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Improved 1-year mortality in elderly patients with a hip fracture following integrated orthogeriatric treatment
SummaryTo improve the quality of care and reduce the healthcare costs of elderly patients with a hip fracture, surgeons and geriatricians collaborated intensively due to the special needs of these patients. After treatment at the Centre for Geriatric Traumatology (CvGT), we found a significant decrease in the 1-year mortality rate in frail elderly patients compared to the historical control patients who were treated with standard care.IntroductionThe study aimed to evaluate the effect of an orthogeriatric treatment model on elderly patients with a hip fracture on the 1-year mortality rate and identify associated risk factors.MethodsThis study included patients, aged 70 years and older, who were admitted with a hip fracture and treated in accordance with the integrated orthogeriatric treatment model of the CvGT at the Hospital Group Twente (ZGT) between April 2008 and October 2013. Data registration was carried out by several disciplines using the clinical pathways of the CvGT database. A multivariate logistic regression analysis was used to identify independent risk factors for 1-year mortality. The outcome measures for the 850 patients were compared with those of 535 historical control patients who were managed under standard care between October 2002 and March 2008.ResultsThe analysis demonstrated that the 1-year mortality rate was 23.2 % (n = 197) in the CvGT group compared to 35.1 % (n = 188) in the historical control group (p < 0.001). Independent risk factors for 1-year mortality were male gender (odds ratio (OR) 1.68), increasing age (OR 1.06), higher American Society of Anesthesiologists (ASA) score (ASA 3 OR 2.43, ASA 4–5 OR 7.05), higher Charlson Comorbidity Index (CCI) (CCI 1–2 OR 1.46, CCI 3–4 OR 1.59, CCI 5 OR 2.71), malnutrition (OR 2.01), physical limitations in activities of daily living (OR 2.35), and decreasing Barthel Index (BI) (OR 0.96).ConclusionAfter integrated orthogeriatric treatment, a significant decrease was seen in the 1-year mortality rate in the frail elderly patients with a hip fracture compared to the historical control patients who were treated with standard care. The most important risk factors for 1-year mortality were male gender, increasing age, malnutrition, physical limitations, increasing BI, and medical conditions. Awareness of risk factors that affect the 1-year mortality can be useful in optimizing care and outcomes. Orthogeriatric treatment should be standard for elderly patients with hip fractures due to the multidimensional needs of these patients.
Journal Article
Turning point : a novel
\"Bill Browning heads the trauma unit at San Francisco's busiest emergency room, SF General. With his ex-wife and daughters in London, he immerses himself in his work and lives for rare visits with his children. A rising star at her teaching hospital, UCSF at Mission Bay, Stephanie Lawrence has two young sons, a frustrated stay-at-home husband, and not enough time for any of them. Harvard-educated Wendy Jones is a dedicated trauma doctor at Stanford, trapped in a dead-end relationship with a married cardiac surgeon. And Tom Wylie's popularity with women rivals the superb medical skills he employs at his Oakland medical center, but he refuses to let anyone get too close, determined to remain unattached forever. These exceptional doctors are chosen for an honor and a unique project: to work with their counterparts in Paris in a mass-casualty training program. As professionals, they will gain invaluable knowledge from the program. When an unspeakable act of mass violence galvanizes them into action, their temporary life in Paris becomes a stark turning point: a time to face harder choices than they have ever made before - with consequences that will last a lifetime\" -- Front jacket flap.
Book
Management of severe trauma worldwide: implementation of trauma systems in emerging countries: China, Russia and South Africa
As emerging countries, China, Russia, and South Africa are establishing and/or improving their trauma systems. China has recently established a trauma system named “the Chinese Regional Trauma Care System” and covered over 200 million populations. It includes paramedic-staffed pre-hospital care, in-hospital care in certified trauma centers, trauma registry, quality assurance, continuous improvement and ongoing coverage of the entire Chinese territory. The Russian trauma system was formed in the first decade of the twenty-first century. Pre-hospital care is region-based, with a regional coordination center that determines which team will go to the scene and the nearest hospital where the victim should be transported. Physician-staffed ambulances are organized according to three levels of trauma severity corresponding to three levels of trauma centers where in-hospital care is managed by a trauma team. No national trauma registry exists in Russia. Improvements to the Russian trauma system have been scheduled. There is no unified trauma system in South Africa, and trauma care is organized by public and private emergency medical service in each province. During the pre-hospital care, paramedics provide basic or advanced life support services and transport the patients to the nearest hospital because of the limited number of trauma centers. In-hospital care is inclusive with a limited number of accredited trauma centers. In-hospital care is managed by emergency medicine with multidisciplinary care by the various specialties. There is no national trauma registry in South Africa. The South African trauma system is facing multiple challenges. An increase in financial support, training for primary emergency trauma care, and coordination of private sector, need to be planned.
