Quality of Care Delivered Before vs After a Quality-Improvement Intervention for Acute Geriatric Trauma

Abstract

Background Older trauma injury patients had improved recovery after we implemented routine geriatric consultation for patients ≥ age 65 at a level-1 academic trauma center. The intervention aimed to improve quality of geriatric care. However, the specific care processes that improved are unknown. Study Design Prospective observation comparing medical care after (December 2007-November 2009) versus before (December 2006-November 2007) implementation of the geriatric consult-based intervention. To measure quality-of-care (QOC) we used 33 previously-validated care-process quality indicators (QIs) from the Assessing the Care of Vulnerable Elders (ACOVE) study, measured by review of medical records for 76 Geriatric Consult [GC] versus 71 control group patients. As pre-specified subgroup analyses, we aggregated QIs by type: geriatric (e.g., delirium screening) versus non-geriatric condition-based care (e.g., thrombosis prophylaxis) and compared QI scores by type of care. Last, we aggregated QI scores into overall, geriatric, and non-geriatric QOC scores for each patient (# QIs passed/# QIs eligible), and compared patient-level QOC for the GC versus control group, adjusting for age, gender, ethnicity, comorbidity, and injury severity. Results 63% of the GC versus 11% of the control group patients received a geriatric consultation. We evaluated 2505 QIs overall (1664 geriatric-type and 841 non-geriatric QIs). In general, fewer geriatric-type QIs were passed than non-geriatric QIs (71% vs 81%, p<.001). We provided better overall-QOC to the GC (77%) than control group patients (73%, p<.05). However, the difference was not statistically significant after multivariable adjustment (p=.08). We improved geriatric-QOC for the GC (74%) compared to the control group (68%, p<.01), a difference that was significant after multivariable adjustment (p=.01). Conclusion Geriatricians and surgeons can collaboratively improve geriatric QOC for older trauma patients.

Association of Loss of Independence With Readmission and Death After Discharge in Older Patients After Surgical Procedures

“…Established models of care (such as the Hospital Elder Life Program 18 ) and geriatric comanagement strategies focus on simple interventions, such as frequent reorientation, hydration, and early ambulation to prevent delirium, deconditioning, and malnutrition. 19,20 Length of stay was a significant risk factor for LOI, with each additional hospital day adding 30% risk. Certainly, deconditioning over the hospital stay is a logical mechanism that may explain LOI.…”

Early geriatric consultation increases adherence to TQIP Geriatric Trauma Management Guidelines

“…Recognizing the difficulties in having geriatricians assess every older trauma patient (geriatric consultation rates in the prior studies range from 40–69% of all older trauma patients), 7,8,10 we focused our care model on older adults with geriatric syndromes or specific needs. The TQIP guidelines suggest using the Identifying Seniors at Risk tool (ISAR), which has been evaluated in other settings for identifying higher risk patients for likelihood of functional decline or poor long-term outcomes.…”

“…6 A quality of care evaluation, measured by the Assessing Care of Vulnerable Elders (ACOVE) validated quality measures, found an increase in quality with geriatric consultation. 7 However the aggregate of ACOVE quality measures does not include many quality measures of high importance to trauma surgeons, such as mortality, discharge to skilled nursing facilities, or code status. Another evaluation of a geriatric consultation model found that geriatricians decreased length of stay and decreased discharge to skilled nursing facilities for older adult trauma patients.…”

Among Patients With Facial Fractures, Geriatric Patients Have an Increased Risk for Associated Injuries

“…Subsequently, the quality of care and functional outcome of elderly trauma patients were found to improve when geriatric consultation was implemented. 10,11 The establishment of a geriatric trauma service for patients at least 60 years old resulted in a decrease in the average emergency department (ED) length of stay, average ED to operating room time, average surgical intensive care unit length of stay, and average hospital length of stay. 12 Moreover, the rates of mortality, pneumonia, respiratory failure, and urinary tract infections decreased.…”