Team-Based Geriatric Protocol Cuts Trauma Mortality

LAKE BUENA VISTA, FLA. – Mortality was sharply reduced in elderly patients undergoing trauma care with an aggressive protocol marked by multidisciplinary teamwork and prompt identification of occult shock.

The survival benefit was significant even among patients older than 75 years, a group with notoriously high mortality rates, Dr. Eric Bradburn said at the annual meeting of the Eastern Association for the Surgery of Trauma.

Injured geriatric patients pose unique challenges to the trauma team because of their abnormal responses to shock and injury and frequent polypharmacy. They are also increasing in numbers with today’s active geriatric population, comprising 36% of all admissions at his own level II trauma center, said Dr. Bradburn, an acute care surgeon at Lancaster General Hospital in Hershey, Pa.

With the protocol, patients older than 65 years were screened on admission for high-risk injuries, comorbidities, and/or physiologic parameters associated with increased geriatric mortality in the literature. If one or more high-risk indicator was present, a high-risk protocol was initiated that included:

• ICU admission.

• STAT arterial blood gas (ABG).

• An ABG every 4 hours, if base deficit is –6 mmol/L or more, until base deficit is –2 mmol/L.

• STAT echocardiogram (EKG).

• Basic metabolic profile; magnesium and phosphorus tests in morning.

• Prothrombin time, partial thromboplastin time, and international normalized ratio in morning.

• Neurologic checks every hour for 24 hours.

• For unexplained hemodynamic instability, obtain a STAT EKG.

• Geriatric medicine consult.

The protocol was initiated in January 2006, with all 4,534 geriatric trauma patients admitted from 2000 to 2010 included in the analysis. Of these, 309 patients died for an overall mortality rate of 6.8%, Dr. Bradburn said.

Mortality rates increased sharply at age 75 years – consistent with the literature – from less than 4% to more than 6% and rose steadily to more than 11% by age 95 years.

In multivariate adjusted analysis of 3,902 patients with full data available, mortality significantly improved for geriatric patients on the protocol (odds ratio, 0.63), he said. The receiver operating curve was 0.86. Variables includes in the analysis were Injury Severity Score (ISS), trauma level, Revised Trauma Score (RTS), and age.

Patients on the protocol had significantly lower mortality rates regardless of whether they were 75-84 years (OR, 2.72), older than 85 years (OR, 4.62), had an Injury Severity Score of 17-25 (OR, 6.45) or ISS greater than 25 (OR, 15.93).

Furthermore, mortality was significantly lower among patients who received the full protocol even at the highest ISS categories, compared with those who did not receive the protocol or received either the protocol or the geriatric consult, "demonstrating the synergy and impact our full protocol has on this population," Dr. Bradburn said.

"We believe the implications of this study demonstrate that an aggressive approach to the geriatric trauma patient can result in a positive outcome in this population," he concluded.

Invited discussant Dr. Carl Schulman, a trauma and burn surgeon at the University of Miami’s Ryder Trauma Center, pointed out that geriatric consultations alone have been shown to improve mortality.

"Can you really show that your protocol added anything to this?" he asked. "Maybe all the results you have shown are from the geriatric consult alone, and this geriatric protocol is unnecessary. This would save a lot of unnecessary testing and improve the cost/benefit ratio, by simply having the geriatric consult."

The audience also questioned what services the geriatricians provided.

Dr. Bradburn said the geriatricians assisted most with social, rehabilitative, and end-of-life issues and medication issues, but also managed some comorbidities. He said the combined approach goes beyond these issues by alerting the trauma team early on to abnormal values "rather than waiting until the reserves are tapped." He noted that elderly trauma patients often present with occult hypotension leading to bias and that the literature is replete with data showing that not enough attention is paid to this population until it is too late.

Later, in a interview following the meeting, Dr. Bradburn explained that his trauma team managed the patients "from the bay to discharge."

Additional input from the geriatric team included recommendations continuing/discontinuing certain medications; assisting with management of delirium; and addressing DNR status, preinjury functional assessments, as well as social and rehab needs, he said.

