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.
Teaching the art of communication between patient and the doctor is a major deficiency in our curriculum. Most of our young graduates don't get adequate exposure to this part of medical training. Lack of emphasis by examining authorities in developing world and additionally paucity of trainers adds to this vicious circle.
Teaching the art of communication between patient and the doctor is a major deficiency in our curriculum. Most of our young graduates don't get adequate exposure to this part of medical training. Lack of emphasis by examining authorities in developing world and additionally paucity of trainers adds to this vicious circle.
Neuro Intensive Care - Prognostication post Cardiac Arrest: Sara GraySMACC Conference
Sara Gray discusses the complex topic of prognostication post cardiac arrest in neuro intensive care. There is a short list of things that keep Sara up at night. She describes a specific cardiac arrest nightmare she has. She is looking after a patient post cardiac arrest. They remain in a coma after cooling. As they meet brain death criteria and they are an organ donor, they are transferred to the operating room. Whilst there, they regain spontaneous respirations.
Although this is terrifying, these situations do happen! And cases like this defy all efforts at accurate prognostication in post cardiac arrest patients. Prognostication matters. It matters for the patient, their family and got judicious resource management.
The trouble is, that varying guidelines around the world do not agree.
In patients who have not been cooled, then you may start prognostication 72 hours post return of spontaneous circulation (ROSC). Before that time the brain may not have had adequate time to heal from the arrest and the clinical indicators may not be accurate.
In the hypothermia group there is differing guidelines. Some guidelines suggest doing it the same way – prognostication after 72 hours. Others suggest 72 hours after achieving normothermia. This equates to 4.5 days.
Why the difference? Different medicolegal environments may play a part. However, as Sara explains, some guidelines may be guided by concern over the emerging data about people who wake up late.
Sara fears looking a family in the eye and telling them the patient won’t wake up and being wrong.
Her advice is to wait 4.5 days. She then recommends starting with a subgroup of patients with a low motor score on GCS. From there you can use indicators with the best accuracy which are bilateral absence of pupillary response, corneal reflex, and somatosensory evoked potentials. Bilateral absence of all three equals a dire prognosis.
For more like this, head to our podcast page. #CodaPodcast
د/ماجد الوراقي
Structured approach for critically ill patient
المحاضرة التي قدمت يوم الاربعاء 9 ابريل 2014 في دار الحكمة بالقاهرة
من فعاليات مشروع اعداد طبيب حكيم ناجح بالتعاون مع معتمد باتحاد الاطباء العرب
و ضمن موديول الطوارئ و التخدير و العناية المركزة
Person Centered Care through Integrating a Palliative Approach: Lessons from ...BCCPA
Aging adults are entering residential care facilities with more advanced disease than in the past and their length of stay is shorter. Most health care providers in these facilities do not receive targeted education and training in palliative care, nor are they confident to have crucial conversations about goals of care and end of life challenges with residents and their families. Due to limited capacity to manage predictable symptoms related to end of life and insufficient planning, many residents are transferred to hospital in crisis and die in the Emergency Department or acute care wards.
This presentation will showcase some of the initiatives by identifying common themes, unique features of each and strategies for success. Opportunity will be given for delegates to ask questions and brainstorm how lessons learned from these initiatives could inform the care provided at their own facility.
Presented by:
- Jane Webley, RN LLB Regional lead, End of Life, Vancouver Coastal Health (EPAIRS and the Daisy project)
- Dr Christine Jones, Island Health (SSC project: Improving end of life outcomes in residential care facilities: A palliative approach to care)
- Kathleen Yue, RN, BSN, MN, CHPCN (c) Education Coordinator, BC Center for Palliative Care
Neuro Intensive Care - Prognostication post Cardiac Arrest: Sara GraySMACC Conference
Sara Gray discusses the complex topic of prognostication post cardiac arrest in neuro intensive care. There is a short list of things that keep Sara up at night. She describes a specific cardiac arrest nightmare she has. She is looking after a patient post cardiac arrest. They remain in a coma after cooling. As they meet brain death criteria and they are an organ donor, they are transferred to the operating room. Whilst there, they regain spontaneous respirations.
Although this is terrifying, these situations do happen! And cases like this defy all efforts at accurate prognostication in post cardiac arrest patients. Prognostication matters. It matters for the patient, their family and got judicious resource management.
The trouble is, that varying guidelines around the world do not agree.
In patients who have not been cooled, then you may start prognostication 72 hours post return of spontaneous circulation (ROSC). Before that time the brain may not have had adequate time to heal from the arrest and the clinical indicators may not be accurate.
In the hypothermia group there is differing guidelines. Some guidelines suggest doing it the same way – prognostication after 72 hours. Others suggest 72 hours after achieving normothermia. This equates to 4.5 days.
Why the difference? Different medicolegal environments may play a part. However, as Sara explains, some guidelines may be guided by concern over the emerging data about people who wake up late.
Sara fears looking a family in the eye and telling them the patient won’t wake up and being wrong.
Her advice is to wait 4.5 days. She then recommends starting with a subgroup of patients with a low motor score on GCS. From there you can use indicators with the best accuracy which are bilateral absence of pupillary response, corneal reflex, and somatosensory evoked potentials. Bilateral absence of all three equals a dire prognosis.
For more like this, head to our podcast page. #CodaPodcast
د/ماجد الوراقي
Structured approach for critically ill patient
المحاضرة التي قدمت يوم الاربعاء 9 ابريل 2014 في دار الحكمة بالقاهرة
من فعاليات مشروع اعداد طبيب حكيم ناجح بالتعاون مع معتمد باتحاد الاطباء العرب
و ضمن موديول الطوارئ و التخدير و العناية المركزة
Person Centered Care through Integrating a Palliative Approach: Lessons from ...BCCPA
Aging adults are entering residential care facilities with more advanced disease than in the past and their length of stay is shorter. Most health care providers in these facilities do not receive targeted education and training in palliative care, nor are they confident to have crucial conversations about goals of care and end of life challenges with residents and their families. Due to limited capacity to manage predictable symptoms related to end of life and insufficient planning, many residents are transferred to hospital in crisis and die in the Emergency Department or acute care wards.
