Geriatric Trauma Collaborative Care
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This document outlines the elements and benefits of a proactive geriatric trauma consultation service. It discusses how such a service was established at St. Michael's Hospital in Toronto through collaboration between geriatrics and trauma specialists. The service utilizes comprehensive geriatric assessments and focuses on common geriatric issues for injured older patients. Evaluation of the service found benefits including reduced delirium, nursing home discharges, other consultations, and length of stay. The 10 essential elements of collaborative care models are presented, which were followed to achieve measured improved outcomes. The service has expanded to other hospitals and continues to demonstrate sustained volumes and adherence to guidelines.
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Geriatric Trauma Collaborative Care
- 1. Proactive Geriatric Trauma Consultation Service Better quality. Better outcomes. February 22, 2019 Hong Kong Hospital Authority Dr. Camilla Wong, MD FRCPC MHSc Geriatrician, St. Michael’s Hospital Associate Professor, University of Toronto
- 2. To recognize the elements of a proactive geriatric trauma consultation service. To discuss the evidence for geriatric trauma collaborative care models. To apply the lessons learned to move geriatric trauma care forward in Hong Kong.
- 3. Geriatric trauma IS different.Geriatric trauma IS different. It is complicated. • Atypical presentation • Frailty • Processes suboptimal • System variability
- 4. A comprehensive geriatric assessment (CGA) is a multidimensional, interdisciplinary diagnostic process to determine the medical, psychological, and functional capabilities of a frail elderly person in order to develop a coordinated and integrated plan for treatment and long-term follow-up.
- 6. J Am Geriatr Soc. 2017;65(9):2115. The 5 M’s
- 7. WHAT MATTERS TO YOU? Moving from “What is the matter?”
- 9. Cochrane Database Syst Rev. 2017; CD006211.
- 10. CGS J CME 2017; 7(1).
- 11. TRAUMA protocols extrication subdural hematoma vasopressors third degree burns REBOA intubation injury severity score FAST falls Glascow coma scale (GCS) transfusion retroperitoneal bleeding resuscitation anxiety gun shot wound oxygenation seizure npo facial fractures cardiac arrest Aspen collar agitationsplenic laceration traumatic brain injury log roll precautions reperfusion sedation subarachnoid hemorrhage crystalloids fentanyl plasma liver laceration ischemia transexamic acid Octaplex shock
- 12. multi morbidity evidence dementia depression hypertension diabetes mellitus stroke parkinsons osteoporosis pain falls benign prostatic hypertrophy incontinence prostate cancer polypharmacy anxiety osteoarthritis colon cancer seizurecirrhosis cataracts macular degeneration presbycusis glaucoma insomniaconstipation functional decline chronic kidney disease hypothyroidism hip fracture myelodysplastic syndrome
- 13. GERIATRIC TRAUMA
- 14. . Slide credit: Amanda McFarlan
- 15. Medication review Sensory impairment Pain Nutrition Mood Mobilization Other medical complications Continence Restraints Discharge planning Comorbidities Fall risk Beers criteria Decubitus risk Cognition Delirium Slide credit: Amanda McFarlan
- 16. The Toronto Star, August 2 2011 The Toronto Star, August 2 2011
- 18. Canada Health Act • Public administration • Comprehensiveness • Universality • Accessibility • Portability
- 20. • downtown Toronto’s designated Level 1 adult trauma centre • academic hospital fully affiliated with the University of Toronto • 455 inpatient beds • 1082 trauma team activations (214 were 65+ years) • member of ACS TQIP
- 22. 1 Partnership 2 Shared Vision 3 Engagement 4 Policy 5 Symmetrical Representation 6 Communication 7 Setting 8 Trust 9 Consistency 10 Evaluation Strategy 10 ESSENTIALELEMENTSOF c ross -sp ec ialty collab orative care mod els
- 23. You are invited TO COFFEE WITH TRAUMA. HALLWAY CONVERSATIONS TO FOLLOW. Partnership.
- 24. Shared Vision. To be a L E A D E R in the care of older adults with traumatic injury.
- 25. GRASSROOTS APPROACH The passion has to come from the FRONTLINE from both sides of the field. Engagement.
- 26. Policy.
- 27. Trauma: surgeon, two nurse practitioners, quality assurance specialist Geriatrics: geriatrician, clinical nurse specialist, research trainees Symmetrical Representation.
