Betwixt and between: a surgical post-acute treatment unit (SPA) for the optimal care of elderly patients with isolated hip fractures

Exploring geriatric trauma unit experiences through patients' eyes: a qualitative study

INTRODUCTION

The surgical management of older patients is complex due to age-related underlying comorbidities and decreased physiological reserves. Comanaged care models, such as the Geriatric Trauma Unit, are proven effective in treating the complex needs of patients with fall-related injuries. While patient-centered care is an important feature of these comanaged care models, there has been minimal research dedicated to investigating the patient experience within Geriatric Trauma Units. Therefore, it remains uncertain whether the Geriatric Trauma Unit's emphasis on a patient-centered approach truly manifests in these interactions. This study explores how patients with fall-related injuries admitted to a Geriatric Trauma Unit perceive and experience patient-centered care during hospitalization.

METHODS

This qualitative generic study was conducted in three teaching hospitals that integrated the principles of comanaged care in trauma care for older patients. Between January 2021 and May 2022, 21 patients were interviewed.

RESULTS

The findings highlight the formidable challenges that older patients encounter during their treatment for fall-related injuries, which often signify a loss of independence and personal autonomy. The findings revealed a gap in the consistent and continuous implementation of patient-centered care, with many healthcare professionals still viewing patients mainly through the lens of their injuries, rather than as individuals with distinct healthcare needs. Although focusing on fracture-specific care and physical rehabilitation aligns with some patient preferences, overlooking broader needs undermines the comprehensive approach to care in the Geriatric Trauma Unit.

CONCLUSION

Effective patient-centered care in Geriatric Trauma Units requires full adherence to its core elements: patient engagement, strong patient-provider relationships, and a patient-focused environment. This study shows that deviations from these principles can undermine care, emphasizing the need for a holistic approach that extends beyond treating immediate medical conditions.

The effect of geriatric comanagement (GC) in geriatric trauma patients treated in a level 1 trauma setting: A comparison of data before and after the implementation of a certified geriatric trauma center

INTRODUCTION

Improvements in life expectancy imply that an increase of geriatric trauma patients occurs. These patients require special attention due to their multiple comorbidity issues. The aim of this study was to assess the impact of the implementation of geriatric comanagement (GC) on the allocation and clinical outcome of geriatric trauma patients.

METHODS

This observational cohort study aims to compare the demographic development and the clinical outcome in geriatric trauma patients (aged 70 years and older) before and after implementation of a certified geriatric trauma center (GC). Geriatric trauma patients admitted between January 1, 2010 and December 31, 2010 were stratified to group pre-GC and admissions between January 1, 2018 and December 31, 2018 to Group post-GC. We excluded patients requiring end-of-life treatment and those who died within 24 h or due to severe traumatic brain injury. Outcome parameters included demographic changes, medical complexity (measured by American Society of Anaesthesiology Score (ASA) and Charlson Comorbidity Index (CCI)), in-hospital mortality and length of hospitalization.

RESULTS

This study includes 626 patients in Group pre-GC (mean age 80.3 ± 6.7 years) and 841 patients in Group post-GC (mean age 81.1 ± 7.3 years). Group pre-GC included 244 (39.0%) males, group post-GC included 361 (42.9%) males. The mean CCI was 4.7 (± 1.8) points in pre-GC and 5.1 (± 2.0) points in post-GC (p <0.001). In Group pre-GC, 100 patients (16.0%) were stratified as ASA 1 compared with 47 patients (5.6%) in Group post-GC (p <0.001). Group pre-GC had significantly less patients stratified as ASA 3 or higher (n = 235, 37.5%) compared with Group post-GC (n = 389, 46.3%, p <0.001). Length of stay (LOS) decreased significantly from 10.4 (± 20.3) days in Group pre-GC to 7.9 (±22.9) days in Group post-GC (p = 0.011). The 30-day mortality rate was comparable amongst these groups (pre-GC 8.8% vs. post-GC 8.9%).

CONCLUSION

This study appears to support the implementation of a geriatric trauma center, as certain improvements in the patient care were found: Despite a higher CCI and a higher number of patients with higher ASA classifications, Hospital LOS, complication rates and mortality did were not increased after implementation of the CG. The increase in the case numbers supports the fact that a higher degree of specialization leads to a response by admitting physicians, as it exceeded the expectable trend of demographic ageing. We feel that a larger data base, hopefully in a multi center set up should be undertaken to verify these results.

Does a Surgical Post-Acute Unit Help Elders With Rib Fractures? Definitely Maybe!

A surgical post-acute treatment unit (SPA) was developed for acutely injured elderly patients who no longer warranted acute care in an intensive care setting to decrease complications by focusing increased bedside attention to cognition, nutrition, respiration, and mobilization. A retrospective review was performed comparing patients 65 years and older with isolated rib fractures treated before the SPA was opened with patients treated in the SPA. The 2 populations were comparable except the SPA group had a higher mean Injury Severity Score. Nine complications occurred in the pre-SPA group, and no complications occurred in the SPA patient population. Four patients in the pre-SPA group died compared with zero deaths for the SPA group. The rates of complications and mortality between elderly patients with isolated rib fractures were not statistically different between patients treated with a traditional admission to an inpatient ward and patients admitted to the SPA, even though the SPA patients had significantly more severe chest injuries. Establishing a physical environment to support the needs of elderly trauma patients with isolated rib fractures who no longer need the intensive care unit (ICU) is effective in decreasing the complications and unplanned returns to the ICU.