This presentation will showcase some of the initiatives by identifying common themes, unique features of each and strategies for success. Opportunity will be given for delegates to ask questions and brainstorm how lessons learned from these initiatives could inform the care provided at their own facility.
Presented by:
- Jane Webley, RN LLB Regional lead, End of Life, Vancouver Coastal Health (EPAIRS and the Daisy project)
- Dr Christine Jones, Island Health (SSC project: Improving end of life outcomes in residential care facilities: A palliative approach to care)
- Kathleen Yue, RN, BSN, MN, CHPCN (c) Education Coordinator, BC Center for Palliative Care
Steve Iliffe: Encouraging innovative approaches and policies to improve prima...The King's Fund
Steve Iliffe, Professor of Primary Care for Older People at University College London, spoke at our conference Making health and care services fit for an ageing population. Steve championed an innovative approach to primary care and explains what we need to do to achieve this.
If there are more family doctors than ever before, why can’t I find one? Usin...DataNB
Across Canada, many people are struggling to find a regular place for primary care and to access care where and when they need it. Policymakers are confronting the fact that after decades of reforms, primary care service volume is falling and inequities are widening. There are more primary care physicians than ever before, but at the same time they are reporting record levels of overwork and exhaustion.
This seminar will present data describing how primary care patient access and physician practice patterns are changing, including national survey data and linked administrative data from British Columbia, Manitoba, Ontario, and Nova Scotia.
We’ll explore factors that may be driving changes and what these might mean for future Healthcare capacity. We’ll conclude by considering different approaches that can help ensure equitable access to quality primary care in Canada.
About the speaker:
Dr. Ruth Lavergne is an Associate Professor in the Department of Family Medicine at Dalhousie University and a Tier II Canada Research Chair in Primary Care. Dr. Lavergne’s program of research aims to address disparities in access and build evidence to ensure primary care organization, delivery, and the workforce meet the needs of Canadians now and in the future. Her expertise is in quantitative analysis of population-based administrative health data. She leads interdisciplinary mixed methods primary care studies in collaboration with experts in qualitative methods, patients, clinicians, and policymakers.
Risk profiling, multiple long term conditions & complex patients, integrated ...Dr Bruce Pollington
Dr Bruce Pollington web-ex presentation to LTC QIPP programme
Utilising risk profiling, and risk stratification to identify patients with multiple long term conditions requiring complex care through integrated care teams.
Evidence Translation and ChangeWeek 7What are the common.docxturveycharlyn
Evidence Translation and Change
Week 7
What are the common barriers to evidence translation in addressing this problem?
There are many barriers when it comes to translating evidence into practice. In regards to obesity, the most common barrier to translate evidence-based changes locally, nationally, and globally are the stakeholders. According to Chamberlain College of Nursing, (2020, translating research into practice relies on the clinician knowing who the stakeholders are and getting them involved in the planning stage and in every aspect of the practice change. Some stakeholders may not be conducive to change. In order to adopt and launch a practice change, the change leader has to be able to sell the project to key stakeholders. For a project leader to get others to go along with a practice change, the leader has to be knowledgeable, motivated, and believe in the research he or she is presenting to the stakeholders.
Additional barriers in translating research evidence into this practice problem would cost, available resources, and timing. For instance, it is less likely for individuals living in a low socioeconomic community to prioritize a 30 minutes time slot five days a week for exercising activities. Barriers like work schedules, family commitment, and financial obligations may impede these practices. The lack of motivation may also be a factor. Most individuals may not have a membership to the local gym, and rain and cold weather may prevent walking in the local park. The lack of appropriate lighting in the parks may fend off participation in outdoor activities in the fall and winter months. According to Tucker, the individuals, the location, and the practice itself and have a huge role in influencing evidence-based practice (2017). For an evidence-based practice to be adapted effectively it must be realistic in all public health settings.
What strategies might you adopt to be aware of new evidence?
I would create an interprofessional group to include clinical and research practitioners to discuss new and upcoming research evidence appropriate to the practice problem. Focus groups both locally and nationally as well as globally are great outlets to discover what is working in different areas of healthcare. Small focus group outlets in which to gather people with the same interest to discuss and present new research (Chamberlain College of Nursing 2020). I would sign up for alerts on new research, evidence-based practice interventions, and quality improvement publications on obesity throughout the country and globally. Tucker indicated that research experts are great resources to look into and introduce the latest pieces of evidence (2017). I also believe an expert Ph.D. colleague would be a great mentor to help guide me in this practice problem intervention. Dang and Dearholt indicated that a team approach between DNP and Ph.D. scholars influenced the best clinical outcome.
How will you det.
Jill Blumenthal, MD
Assistant Professor of Medicine
Division of Infectious Diseases and Global Public Health
Department of Medicine
University of California, San Diego
final project (nursing major) najah universitymahdyvika
The knowledge of nursing toward the role of them in End of life care in Intensive care units and oncology units in Nablus hospitals- Cross sectional study.
Geriatric Oncology
1. Relationship between aging and cancer
2. Constructs of frailty and multimorbidity
3. Evidence for geriatric assessment in older adults living with cancer
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Hemodialysis: Chapter 3, Dialysis Water Unit - Dr.Gawad
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.
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
21.
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.
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 )
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.
43.
44.
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.
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!