- 28. • Electronic consultation notes and orders • Verbal communication • Weekly interdisciplinary rounds Communication.
- 29. Setting.
- 30. TRUST There must be mutual respect for one another’s domain of expertise. Trust.
- 31. Consistency. CONSISTENCY for CONTINUITY s a m e c l i n i c a l n u rs e s p e c i a l i s t ( g e r i a t r i c s ) s a m e n u rs e p ra c t i t i o n e r ( t ra u m a )
- 32. SYSTEMATIC DATA COLLECTION evaluation and quality improvement Evaluation Strategy.
- 33. 1 Partnership 2 Shared Vision 3 Engagement 4 Policy 5 Symmetrical Representation 6 Communication 7 Setting 8 Trust 9 Consistency 10 Evaluation Strategy 10 ESSENTIALELEMENTSOF c ross -sp ec ialty collab orative care mod els
- 34. RESEARCH (EVALUATION) DRIVES SUSTAINABILITY When you have positive, measurable, published, impact, everyone will want to keep the collaboration model going.
- 35. Ann Surg 2012;256: 1098–1101.
- 36. Sensory impairment 40.7% Pain 30.1% GERIATRIC ISSUES ADDRESSED Ann Surg 2012;256: 1098–1101.
- 37. Reduction in delirium 51% vs 41%, p<.05 Ann Surg 2012;256: 1098–1101.
- 38. Reduction in nursing home discharge Ann Surg 2012;256: 1098–1101.
- 39. Reduction in other consultations Internal Medicine p=.04; Psychiatry p=.02 Ann Surg 2012;256: 1098–1101.
- 40. Reduction in length of stay 19.4 vs 15.4 days, p=.13 Ann Surg 2012;256: 1098–1101.
- 41. AGREEMENT Adherence to recommendations was 93%. Ann Surg 2012;256: 1098–1101.
- 42. Camilla L. Wong Raghda Al Atia Amanda McFarlan Holly Y. Lee Christina Valiaveettil Barbara Haas Can J Surg. 2017;60(1):14-18. Demonstrated sustained service volumes, funding, adherence and outcomes.
- 45. J Am Coll Surg. 2015;220(5):820-30. Improved geriatric quality of care indicators (p<.01).
- 46. J Surg Res. 2017;216:56-64. Improved adherence to TQIP guidelines.
- 47. JAMA Surg. 2014 Jan;149(1):83-9. Better recovery of function in the year following traumatic injury (p<.01).
- 48. J Am Coll Surg 2016; 222:1029-1035. Improved advanced care planning and reduced intensive care readmission rates.
- 49. Cureus. 2018;10(11):e3649. Reduction in high- risk medication usage at discharge.
- 50. Better quality. Better outcomes.
- 51. Royal Columbian Hospital New Westminster, BC Sunnybrook Hospital Toronto, ON St. Michael’s Hospital Toronto, ON Moncton Hospital Moncton, NB
- 52. 1 Partnership 2 Shared Vision 3 Engagement 4 Policy 5 Symmetrical Representation 6 Communication 7 Setting 8 Trust 9 Consistency 10 Evaluation Strategy 10 ESSENTIALELEMENTSOF c ross -sp ec ialty collab orative care mod els
- 53. GERIATRIC TRAUMA … and they lived happily ever after.
- 54. Thank you. Dr. Camilla Wong, MD FRCPC MHSc Geriatrician, St. Michael’s Hospital Associate Professor, University of Toronto
Editor's Notes
- The elderly are not older adults. It’s like comparing apples to oranges. Things are not crystal clear on how trauma systems should best care for elderly individuals. Atypical presentation Frailty Protocols suboptimal System variability How to identify atypical presentations and anticipate atypical responses to standard treatments. How to operationalize frailty in trauma decision making How to develop trauma systems that do not under or over triage How to disseminate the structures and processes of care of the higher performing centre that may account for the inter-hospital differences in risk-adjusted mortality.
- So integrate in geriatric medicine. One of the cornerstones of modern geriatric care is the Comprehensive Geriatric Assessment (CGA). A CGA is a multidimensional interdisciplinary diagnostic process focused on determining a frail older person’s medical, psychological and functional capabilities in order to develop a coordinated and integrated plan for treatment and long-term follow-up.