"They were key in addressing the polypharmacy issue removing many of those medications that might lead to falls or increased risk for delirium."

Geriatricians’ direction on appropriate rehabilitation can boost measures such as 30-day mortality or 6-month mortality, he said. For example, in the case of an elderly fall resulting in a traumatic brain injury and extremity fractures, aggressive focused rehab to address the preexisting physical deficits that led to the fall, as well as the deficits acquired by the fall, would certainly improve the quality of life for that individual and potentially prevent additional falls.

At the meeting, Dr. Schulman also asked whether the high DNR rate of 20% could have contributed to the results. Dr. Bradburn responded that if a DNR is put into the regression model, it actually makes the results better, changing the odds ratio from 0.63 to 0.36.

Dr. Bradburn said his team had hoped to investigate functional outcomes, but that these data were not complete.

He noted that the current study is limited by its retrospective design and acknowledged that "from our data you cannot fully attribute its success solely to one part of our protocol." Still, he said, the benefits are "clear."

"This study lays the groundwork for a prospective multi-institutional study – in which we can potentially tease if one part of our protocol is more effective than any other."

The protocol should be replicable beyond Lancaster General Hospital, he said. "We think the approach is unique, but believe with further study we can show this can be applied at other institutions with equivalent successes."

Dr. Bradburn and Dr. Schulman reported no relevant conflicts of interest.

LAKE BUENA VISTA, FLA. – Mortality was sharply reduced in elderly patients undergoing trauma care with an aggressive protocol marked by multidisciplinary teamwork and prompt identification of occult shock.

The survival benefit was significant even among patients older than 75 years, a group with notoriously high mortality rates, Dr. Eric Bradburn said at the annual meeting of the Eastern Association for the Surgery of Trauma.

Injured geriatric patients pose unique challenges to the trauma team because of their abnormal responses to shock and injury and frequent polypharmacy. They are also increasing in numbers with today’s active geriatric population, comprising 36% of all admissions at his own level II trauma center, said Dr. Bradburn, an acute care surgeon at Lancaster General Hospital in Hershey, Pa.

With the protocol, patients older than 65 years were screened on admission for high-risk injuries, comorbidities, and/or physiologic parameters associated with increased geriatric mortality in the literature. If one or more high-risk indicator was present, a high-risk protocol was initiated that included:

• ICU admission.

• STAT arterial blood gas (ABG).

• An ABG every 4 hours, if base deficit is –6 mmol/L or more, until base deficit is –2 mmol/L.

• STAT echocardiogram (EKG).

• Basic metabolic profile; magnesium and phosphorus tests in morning.

• Prothrombin time, partial thromboplastin time, and international normalized ratio in morning.

• Neurologic checks every hour for 24 hours.

• For unexplained hemodynamic instability, obtain a STAT EKG.

• Geriatric medicine consult.

The protocol was initiated in January 2006, with all 4,534 geriatric trauma patients admitted from 2000 to 2010 included in the analysis. Of these, 309 patients died for an overall mortality rate of 6.8%, Dr. Bradburn said.

Mortality rates increased sharply at age 75 years – consistent with the literature – from less than 4% to more than 6% and rose steadily to more than 11% by age 95 years.

In multivariate adjusted analysis of 3,902 patients with full data available, mortality significantly improved for geriatric patients on the protocol (odds ratio, 0.63), he said. The receiver operating curve was 0.86. Variables includes in the analysis were Injury Severity Score (ISS), trauma level, Revised Trauma Score (RTS), and age.

Patients on the protocol had significantly lower mortality rates regardless of whether they were 75-84 years (OR, 2.72), older than 85 years (OR, 4.62), had an Injury Severity Score of 17-25 (OR, 6.45) or ISS greater than 25 (OR, 15.93).

Furthermore, mortality was significantly lower among patients who received the full protocol even at the highest ISS categories, compared with those who did not receive the protocol or received either the protocol or the geriatric consult, "demonstrating the synergy and impact our full protocol has on this population," Dr. Bradburn said.

