and trauma services thereby facilitated the development of quality measures and care for older adults across the institution.

CONFLICT OF INTEREST

The authors have no conflicts of interests.

AUTHOR CONTRIBUTIONS

All authors meet the criteria for authorship stated in the Uniform Requirements for Manuscripts Submitted to Biomedical Journals. Dr. Amanda R. A. Roberts, DO, served as primary investigator and worked on study design, acquisition of data, interpretation of data, drafting the article, revisions, and final approval of the submission. Dr. Carolyne R. Falank, PhD, worked on study design, acquisition of data, interpretation of data, drafting the article, revisions, and final approval of the submission. Dr. Julianne B. Ontengco, DNP, contributed to study conception and design, acquisition of data, interpretation of data, revisions, and final approval of the submission. Dr. Emily L. Carter, MD, worked on conception and design, interpretation of data, drafting the article, revisions, and final approval of the submission. Dr. Sarah A. M. Hallen, MD, worked on conception and design, revisions, and final approval of the submission.

SPONSOR'S ROLE

This study was not sponsored.

REFERENCES

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