Frailty Identification and Care Pathway: An Interdisciplinary Approach to Care for Older Trauma Patients

Bryant, Elizabeth A.; Tulebaev, Samir; Castillo-Ángeles, Manuel; Moberg, Esther; Senglaub, Steven S.; O'Mara, Lynne; McDonald, Meghan; Salim, Ali; Cooper, Zara

doi:10.1016/j.jamcollsurg.2019.02.052

Cited by 78 publications

(100 citation statements)

References 31 publications

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“…First, including frailty screens as part of risk analysis tools in the perioperative setting may support decision making and also improve outcomes. For example, Bryant et al showed that implementation of a standardized care pathway triggered by a frailty screen reduced delirium rates in trauma patients by 50% . Although small sample size and single‐site design limit the generalizability of these findings, this intervention demonstrates proof of concept that screening interventions benefit frail nonelective surgical patients.…”

Section: Discussionmentioning

confidence: 99%

“…In this context, the index EGS hospitalization presents an opportunity to engage in advance care planning to inform future medical care, set expectations about post‐discharge care, and anticipate the high likelihood of future hospital encounters. In addition to targeted clinical pathways, interventions to smooth care transitions and improve care continuity in older EGS patients may reduce unnecessary and avoidable rehospitalizations among older patients with frailty …”

Section: Discussionmentioning

confidence: 99%

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The Impact of Frailty on Long‐Term Patient‐Oriented Outcomes after Emergency General Surgery: A Retrospective Cohort Study

Lee

Streid

Sturgeon

et al. 2020

J American Geriatrics Society

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OBJECTIVES: Few studies examine the impact of frailty on long-term patient-oriented outcomes after emergency general surgery (EGS). We measured the prevalence of frailty among older EGS patients and examined the impact of frailty on 1-year outcomes. DESIGN: Retrospective cohort study using 2008 to 2014 Medicare claims. SETTING: Acute care hospitals. PARTICIPANTS: Patients 65 years or older who received one of the five EGS procedures with the highest mortality burden (partial colectomy, small bowel resection, peptic ulcer disease repair, adhesiolysis, or laparotomy). MEASUREMENTS: A validated claims-based frailty index (CFI) identified patients who were not frail (CFI < .15), prefrail (.15 ≤ CFI < .25), mildly frail (.25 ≤ CFI < .35), and moderately to severely frail (CFI ≥ .35). Multivariable Cox regression compared 1-year mortality. Multivariable Poisson regression compared rates of post-discharge hospital encounters (hospitalizations, intensive care unit stay, emergency department visit) and home time over 1 year after discharge. All regression models adjusted for age, sex, race, admission from facility, procedure, sepsis, inpatient palliative care delivery, trauma center designation, hospital bed size, and teaching status, and they were clustered by patient and hospital referral region. RESULTS: Among 468 459 older EGS adults, 37.4% were pre-frail, 12.4% were mildly frail, and 3.6% were moderately to severely frail. Patients with mild frailty experienced a higher risk of 1-year mortality compared with non-frail patients (hazard ratio = 1.97; confidence interval [CI] = 1.94-2.01). In the year after discharge, patients with mild and moderate to severe frailty had more hospital encounters compared with non-frail patients (7.8 and 11.5 vs 2.0 per person-year; incidence rate ratio [IRR] = 4.01; CI = 3.93-4.08 vs IRR = 5.89; CI = 5.70-6.09, respectively). Patients with mild and moderate to severe frailty also had fewer days at home in the year after discharge compared with non-frail patients (256 and 203 vs 302 mean days; IRR = .97; CI = .96-.97 vs IRR = .95; CI = .94-.95, respectively). CONCLUSION: Older EGS patients with frailty are at increased risk for poor 1-year outcomes and decreased home time. Targeted interventions for older EGS patients with frailty during the index EGS hospitalization are urgently needed to improve long-term outcomes.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

The Impact of Frailty on Long‐Term Patient‐Oriented Outcomes after Emergency General Surgery: A Retrospective Cohort Study

Lee

Streid

Sturgeon

et al. 2020

J American Geriatrics Society

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“…The FRAIL scale has been used at our institution since 2015 to identify frail geriatric trauma patients and subsequently admit them under an interdisciplinary protocol, which resulted in a decrease in delirium and 30-day readmission risk. 9 In the elective preoperative setting, a positive frailty screen can be followed up with comprehensive geriatric assessment or initiation of case management to individualize care for frail older adults while remaining sensitive to resource utilization for a hospital system. 10,[20][21][22] To improve efficiency and minimize the time burden of screening, future validation studies should investigate the reliability and validity of this abbreviated patient-reported scale.…”

Section: Discussionmentioning

confidence: 99%

“…8 Professional societies including the American Geriatrics Society and American College of Surgeons (ACS) recommended using frailty screens for older adults admitted for surgery to prompt interdisciplinary care teams to effectively preserve functional independence, decrease delirium, and reduce 30-day readmission risk in their admitted patients. 4,[9][10][11] However, less is known about the use of frailty screens in a preoperative setting to predict postdischarge needs. The ideal screening tool is accessible, inexpensive, and noninvasive, and it requires little time to complete.…”

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confidence: 99%

Association Between Patient‐Reported Frailty and Non‐Home Discharge Among Older Adults Undergoing Surgery