"We believe the implications of this study demonstrate that an aggressive approach to the geriatric trauma patient can result in a positive outcome in this population," he concluded.

Invited discussant Dr. Carl Schulman, a trauma and burn surgeon at the University of Miami’s Ryder Trauma Center, pointed out that geriatric consultations alone have been shown to improve mortality.

"Can you really show that your protocol added anything to this?" he asked. "Maybe all the results you have shown are from the geriatric consult alone, and this geriatric protocol is unnecessary. This would save a lot of unnecessary testing and improve the cost/benefit ratio, by simply having the geriatric consult."

The audience also questioned what services the geriatricians provided.

Dr. Bradburn said the geriatricians assisted most with social, rehabilitative, and end-of-life issues and medication issues, but also managed some comorbidities. He said the combined approach goes beyond these issues by alerting the trauma team early on to abnormal values "rather than waiting until the reserves are tapped." He noted that elderly trauma patients often present with occult hypotension leading to bias and that the literature is replete with data showing that not enough attention is paid to this population until it is too late.

Later, in a interview following the meeting, Dr. Bradburn explained that his trauma team managed the patients "from the bay to discharge."

Additional input from the geriatric team included recommendations continuing/discontinuing certain medications; assisting with management of delirium; and addressing DNR status, preinjury functional assessments, as well as social and rehab needs, he said.

"They were key in addressing the polypharmacy issue removing many of those medications that might lead to falls or increased risk for delirium."

Geriatricians’ direction on appropriate rehabilitation can boost measures such as 30-day mortality or 6-month mortality, he said. For example, in the case of an elderly fall resulting in a traumatic brain injury and extremity fractures, aggressive focused rehab to address the preexisting physical deficits that led to the fall, as well as the deficits acquired by the fall, would certainly improve the quality of life for that individual and potentially prevent additional falls.

At the meeting, Dr. Schulman also asked whether the high DNR rate of 20% could have contributed to the results. Dr. Bradburn responded that if a DNR is put into the regression model, it actually makes the results better, changing the odds ratio from 0.63 to 0.36.

Dr. Bradburn said his team had hoped to investigate functional outcomes, but that these data were not complete.

He noted that the current study is limited by its retrospective design and acknowledged that "from our data you cannot fully attribute its success solely to one part of our protocol." Still, he said, the benefits are "clear."

"This study lays the groundwork for a prospective multi-institutional study – in which we can potentially tease if one part of our protocol is more effective than any other."

The protocol should be replicable beyond Lancaster General Hospital, he said. "We think the approach is unique, but believe with further study we can show this can be applied at other institutions with equivalent successes."

Dr. Bradburn and Dr. Schulman reported no relevant conflicts of interest.

LAKE BUENA VISTA, FLA. – Mortality was sharply reduced in elderly patients undergoing trauma care with an aggressive protocol marked by multidisciplinary teamwork and prompt identification of occult shock.

The survival benefit was significant even among patients older than 75 years, a group with notoriously high mortality rates, Dr. Eric Bradburn said at the annual meeting of the Eastern Association for the Surgery of Trauma.

Injured geriatric patients pose unique challenges to the trauma team because of their abnormal responses to shock and injury and frequent polypharmacy. They are also increasing in numbers with today’s active geriatric population, comprising 36% of all admissions at his own level II trauma center, said Dr. Bradburn, an acute care surgeon at Lancaster General Hospital in Hershey, Pa.

With the protocol, patients older than 65 years were screened on admission for high-risk injuries, comorbidities, and/or physiologic parameters associated with increased geriatric mortality in the literature. If one or more high-risk indicator was present, a high-risk protocol was initiated that included:

• ICU admission.

• STAT arterial blood gas (ABG).

• An ABG every 4 hours, if base deficit is –6 mmol/L or more, until base deficit is –2 mmol/L.

• STAT echocardiogram (EKG).

• Basic metabolic profile; magnesium and phosphorus tests in morning.

• Prothrombin time, partial thromboplastin time, and international normalized ratio in morning.