Journal Article
The orthogeriatric comanagement improves clinical outcomes of hip fracture in older adults
SummaryTreatment of older adults with hip fracture is a healthcare challenge. Orthogeriatric comanagement that is an integrated model of care with shared responsibility improves time to surgery and reduces the length of hospital stay and mortality compared with orthopedic care with geriatric consultation service and usual orthopedic care, respectively.IntroductionTreatment of fractures in older adults is a clinical challenge due partly to the presence of comorbidity and polypharmacy. The goal of orthogeriatric models of care is to improve clinical outcomes among older people with hip fractures. We compare clinical outcomes of persons with hip fracture cared according to orthogeriatric comanagement (OGC), orthopedic team with the support of a geriatric consultant service (GCS), and usual orthopedic care (UOC).MethodsThis is a single-center, pre-post intervention observational study with two parallel arms, OGC and GCS, and a retrospective control arm. Hip fracture patients admitted to the trauma ward were assigned by the orthopedic surgeon to the OGC (n = 112) or GCS (n = 108) group. The intervention groups were compared each with others and both with the retrospective control group (n = 210) of older adults with hip fracture. Several clinical indicators are considered, including time to surgery, length of stay, in-hospital, and 1-year mortality.ResultsPatients in the OGC (OR 2.62; CI 95% 1.40–4.91) but not those in the GCS (OR 0.74; CI 95% 0.38–1.47) showed a higher probability of undergoing surgery within 48 h compared with those in the UOC. Moreover, the OGC (β, − 1.08; SE, 0.54, p = 0.045) but not the GCS (β, − 0.79; SE, 0.53, p = 0.148) was inversely associated with LOS. Ultimately, patients in the OGC (OR 0.31; CI 95 % 0.10–0.96) but not those in the GCS (OR 0.37; CI 95% 0.10–1.38) experienced a significantly lower 1-year mortality rate compared with those in the UOC. All analyses were independent of several confounders.ConclusionsOlder adults with hip fracture taken in care by the OGC showed better clinical indicators, including time to surgery, length of stay and mortality, than those managed by geriatric consultant service or usual orthopedic care.
Journal Article
The Cost Of Overtriage: More Than One-Third Of Low-Risk Injured Patients Were Taken To Major Trauma Centers
Regionalized trauma care has been widely implemented in the United States, with field triage by emergency medical services (EMS) playing an important role in identifying seriously injured patients for transport to major trauma centers. In this study we estimated hospital-level differences in the adjusted cost of acute care for injured patients transported by 94 EMS agencies to 122 hospitals in 7 regions, overall and by injury severity. Among 301,214 patients, the average adjusted per episode cost of care was$5,590 higher in a level 1 trauma center than in a nontrauma hospital. We found hospital-level differences in cost among patients with minor, moderate, and serious injuries. Of the 248,342 low-risk patients-those who did not meet field triage guidelines for transport to trauma centers-85,155 (34.3 percent) were still transported to major trauma centers, accounting for up to 40 percent of acute injury costs. Adhering to field triage guidelines that minimize the overtriage of low-risk injured patients to major trauma centers could save up to $ 136.7 million annually in the seven regions we studied. [PUBLICATION ABSTRACT]
Journal Article
Charges, length of stay, and complication associations with trauma center ownership in adult patients with mild to moderate trauma
For-profit (FP) trauma centers (TCs) charge more for trauma care than not-for-profit (NFP) centers. We sought to determine charges, length of stay (LOS), and complications associations with TC ownership status (FP, NFP, and government) for three diagnoses among patients with overall low injury severity.
Adult patients treated at TCs with an International Classification of Diseases-based injury severity score (ICISS) survival probability ≥ 0.85 were identified. Only those who with a principal diagnosis of femur, tibial or rib fractures were included.
Total charges were significantly higher at FP centers than NFP and lower at government centers (89.6% and −12.8%, respectively). FP TCs had a 12.5% longer LOS and government TCs had a 20.4% longer LOS than NFP TCs.
Patients presenting to FP TCs with mild/moderate femur, tibial, or rib fractures experienced higher charges and increased LOS compared with government or NFP centers. There was no difference in overall complication rates.
•Risk-adjusted mean total hospital charges were nearly two-fold higher at for-profit trauma centers.•Risk-adjusted mean total hospital charges were 13% lower at government/public trauma centers.•Risk-adjusted lengths of stay were higher at for-profit and government trauma centers.