- Mind: delirium, dementia, depression Mobility: gait and balance, falls Medications: polypharmacy, deprescribing, optimal prescribing, adverse effects Multicomplexity: multimorbidity, social frailty Matters Most: values, goals and preferences
- Seeing the forest for the trees. Moving from “What is the matter?” to “What Matters to You?”
- Ultimately, the goal is to achieve therapeutic harmonization, that is, aligning prognosis with goals with the care that we deliver.
- A Cochrane systematic review of 29 trials of 13,766 participants from 9 countries comparing CGA with usual medical care for hospitalized older adults demonstrated patients in receipt of CGA were more likely to be alive and in their own homes at discharge, equating to an NNT of 33.
- In the traditional model of CGA, a consultation is requested by a referring service. Thus, the intervention is usually reactive (e.g. requested after the onset of delirium, a fall or loss of function) and passive (suggestions are made but not directly implemented). Instead of geriatric involvement on day 10 of admission when the older adult has developed delirium and hospital-associated disability, the proactive CGA emphasizes systematic case finding, early involvement, a focus on the prevention of geriatric syndromes, and direct implementation of recommendations.
- Trauma care is complex.
- The older patient is complex even before the traumatic injury.
- Complexity of trauma. Complexity of frailty. How do we manage the complexity of trauma without losing sight of the complexity of frailty? This may seem an unlikely collaboration..
- But as I showed you from the Canadian National Trauma Registry, over 2/3 of trauma admissions in older adults is due to falls. Take this case as an example. An older adult who has a fall, resulting in traumatic injury and the hospital events that then follow. Let’s put this together another way.
- Well in fact, when you look at this through a geriatric lens, there is intersectionality in almost the entire course of events. A collaborative intersection of complex trauma care and complex geriatrics care. So this unlikely collaboration, is in fact a very much needed one.
- The principles and processes of CGA are increasingly integrated into the care of subspecialty conditions such as hip fracture, cancer, and vascular surgery. These cross-specialty collaborative models have shows reduction in in-hospital mortality, lower chemotherapy toxicity and decreased lengths of study.
- And that was the beginning of the proactive GTCS. We talked about the four principles of proactive CGA, but what I’ll go through now are the program and operational aspects of this model of care.
- Secondary Services: For the most part, home and continuing care services are not covered by the Canada Health Act; however, all the provinces and territories provide and pay for certain home and continuing care services. Supplementary Services The provinces and territories provide coverage to certain people (e.g., seniors, children and low-income residents) for health services that are not generally covered under the publicly funded health care system. These supplementary health benefits often include prescription drugs outside hospitals, dental care, vision care, medical equipment and appliances (prostheses, wheelchairs, etc.), and the services of other health professionals such as physiotherapists. The level of coverage varies across the country.
- Ontario is a large province with heavily populated areas in the south, and sparse populations in the remote areas of the province. Ontario's trauma system has 9 specialized adult trauma care centres. 15% of Ontario's population lives more than 1 hours from a major trauma centre. There is evidence that dedicated trauma services and systems of trauma care save lives. Major advances in trauma treatment and care have come from the battlefields of the 20th century, and great progress has been made in trauma systems, transport, resuscitation and hospital trauma teams. All are geared towards rapid access of severely injured patients to a specialized team of health professionals working at a centre with access to sophisticated equipment. In a trauma centre, protocols are in place to ensure that the care of the patient meets evidence-based guidelines. In Ontario there is a trauma registry, which collects data on all trauma patients in the province. These centres are expected to provide definitive care to the majority of major trauma (defined as ISS>12) caseload in the system. So lets start by defining trauma…Trauma means physical injury sustained from an identifiable mechanism such as a fall, a car crash, a pedestrian or cyclist or scooter rider being struck, a stabbing or shooting or injuries sustained during recreational activities such as ATV crashes or golf cart incidents. In Ontario there are 9 designated adult trauma centres that are funded to provide trauma care to severely injured people and include centres such as Sunnybrook, St. Michael’s, Hamilton Heath Sciences, London Health Sciences Thunder Bay to the north etc. These centres focus their attention on the sickest trauma patients. Patients that fall and sustain minor bruises or bumps or an isolated wrist # do not fit in the definition of a trauma patient but if the same patient fell and sustained a SDH and some rib fractures they would meet the criteria for trauma. The level of injury severity is the difference. Trauma centres are charged with rapidly mobilizing the resources and expertise required to respond efficiently and effectively when a trauma patient arrives in the ED. The resources and expertise include house 24/7 trauma team activation in the ED with a full team of RT’s, RN’s, chaplaincy, imaging staff, medical staff from all the surgical specialties, 24/7 OR and imaging availability, angio capability etc. They come together for 20-35 minutes rapidly assess these patients and then disburse once the trajectory for the patient is decided (the ED disposition could be OR, the angio suite, ICU etc, at which time the in-house trauma service takes over the patients care. Trauma centres are required to have additional staff training and expertise and standardized protocols and policies in place that are focused on ensuring the best possible care is provided to these patients. What you see on the map before you all the adult trauma centres in Ontario and the referral patterns of severely injured trauma patients that they receive..