• Neurologic checks every hour for 24 hours.

• For unexplained hemodynamic instability, obtain a STAT EKG.

• Geriatric medicine consult.

The protocol was initiated in January 2006, with all 4,534 geriatric trauma patients admitted from 2000 to 2010 included in the analysis. Of these, 309 patients died for an overall mortality rate of 6.8%, Dr. Bradburn said.

Mortality rates increased sharply at age 75 years – consistent with the literature – from less than 4% to more than 6% and rose steadily to more than 11% by age 95 years.

In multivariate adjusted analysis of 3,902 patients with full data available, mortality significantly improved for geriatric patients on the protocol (odds ratio, 0.63), he said. The receiver operating curve was 0.86. Variables includes in the analysis were Injury Severity Score (ISS), trauma level, Revised Trauma Score (RTS), and age.

Patients on the protocol had significantly lower mortality rates regardless of whether they were 75-84 years (OR, 2.72), older than 85 years (OR, 4.62), had an Injury Severity Score of 17-25 (OR, 6.45) or ISS greater than 25 (OR, 15.93).

Furthermore, mortality was significantly lower among patients who received the full protocol even at the highest ISS categories, compared with those who did not receive the protocol or received either the protocol or the geriatric consult, "demonstrating the synergy and impact our full protocol has on this population," Dr. Bradburn said.

"We believe the implications of this study demonstrate that an aggressive approach to the geriatric trauma patient can result in a positive outcome in this population," he concluded.

Invited discussant Dr. Carl Schulman, a trauma and burn surgeon at the University of Miami’s Ryder Trauma Center, pointed out that geriatric consultations alone have been shown to improve mortality.

"Can you really show that your protocol added anything to this?" he asked. "Maybe all the results you have shown are from the geriatric consult alone, and this geriatric protocol is unnecessary. This would save a lot of unnecessary testing and improve the cost/benefit ratio, by simply having the geriatric consult."

The audience also questioned what services the geriatricians provided.

Dr. Bradburn said the geriatricians assisted most with social, rehabilitative, and end-of-life issues and medication issues, but also managed some comorbidities. He said the combined approach goes beyond these issues by alerting the trauma team early on to abnormal values "rather than waiting until the reserves are tapped." He noted that elderly trauma patients often present with occult hypotension leading to bias and that the literature is replete with data showing that not enough attention is paid to this population until it is too late.

Later, in a interview following the meeting, Dr. Bradburn explained that his trauma team managed the patients "from the bay to discharge."

Additional input from the geriatric team included recommendations continuing/discontinuing certain medications; assisting with management of delirium; and addressing DNR status, preinjury functional assessments, as well as social and rehab needs, he said.

"They were key in addressing the polypharmacy issue removing many of those medications that might lead to falls or increased risk for delirium."

Geriatricians’ direction on appropriate rehabilitation can boost measures such as 30-day mortality or 6-month mortality, he said. For example, in the case of an elderly fall resulting in a traumatic brain injury and extremity fractures, aggressive focused rehab to address the preexisting physical deficits that led to the fall, as well as the deficits acquired by the fall, would certainly improve the quality of life for that individual and potentially prevent additional falls.

At the meeting, Dr. Schulman also asked whether the high DNR rate of 20% could have contributed to the results. Dr. Bradburn responded that if a DNR is put into the regression model, it actually makes the results better, changing the odds ratio from 0.63 to 0.36.

Dr. Bradburn said his team had hoped to investigate functional outcomes, but that these data were not complete.

He noted that the current study is limited by its retrospective design and acknowledged that "from our data you cannot fully attribute its success solely to one part of our protocol." Still, he said, the benefits are "clear."

"This study lays the groundwork for a prospective multi-institutional study – in which we can potentially tease if one part of our protocol is more effective than any other."

The protocol should be replicable beyond Lancaster General Hospital, he said. "We think the approach is unique, but believe with further study we can show this can be applied at other institutions with equivalent successes."

Dr. Bradburn and Dr. Schulman reported no relevant conflicts of interest.