Frailty in Geriatric Trauma Pa1ents

Transcription

1 Division of Trauma, Burn, Surgical Critical Care, & Emergency General Surgery Frailty in Geriatric Trauma Pa1ents Zara Cooper, MD, MSc, FACS Elizabeth Bryant, MPH

2 Disclosures NIA R01AG NCI R35CA PCORI CDR

3 Objec1ves Understand the conceptual model of frailty Recognize the prognos1c significance of frailty in trauma Describe interven1ons that improve outcomes

4 Grey tsunami

5 Trauma in older adults Uninten&onal Injury is the 7 th leading cause of death in older adults 56% Falls 23% MVC Mortality of TBI 2 X younger pa&ents 18% Mortality afer rib fractures In hospital mortality for older trauma pa&ents ~ 11% % Trauma pa&ents admiled to US hospitals % Other Acute Trauma

6 Frailty vs Aging Frail: 10% of pa1ents over aged 65 50% of pa1ents over % of older trauma pa1ents

7 Normal physiology of aging Cardiac Pulmonary Endocrine Renal Increased resistance Decreased compliance Decreased compliance Decreased FRC Decreased thyroid ac1vity Impaired glycemic response to injury Decreased thirst Inability to concentrate urine Volume overload

8 The cycle of frailty Falls Delirium Func1onal Impairment Dependence Social Isola1on Increased care needs

9 Living on the edge

10 Markers of frailty Criteria Shrinkage Weakness Exhaus&on Low physical ac&vity Slowness Mul&morbidity

11 What happens when you have trauma and you re frail?

12 Impact of trauma Fluid loss Hemodynamic changes Respiratory change Impaired glucose regula1on Func1onal changes Mental status changes

13 Op1mizing outcomes from surgery & trauma UH OH Best if you can: Pee Poop Breathe Eat Walk Par1cipate Older pa1ents: Decreased renal func1on Cons1pa1on Decreased func1onal capacity Dysphagia Func1onal limita1ons Cogni1ve impairment or delirium

14 Complica&ons 40% 60% 180%

15 Adverse Discharge* 60% 40% 50%

16 40% 30%

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18 More experienced hospitals have lower mortality rates TC Level Level II had 27% lower mortality Propor&on of Volume 28% lower mortality 31% lower failure to rescue 11% reduc1on in mortality/100 increase in geriatric trauma admissions

19 Interven1ons

20 He s vigorous and sharp as a tack History from wife and children is that he s able to perform all ac1vi1es of daily living But when you probe Has been having mild memory and hearing loss Doesn t drive very far anymore Messing up the bills He just hasn t been feeling well lately

21 Comprehensive Geriatrics Assessment Domain Physical medical condi1ons Mental health Func1oning Social circumstances Environment Advance care planning Cochrane review: 25% reduc1on in death or cogni1ve decline at 6 months 31% higher chance of being alive and in own home at 6 months Number needed to treat =13 to avoid one death

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23 Background Academic, urban, Level I trauma center Majority of pa1ents are 65 years Primary mechanism of injury is falls

24 2014: Triggered Geriatrics Consults Admiged pa1ents > 70 years Seen within 72 hours of admission Comprehensive Geriatrics Assessment

25 Improved Processes of Care Proportion of population, % Process of Care Pre-intervention Post-intervention P value* Geriatric consult <0.01 Documentation of delirium DNR/DNI code status <0.01 Referral for formal cognitive evaluation <0.01 Recogni1on of delirium 7% DNR/DNI code status 28% Referral for cogni1ve evalua1on 12%

26 Improved Outcomes Proportion of population, % Patient Outcome Pre-intervention Post-intervention P value* In-hospital mortality day mortality ICU readmission day hospital readmission Hospital length of stay, days In hospital mortality 4% 30-day mortality 4.8% ICU readmission 6.6%

27 Background Problem: Discon1nui1es in care when trauma geriatrician isn t available Objec1ves: 1. Reduce variability 2. Reduce delirium 3. Improve func1on

28 Methods Step 1: Iden1fy specific components of care to accomplish the pathway s objec1ve In person mee1ngs with stakeholders Literature reviews

29 Pathway Components DELIRIUM Non-pharm preven1on Sleep-wake cycle Confusion Assessment Method (CAM) Early mobility Bowel and pain regimens Consults FUNCTION Vitamin D/ Ca 2+ labs Orthosta1cs Swallow screen

30 Step 2: The FRAIL Scale Fa1gue Resistance (inability to walk up flight of stairs) Ambula1on (inability to walk length of football field) Illness (5 or more) Loss of weight (5% or more body weight)

31 Pathway Overview ED: Trauma pa&ent 65+ screened FRAIL scale posi&ve Enters Pathway

32 Pathway Overview Admission Order Set -Vitamin 25-OH D and Ca 2+ labs -Orthosta1cs -Bowel regimen -Pain regimen -Healthcare proxy iden1fied, MOLST/advance direc1ves -Aspira1on precau1ons Nursing Care -Pain Assessments -Bowel checks -Early mobiliza1on -Swallow screen -CAM/delirium preven1on Consults -CGA - Nutri1on - Physical therapy -Social work (if lives by self) - Family mee1ng Educa&on -Fall preven1on packet

33 Implementa1on Staff educa1on Residents Nurses, physician care assistants (PCAs) Fellows, agendings Physician assistants (PAs) Other clinical staff Kick off date for step-down: April 11, 2016 Kick off date for ICU: June 16, 2016

34 Maintenance Mul1disciplinary rounds twice a week Monthly check-in mee1ngs Data presenta1on at monthly PIPs Online educa1onal module for all clinical staff who work on the trauma service

35 Process Outcomes July 2016 February 2017 Goal Median number of CAM/day Family mee1ngs if pa1ent had LOS 5 days Nutri1on within 72 hours of admission % 50% 100% 75% 87% 100% Fall preven1on informa1on 6.25% 33% 100%

36 Challenges/Piqalls Electronic medical records Documenta1on Nursing checklist PCA involvement

37 Next Steps Expand to other floors/services that regularly see this pa1ent popula1on Long-term outcomes Expand fall preven1on component