JULY 1, 2016
As our population ages, hospital emergency rooms will see an increasing number of older patients. This population poses unique challenges because, in the world of health care trauma, geriatric patients are at greater risk of complications and death than the overall population. A number of reasons explain this increased risk. The older a patient is, the longer it takes to recover from a traumatic injury. An older patient is more likely to have one or more underlying chronic health conditions – a comorbidity – that complicates recovery. And the longer older patients are in the hospital, the weaker they get, lessening their chances to enter rehabilitation or return home.
Recognizing the growth in the geriatric patient population and the challenges it faces, John Peter Smith (JPS) Hospital, the only Level I Trauma Center in Tarrant County, launched a multidisciplinary, specialized geriatric trauma care program – GT55 – in early 2014. The program was created by Dr. Raj Gandhi, a Texas Health Care trauma surgeon who leads the JPS trauma team; Carrie Hecht, the Administrative Director; and Elizabeth Price, an Advanced Practice Nurse Practitioner. The team collaborated to create GT55 after Dr. Gandhi attended an American College of Surgeons Trauma Quality Improvement Program conference in 2013.
“GT55 is a great example of a public-private partnership, resulting from the collaboration of JPS administration and Texas Health Care trauma surgeons,” says Dr. Gandhi. “Through this innovative program, we are providing specialized care to geriatric patients in order to reduce their stay in the hospital and get them home or into rehab as quickly as possible.”
Identifying the Need
“As our population gets older, geriatric trauma care will naturally continue to increase,” observes Dr. Gandhi. Data from the 2010 U.S. Census show there were more people over the age of 65 than in any other prior decade. Furthermore, the U.S. Department of Health and Human Services Administration on Aging projects that by 2030, persons age 65 and older will comprise 19 percent of the overall population, up from just 13 percent in 2010. In Texas, slightly more than 20 percent of the population will be age 60 or older.
At the same time that the share of older Americans is increasing, so is their activity level. An increasing number of older adults are engaging in sports and physical activity, increasing their risk for injury. And older adults are more likely to have an underlying chronic health condition, such as hypertension or diabetes, which can complicate recovery from a traumatic injury.
Elderly trauma accounts for one-quarter of all injury-related deaths and is the seventh leading cause of death overall. One of the top causes of geriatric trauma is a fall from a standing position, a trauma that often leads to a hip fracture. Hip fractures in elderly persons tend to have a high mortality rate, so specializing care for this population is particularly important.
Geriatric trauma care is complicated by several factors in addition to preexisting comorbidities. Older patients tend to have reduced lean body mass and muscle mass, reduced blood flow to lower extremities and degeneration of joints, all of which contribute to an overall physical decline. In addition, osteoporosis, frailty and reduced functional capacity and medications the patient may be on, such as anticoagulants (blood thinners), can be complicating factors. Older patients are also prone to dehydrate more easily. All of these are reasons why overall mortality rates for the geriatric population are twice as high when compared to younger patients.
How GT55 Works
Dr. Gandhi says when analyzing trauma patient data, it became clear that many patients in their mid- to late-50s and older are at greater risk of dying from a traumatic injury. Hence the name GT55 – a program designed especially for certain trauma patients age 55 and older.
When a trauma patient age 55 or older is admitted to the Emergency Department, the GT55 team conducts an evaluation to determine if a comorbid condition is present. If a patient does not require emergency surgery and meets the criteria for GT55, the multidisciplinary team comprised of Texas Health Care trauma critical care surgeons, Advanced Practice Registered Nurses, Physician Assistants, Geriatric Medicine staff and pharmacists take over the patient’s care.
The GT55 team then works to:
- Conduct a preoperative assessment for all GT55 patients. The assessment, created using guidelines from the American Heart Association, American Geriatric Society and American College of Surgeons, includes screenings for cardiac, pulmonary and renal function.
- Determine which screenings and tests must be conducted and eliminate any unnecessary screenings. “Non-essential screenings can delay surgery, and we want to eliminate every possible delay,” says Dr. Gandhi.
- Maximize pain control so the patient is as comfortable as possible. At the same time, geriatric patients need 20 – 40 percent less pain medication than younger patients, due to smaller body mass. Additionally, any time localized pain medication can be delivered to the patient, this technique is used in order to avoid the use of opiates or other strong painkillers.
- Accelerate pre-op preparations so the patient spends the least amount of time possible in the hospital. Data show that geriatric patients with a fracture that requires surgery have a four-fold increase in mortality if not taken to the operating room within 48 hours of injury. GT55’s goal is to get all such patients into surgery within 36 hours.
- Early mobilization and nutrition: Following surgery, get the patient moving as quickly as possible and provide nutrition to help rebuild strength.
- Decrease risk of delirium, especially for older patients, by carefully managing medications, keeping lights on during the day and off at night, as well as other steps.
- Decrease risk of infection by discontinuing use of intravenous lines and urinary catheters as soon as possible.
Another feature of the GT55 program is that patients’ care is overseen by a trauma intensivist, 24 hours a day, seven days a week. In addition to Dr. Gandhi, the Texas Health Care trauma intensivists at JPS are Dr. Therese Duane, Dr. Bradley Putty, Dr. Mark Tellez and Dr. Daniel Ziegler.
Why Shorter Stays Matter
Trauma surgeons agree it is critically important to reduce the time to get to the operating room. One reason for this is the patient’s strength. A patient will lose three percent of his or her muscle mass per day when confined to bed – that’s 20 percent in one week. “Because the muscles atrophy at such a rapid rate, every day we can eliminate from a patient’s hospital stay means the patient is that much stronger,” says Dr. Putty, who is associate director of the GT55 program. In addition to muscle atrophy, extended immobility increases the risk of skin breakdown, pneumonia, deep vein thrombosis and depression.
The stronger the patient is when he or she leaves the hospital, the greater the chance for recovery. The GT55 goal is to allow a hip fracture patient, when discharged from the hospital, to go home or directly to a physical rehabilitation facility, instead of a nursing home. Hip fracture patients who go straight from a hospital to a nursing home have a 75 percent one-year mortality rate because, in many cases, they are simply too weak to ever fully recover.
“Another advantage that comes with reducing the length of the hospital stay is reducing the likelihood of infection,” adds Dr. Ziegler, who serves as medical director of the JPS Intensive Care Unit.
After two and a half years, the data show the GT55 program is making a positive difference for JPS’ geriatric patients. More than 1,500 patients have been served by GT55 so far, and the results are encouraging: for all patients, the average length of stay has decreased from 6.09 days to 4.72 days since GT55 has been in effect.
For hip fracture patients, the improvements are even more dramatic: the time to the operating room has been reduced from 2.83 days to 1.72 days. Further, those patients’ length of stay has decreased from 7.94 days to 6.05 days. The most dramatic change is in the percentage of patients who are discharged to a nursing home – before GT55, 52 percent of hip fracture patients went to a nursing home; today only 20.9 percent do. The percentage of patients going home or to inpatient rehab has seen a corresponding increase.
When JPS received reverification as a Level I Trauma Center in 2015, GT 55 was one of the many positive factors the American College of Surgeons cited in its report: “The geriatric trauma service (GT55) is well-planned, executed and monitored for improvements in care.”
“GT55 has improved the efficacy of care and added to the value of care,” says Dr. Gandhi. “The public expects and deserves to see patients having better health outcomes with less cost. This value we provide with the GT55 service.”