- SMH Trauma Team Activation (TTA) guidelines identify those patients who have a significant likelihood of requiring urgent operative intervention or admission to a critical care setting and/or a high likelihood of significant morbidity or death. We have a 100% acceptance rate for appropriate provincial trauma referrals, emphasizing our commitment to trauma care.
- Herein I describe our geriatric trauma collaborative model and use it to reflect on 10 essential elements of successful cross-specialty collaborative care models.
- Where do all great Canadian ideas begin? In the line-up for a double-double during Roll Up to Win season. At the very outset, there was a partnership. From brainstorming about the collaborative model through to implementation, the input on design, clinical scope, and research evaluation occurred ACROSS teams. In collaboration, the investment from both teams is deeper cooperation – the act of working together. In cross-specialty collaboration, the partnership is bi-directional.
- This collaborative care model was started in 2007 after informal discussions between frontline staff from the trauma team (surgeon, nursing) and geriatrics team (geriatrician, nursing) uncovered a shared common goal – to be a leader in improving the care of older adults after traumatic injury.
- Meaningful collaboration is not an administrative exercise and thus should be driven by engagement from front line members. Input from allied health from both the trauma program and the geriatrics program was sought. This feedback informed the development of a hospital policy to facilitate the operationalization of this model of care as well as a process to align roles of the team members.
- Policy defines target population, roles and responsibilities of team members, screening tools, data collection elements. CGA within 72 hours of admission by a clinical nurse specialist and geriatrician, verbal and written communication of recommendations, weekly interdisciplinary meetings with the trauma team, and measurement of quality indicators. In our model, a CGA is completed, within 72 hours of admission to the trauma service for everyone 65 years old or better. The geriatrics team consists of a CNS and geriatrician. There may be trainees as well. The recommendations are communicated in a written form on the EMR with a copy sent to the primary care provider, but also communicated verbally to the trauma team immediately. Some recommendations are implemented directly, while others are “suggestions” requiring approval by the trauma team. In addition, we attend weekly interdisciplinary trauma rounds to review cases. The last component is that there is ongoing measurement of quality indicators as part of the trauma registry : 72 business hours, data collection , triage criteria, etc While there is only one MRP, true partnership includes clear delineation that each team can implement management plans that pertain to each respective care of experyise.
- Shared investment, that is, similar team composition, promotes balance in the roles between teams. We work collaboratively with the interdisciplinary trauma team, which importantly has two nurse practitioners who provide continuity of care through the rotating trauma surgeons and trainees. For every patient, we connect with the: family physician outpatient pharmacy family and friends community services
- Multimodal timely communication between geriatric and trauma teams: Multimodal Timely (verbal and written) Informal and formal (cross-specialty multidisciplinary rounds) The CGA is informed by the patient and collateral information from the family doctor, outpatient pharmacy, caregivers and/or community services. The GTCS consultation note is transcribed onto the hospital electronic medical record and is also distributed to the primary care physician and any other specialist physicians involved. Verbal communication between the GTCS and trauma team takes place immediately after the CGA. The frequency and length of follow-up by the GTCS is individualized per case. The GTCS may participate once weekly in the multidisciplinary trauma team rounds to discuss cases or facilitate knowledge exchange.
- All trauma patients are co-located on a trauma ward or trauma-neurosurgical intensive care unit.
