Another Trauma Center's Experience

1. Connie DeLa’O MD
Aurelio Rodriguez MD FACS
Jami Zipf RN BSN
Conemaugh Memorial Medical Center,
Johnstown, PA

2. Connie M. DeLa’O MD
Aurelio Rodriguez MD FACS
Jami Zipf BSN RN

5. • UN’s population projections: 600m people 65 or older alive today
• By 2035, more than 1.1 billion people (13% of the population)
will be above 65
• In 2040 20% of the US population ≥ 65 yrs of age
• All these facts:
→ increasing burden on trauma and health care systems

6. ARE WE READY FOR THIS ?

7. • Number 5 cause of
death for age > 65 yrs
• Mortality rate is
15 to 30%
• 4 to 5 times the mortality
rate of younger patients
• Mortality increase > 45
years old for males

8. • 2.3 million non-fatal fall injuries alone among geriatrics
were treated in emergency departments resulting in
more than 662,000 hospitalizations
• Direct medical costs of falls
adjusted for inflation →
$30.0 billion

9. 0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
2010 2011 2012
50%
38%
43%
% Total Trauma Patients > 65 years of age
CMMC

10. • Those > 65 years comprise 33% of all health care
$$$ and 25% of all trauma care costs
• Medicare - DRG based
Grossly underpays hospital costs for trauma
especially in the elderly

11. Delay in transfer
→ death cascade
Worse prognosis
are the MVC
Higher mortality even
with less severe injuries

12. Pre GTI
• 1989 Publication:
Blunt Chest Trauma in the Elderly
Shorr, R.M., Rodriguez, A., Indeck, M.C.,
Crittenden, M.D., Hartunian, S., Cowley, R.A. (1989).
Journal of Trauma, 29(2), 234-237.
• Questioning the masters “old people triage”
• Stoned by the masters
• Eight years of struggle to convince hospital

13. • Created in 2008 at AGH
• Departure 2010

14. • Created 2012 – Conemaugh Memorial Hospital
• Departure 2014

15. The Geriatric Trauma Institute: Reducing the
Increasing Burden of Senior Trauma Care
DeLa’O, C.M., Kashuk, J., Rodriguez, A., Zipf, J., Dumire,
R.D. (2014). American Journal of Surgery 208(6), 988-994.
From Trauma Quality Improvement Project to the
Geriatric Trauma Institute: Developing an
Innovative Care Model for the Coming Storm
DeLa”O, C.M., Rodriguez, A., Boer, J., Simunich, T.,
Dumire, R. (2014). Panamerican Journal of Trauma, Critical
Care & Emergency Surgery 3(3), 105-108.

16. • Assess the impact of a dedicated geriatric trauma
institute when compared to traditional primary care
management
• Hypothesis
A dedicated geriatric trauma service results in
reduce length of stay, reduced mortality, reduced
cost of care

17. • Retrospective analysis
• 7 months PGTI and 8 months AGTI
• 338 PGTI and 460 AGTI
• Lean Six Sigma tools were used to create, develop,
and implement

20. 546
782
0
100
200
300
400
500
600
700
800
900
Pre GTI Post GTI
GTI Patients

21. • 338 PGTI and 460 AGTI
• 78.2% decrease NTA service
• Overall mortality remained unchanged 0.04 % vs 0.03%
• LOS 5.99 vs 4.2 days (p=0.03)
• 21.4% charge reduction

22. 220
225
230
235
240
245
250
255
260
265
270
275
Pre GTI Post GTI
ED LOS in Minutes
Decreased by
½ hour

23. 0
500
1000
1500
2000
2500
3000
3500
Pre GTI Post GTI
ED to OR in Minutes
Pre GTI Post GTI
Decreased by appx 1 day

24. 0
1
2
3
4
5
6
Pre GTI Post GTI
Hospital LOS in Days
Decreased by 1.5 days

25. • Pre-Operative
• Intra-Operative
• Post Operative
Goal: Reduced Morbidity and Mortality

26. K://Geriatric Institute/Management Guidelines
7.14
Pre-Op Management Guideline for GTI Hip Fracture Patient
Abnormal with Ischemia
CXR
EKG
Labs:
ABGs
Lactate
Troponin
ROTEM
CBC w/Diff
Chem 7
BNP
Type & Screen
Consult Ortho
Admit to
Trauma
Consult Cardiology
Echo
Spot Check
STO2
< 70 – Continuous
< 65 – consider
transfusion
Anticoagulation
When to Discontinue/Bridge

27. itutue/Management Guidelines
Intra-Op Management Guideline for GTI Hip Fracture Patient
Spinal versus General Anesthesia
Continuous
STO2
Transfuse if
< 65
Communication Post-Op Disposition
• Trauma
• Anesthesia
• Ortho Surgeon
• ICU Attending if applicable
Update E-Hand off

28. K://Geriatric Institute/Management Guidelines
7.14
Post-Op Management Guideline for GTI Hip Fracture Patient
If ineffective
To ICU:
(Clinical Discretion)
CHF
COPD
CAD
STO2 < 70
To Ortho Floor
Stable
STO2 > 70
Continuous or
Spot
STO2
X 24 hours
Continuous
STO2
X 24 hours
Tylenol Elixir
DVT Prophylaxis
Low Dose
Ketamine Drip
Anticoagulation:
When to restart

29. • Reduction in geriatric trauma care charges of greater
than $775,200.00 in the first 5 months
(room charges only)
• A $2 million estimated in the first year

30. • Decreased Discharge to SNF - 15.3%
• Decreased Discharge to psychiatric facilities - 58%
• Increased Discharge to home - 28%

31. • Tai Chi – Role in Falls Prevention
Elizabeth Katrancha, DNP, RN, CCNS, CSN, CNE
“Effects of video guided Tai Chi interventions”
• Enforcement of Fall Risk Protocols in
nursing homes – is it possible?
• Balance Evaluations
• Home Fall Risk Assessments
A role of Pre-hospital care providers?
• Inflatable Suits - Japan

32. With new Health Care Reimbursements:
Maryland has 14 Hospitals on board
• Total Patient Revenue (TPR)
• Global schemes of reimbursement
Are we Ahead or On Top of the Game?
• Decreased LOS = less patients in the hospital
• Bonus from insurance companies
• Preventing falls =
Less patients in ER’s and on hospital floors

33. A) Increased awareness of the Problem:
- ACS, USA government, citizens
- Increased elder population
- Economical impact
- Healthcare impact
B) “The new Prophets”
- The Geriatric Trauma Center
- Geriatric Trauma qualifications
- Geriatric Hospitals

36. The American Association of Geriatric Trauma
(AAGT)
The International Geriatric Trauma
Conference