Optimizing Geriatric Traumacare

Abstract

Chapter 2 presented a clinical lesson on the importance of a multidisciplinary approach and concentration of care. It emphasized that hip fractures in geriatric patients are a major public health problem, with high morbidity, mortality, and health and social care costs. Recent literature showed that a multidisciplinary approach and concentration of care result in better outcome of geriatric trauma patients.

In chapter 3, the implementation of a traumageriatric treatment model (GFC) for hip fracture patients in Switzerland was evaluated. The implementation of the GFC led to improved processes and outcomes for geriatric patients with THFs with a mortality reduction and reduced HLOS. Increased awareness and recognition led to an increase in the diagnosis of complications that would otherwise remain untreated. Expanding these efforts could lead to a significant reduction of morbidity and mortality in the future.

In chapter 4, the implementation of an orthogeriatric trauma unit for hip fracture patients in the Netherlands was evaluated. After implementation, there was a significant decrease in postoperative complications and turnaround time at the emergency department was reduced by 38 minutes. Additionally, there was significantly fewer missing data after implementation of the orthogeriatric trauma unit. After correcting for covariates, patients in the orthogeriatric trauma unit cohort had a lower chance of complications and a lower chance of 1-year mortality.

In chapter 5, two geriatric treatment models (geriatric care pathway vs. extensive standard care) for hip fracture patients in the Netherlands were compared. No differences in postoperative complications, 30-day mortality, hospital length of stay (HLOS) and the amount of secondary surgical interventions were found. This inter-hospital comparison of two types of geriatric care models showed no outcome that favors one specific geriatric care model over another.

In chapter 6, two traumageriatric care models, one Swiss (CH) and one Dutch (NL) were compared, to assess whether these models would perform similarly despite the possible differences in local clinical practices. This study showed that quality of care in terms of mortality was equal. The difference in complicated course was mainly caused by a difference in delirium diagnosis. Differences were seen in surgical techniques, operation duration and timing. The local clinical practices did not result in a difference in patient outcomes between the two care pathways.

In chapter 7 we evaluated if the Parker Mobility Score (PMS) was associated with discharge disposition and HLOS of geriatric traumatic hip fracture patients and whether it could be incorporated in a decision tree for the prediction of discharge disposition upon admittance. The PMS was strongly associated with discharge disposition and HLOS. The decision tree for the discharge disposition of geriatric traumatic hip fracture patients offers a practical solution to start discharge planning upon admittance which could potentially reduce HLOS.

In chapter 8, the effect of a preoperative hemodynamic preconditioning (PHP) protocol using only clinical parameters to assess cardiovascular performance was examined. Patients who had been treated according to the PHP protocol showed a significant reduction in mortality at 30 days and a reduced mortality at 90 days and at 1 year, respectively. The PHP protocol is a safe, strictly regulated, non-invasive fluid resuscitation protocol for the optimization of geriatric patients with a THF that requires minimal effort.

Chapter 9 showed the inter-rater agreement in pPOSSUM scores of geriatric trauma patients in a prospective evaluation. The overall inter-rater agreement of clinicians and interdisciplinary agreement when scoring geriatric hip fracture patients with pPOSSUM was low and prone to subjectivity. A higher work-experience level did not lead to better agreement. When pPOSSUM is calculated without clinical assessment by the same clinician, caution is advised to prevent over-reliance on the pPOSSUM risk prediction model.