Journal Article
The Knowledge, Attitude, and Practice of Nurses Regarding Trauma‐Informed Care for Traumatic Injured Patients: A Multicenter Cross‐Sectional Study
Traumatic injured patients frequently present with both acute physical injuries and the exacerbation of preexisting trauma events, substantially compromising their mental health and quality of life. Trauma-informed care is a supportive intervention approach that requires understanding of trauma experiences encountered by patients. Nurses must follow the principles of trauma-informed care during interactions with patients to improve clinical outcomes. However, the current status of knowledge, attitude, and practice regarding trauma-informed care among nurses in trauma centers has not been fully investigated.
To investigate the current status of knowledge, attitude, and practice regarding trauma-informed care among nurses caring for traumatic injured patients in trauma center-certified hospitals and to identify potential influencing factors.
Cross-sectional survey.
Nurses from 11 trauma center-certified hospitals in Sichuan Province, China.
The assessment was conducted using standardized instruments, including a demographic survey, a trauma-informed care knowledge, attitude, and practice (TIC-KAP) questionnaire, Interpersonal Reactivity Index-Chinese version (IRI-C), and Organizational Climate Scale for Nursing (OCSN). Univariate analysis and subsequent multiple linear regression analysis were used to explore associations between TIC-KAP and other factors.
A total of 304 individuals participated in the survey, with 267 valid responses. Multiple linear regression analysis identified several significant predictors of TIC-KAP scores: work in emergency department, prior knowledge of trauma-informed care, psychological trauma nursing training experience, dedicated psychological nursing positions, IRI-C scores, and OCSN scores.
Although the participating nurses demonstrated favorable scores in trauma-informed care attitude and practice, significant gaps persist in knowledge domains, with emergency nurses exhibiting particularly notable deficiencies. The implementation of trauma-informed care could be promoted through several strategic interventions: engagement in trauma-informed care or psychological nursing training programs, establishment of dedicated psychological nursing positions, and improvement of both empathy level among nurses and organizational climate.
Journal Article
Improving communication during damage control surgery: a survey of adult major trauma centres in England
Deficiencies in non-technical skills can severely impede the functioning of teams in high-intensity scenarios, such as in damage control surgery for the critically injured trauma patient. Truncated preoperative checklists, modified from the standard World Health Organization preoperative checklist, and situational reporting at intervals during surgery are long-established practices in the military, and are recommended in the National Health Service guidelines on major incidents. These tools allow the multiprofessional team to create a shared mental model of the anaesthetic and operative plan, thereby improving team efficiency. Our aim was to establish whether adult major trauma centres in England are using truncated preoperative checklists and situational reporting for damage control surgery.
An online survey was devised and distributed via the national programme of care for trauma in November 2020.
Responses were received from all 23 adult major trauma centres in England. Nine centres (39.1%) reported using a truncated preoperative checklist for damage control surgery albeit in a variety of formats. Common components were blood products received and/or available, presence of allergies, tranexamic acid and antibiotic administration, availability of viscoelastic tests, equipment required, availability of cell saver, role allocation and reference to other personnel needed, and discussion of the plan. Twelve centres (52.2%) have formal policies in place for situational reporting. Again, these were in multiple formats but all focused on patient physiology to direct surgical planning.
We have identified key components to advanced communication aids for damage control surgery, providing a foundation on which other major trauma centres can build their own versions of these potentially lifesaving tools.
Journal Article
Pediatric trauma transfer patients have low rates of additional traumatic injuries
Pediatric trauma patients often require interfacility transfer for subspecialty management of presumed isolated injuries. Understanding the frequency of additional injury in these low-acuity patients may improve resource utilization.
Pediatric trauma patients transferred to a level 1 trauma center in 2019 were compared by type of presenting injury in a retrospective review. Primary outcome was additional traumatic injuries identified.
530 pediatric trauma patients were transferred, most commonly for an isolated orthopedic injury (56.5 %). The overall rate of additional injuries identified was 2.8 %, with the highest rate in patients transferred with neurosurgical injuries (6.7 %). When compared to other transfer patients, patients with isolated orthopedic injuries were least likely to have any additional injuries (1.0 % vs. 4.8 %, p = 0.01).
Pediatric trauma patients transferred with isolated injuries rarely had additional injuries identified after transfer. Streamlining care for this population while maintaining vigilance for missed injuries is a target for future interventions.
•There was a low rate of additional injuries identified in pediatric trauma patients transferred for subspecialty evaluation.•Isolated orthopedic transfer patients had a significantly lower rate of additional injuries identified on trauma workup.•The lower rate of additional injuries in isolated orthopedic injury patients persisted on multivariate analysis.•Alternative means of patient assessment for this specific group may help with resource optimization.
Journal Article