Sokas

Cowan

Dalton

et al. 2020

J American Geriatrics Society

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BACKGROUND/OBJECTIVES Identifying surgical patients at risk for discharge to a post‐acute facility has the potential to reduce hospital length of stay, improve postoperative planning, and increase patient satisfaction. We sought to examine the association between a positive response to a preoperative patient‐reported frailty screen and non‐home discharge (NHD). DESIGN Prospective cohort. SETTING Urban tertiary academic preoperative evaluation center. PARTICIPANTS Convenience sample of patients aged 60 and older evaluated from November 2018 to August 2019) undergoing one of 14 major elective general and vascular operations with an expected length of stay of 3 days or longer. METHODS Items from the previously validated Fatigue, Resistance, Ambulation, Illnesses, Loss of weight (FRAIL) screen were modified, and patients were queried on fatigue, activity against resistance, ambulation, and weight loss. Multivariable logistic regression adjusting for age and sex was used to determine the association between patient‐reported items and NHD. RESULTS A total of 230 patients were included for analysis. The average age of the cohort was 70.1 (standard deviation = 7.1); 91.7% were White, and 52.4% were female. There were 24 patients (10.4%) who were not discharged home. They were more likely to report fatigue (54% vs 29%; P = .01), weight loss (58% vs 21%; P < .01), and difficulty with activity against resistance (33% vs 7%; P < .01) before surgery. In adjusted analysis, patients who self‐reported frailty (FRAIL screen ≥2) were significantly more likely to have an NHD (odds ratio [OR] = 4.5; 95% confidence interval [CI] = 1.7–11.7; P < .01), as were patients who responded “yes” to any question from the FRAIL screen (OR = 2.5; 95% CI = 1.7–3.5; P < .01). A positive response to difficulty with activity against resistance or recent weight loss showed similar odds of NHD (OR = 7.6; 95% CI = 2.6–23.9; P < .01; and OR = 7.9; 95% CI = 2.9–21.6; P < .01, respectively). Conclusion Patient response to screening questions on the FRAIL screen identified those at highest risk of NHD. The FRAIL screening tool is practical, easy to apply, and could be used during preoperative counseling to identify patients likely to have increased discharge planning needs.

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“… 30 A similar interdisciplinary approach has been demonstrated to reduce 30-day readmissions in a more diverse older trauma patient population. 31 Whether such interdisciplinary care is achieved through geriatric consultation or development of a specialized geriatric trauma service with evidence-based protocols is dependent on each hospital’s resources and surgeons’ preferences.…”

Section: Discussionmentioning

confidence: 99%

Different strokes: differences in the characteristics and outcomes of BCVI and non-BCVI strokes in trauma patients

McNutt

Slovacek

Rosenbaum

et al. 2020

Trauma Surg Acute Care Open

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BackgroundAlthough strokes are rare in trauma patients, they are associated with worse functional and cognitive outcomes and decreased mobility. Blunt cerebrovascular injury (BCVI)–related strokes and mortality have decreased, likely due to refined screening and treatment algorithms in trauma literature; however, there is a paucity of research addressing non-BCVI strokes in trauma. The purpose of this study is to evaluate the incidence, etiology, and risk factors of stroke in our trauma population in order to identify preventive strategies.MethodsThis study was a retrospective review of all adult trauma patients admitted to a level 1 trauma hospital who suffered a stroke during trauma admission from 2010 to 2017. Data were collected from the prospectively maintained trauma and stroke databases. Stroke etiology was determined by a vascular neurologist.ResultsOf the 43 674 adult trauma patients admitted during the study period, 99 (0.2%) were diagnosed with a stroke during the index admission. Twenty-one (21%) strokes were due to BCVI. Seventy-eight (79%) strokes were due to non-BCVI etiologies. Patients with non-BCVI strokes were older, less severely injured, and had more medical comorbidities compared with patients with a BCVI stroke. While patients with a BCVI stroke were more likely to suffer multiple traumatic injuries from MVC (76% vs 28%, p<0.001), non-BCVI strokes had more isolated extremity injuries from fall mechanism (55% vs 10%, p<0.001). Over the study period, the age and incidence of stroke and BCVI (p<0.001) increased. However, the rate of BCVI strokes decreased while the rate of non-BCVI strokes increased.DiscussionThe incidence of stroke has increased despite aggressive screening and treatment of BCVI. This increase is primarily due to non-BCVI strokes which are associated with advanced age and medical comorbidities after low mechanism traumatic injury. Medical optimization of comorbid conditions during trauma hospitalization will become increasingly important for stroke prevention as the population ages.Level of evidence: Level III

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Frailty Identification and Care Pathway: An Interdisciplinary Approach to Care for Older Trauma Patients

Cited by 78 publications

References 31 publications

The Impact of Frailty on Long‐Term Patient‐Oriented Outcomes after Emergency General Surgery: A Retrospective Cohort Study

The Impact of Frailty on Long‐Term Patient‐Oriented Outcomes after Emergency General Surgery: A Retrospective Cohort Study

Association Between Patient‐Reported Frailty and Non‐Home Discharge Among Older Adults Undergoing Surgery

Different strokes: differences in the characteristics and outcomes of BCVI and non-BCVI strokes in trauma patients

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