- But to succeed, we couldn’t doubt one another’s expertise and needed to trust each other. Trust for the other team’s competence, reliability, and professionalism. Adherence rates was 93%
- The secret sauce in geriatrics is low tech, high touch. The consistency of a seasoned CNS in geriatrics and the consistency of the NPs from trauma, provide effective paired leadership. As individuals on a team may change over time (and this is particularly true with an academic centre with rotating trainees), there should be apoint-person from each team to provide stability and continuity for the collaborative care model
- Data is routinely collected as part of the trauma registry database. The registry is routinely reviewed by CIHI and the National Trauma Data Bank in the United States. This information is also used to participate in the ACS TQIPs. Incorporated geriatric data elements into the trauma registry to reflect process and outcome metrics. Alongside clinical teams, there are research personnel from both trauma and geriatrics working in partnership on an evaluation strategy.
- As quality indicator reporting and research evaluation of clinical outcomes have consistently shown superior results with this model, this drives everyone’s desire to keep a good thing going.
- ARR in delirium was 10%. ARR in discharge to LTC was 5%.
- As can be expected when a CGA is performed, many geriatric issues are identified and addressed.
- The rate of adherence to recommendations made by the GTCS team was 93.2% suggesting that the input was valued by our trauma colleagues.
- 6.9 patients per month Funding 88.2% adherence 1.4% discharge to long term care
- Within 72 hours of admission the elderly patient should receive a review and assessment by the consultant geriatric team for: - Comprehensive Geriatric Assessment. - Any need for mental health or psychology input (eg self harm, victim of violent crime, domestic abuse). - Confirmed collateral history of premorbid level of function (ie further details added to admission information from primary care, Coordinate My Care, family, etc). - Consideration of poor prognosis and pre injury baseline with ‘watchful waiting’ of the patient’s progress. The lack of response to injury or treatment may take longer in elderly patients. This should include exclusion of reversible medical causes and decision about the optimum location for care. - Advanced care/palliative planning.
- The ACS TQIPS geriatric trauma guidelines now have a chapter on the role of specialized geriatric services. “The assistance of a geriatric specialist in a multi-disciplinary co-management or consultation model to better address the complex care needs of older adults.”
- Since our publication in 2012, other centres have published results of their programs. Thhe UCLA group demonstrated in a before-and-after study design that geriatric quality of care indicators were better in the GTCS group (74%) compared with the control group (68%; p < 0.01), a difference that was significant after multivariable adjustment (p = 0.01). Used 33 previously validated care-process quality indicators (QIs) from the Assessing the Care of Vulnerable Elders (ACOVE) study
- Ohio group.
- The same UCLA group then reported on long term functional outcomes, using the Short Functional Status survey. SFS measures the ability to perform 5 ADLs independently, without help from another person: shopping, bathing, walking across the room, lighthousework, and managing finances. The intervention group had better recovery at one year.
- A study published last year from Harvard using prospectively collected data, with also a pre- and post-intervention design. There were 215 and 191 patients included in the preintervention and postintervention cohorts, respectively. Patients with DNR and do not intubate status increased from 10.23% to 38.22% (p < 0.01). Referral for formal cognitive evaluation increased from 2.33% to 14.21% (p < 0.01) and delirium documentation increased from 31.16% to 38.22% (p = 0.14).
- New Jersey group. GC group was 74% less likely to be discharged on high-risk medications than the non-GC group. In this study, high-risk medications were defined using the Beers criteria [17]. The Beers criteria (2) provides guidelines for safe and effective medication use while minimizing adverse drug events for the geriatric population. The criteria itself is a comprehensive medication list published elsewhere [17]. The variable “high-risk geriatric meds” included the following five categories of medications: anti-depressants, antipsychotics, benzodiazepines, sedatives, and opioids. Polypharmacy was defined as the use of more than five medications of any type at admission or discharge.
- Building on the pilot program at St. Michael’s, we later got a grant to implement and evaluate this model at Sunnybrook Hospital. The folks at the Royal Columbian Hospital (BC) and Horizon Nealth (NB) also subsequently setup a similar service. Academic cross pollination has been central to the original shared vision – to be a leader in improving the care of older adults after traumatic injury. The trauma world has embraced geriatrics expertise and incorporated this model into the American College of Surgeons geriatric trauma guidelines. Similarly, our trauma colleagues have given rounds at geriatric emergency management forums.
- This collaborative was started in 2007 … … and they lived happily ever after!