Optimizing Outcomes for Frail High Risk Seniors Through Specialist and Primary Care Collaborative

Models: The Geriatric Trauma Collaborative

Camilla Wong, MD FRCPC MHScGeriatrician, St. Michael’s HospitalProject Investigator, Li Ka Shing Knowledge InstituteAssistant Professor, University of Toronto

The Toronto Star, August 2 2011

A comprehensive geriatric assessment (CGA) is a multidimensional, interdisciplinary diagnostic process to determine the medical, psychological, and functional capabilities of a frail elderly person in order to develop a coordinated and integrated plan for treatment and long-term follow-up

TRAUMA

protocols

extricationsubdural hematoma

vasopressors

third degree burns

REBOA

intubation

injury severity score

FASTfalls

Glascow coma scale (GCS)

transfusion

retroperitoneal bleeding

resuscitationanxiety

gun shot wound

oxygenation

seizurenpo

facial fractures

cardiacarrest

Aspen collar

agitationsplenic laceration

traumatic brain injurylog roll precautions

reperfusion

sedation

subarachnoid hemorrhage

crystalloids

fentanyl

plasma

liver laceration

ischemiatransexamic acid

Octaplex

shock

multimorbidity

evidence

dementia depression

hypertension

diabetes mellitus

stroke

parkinsons

osteoporosis

painfalls

benign prostatic hypertrophy

incontinence

prostate cancer

polypharmacyanxiety

osteoarthritis

colon cancer

seizurecirrhosis

cataracts

maculardegeneration

presbycusis

glaucoma

insomniaconstipation

functional decline

chronic kidney disease

hypothyroidism

hip fracture

myelodysplastic syndrome

GERIATRIC TRAUMA

.

Medication review

Sensory impairment

Pain

NutritionMood

Mobilization

Other medical complications

ContinenceRestraints

Discharge planning

ComorbiditiesFall risk

Beers criteria

Decubitus risk

Cognition

Delirium

Ann Surg 2012;256: 1098–1101.

93%

9.6%

4.8%

Adherence rate to recommendations.

Reduction in discharge to long term care. 6.5% vs 1.7%, p=0.03

Reduction in delirium. 50.5% vs 40.9%, p<.05

Proactive Geriatric Trauma Consultation ServiceCGA within 72 hours of admission by a clinical nurse specialist and geriatrician, verbal and written communication of recommendations, weekly interdisciplinary meetings with the trauma team, and measurement of quality indicators.

Camilla L. WongRaghda Al AtiaAmanda McFarlanHolly Y. LeeChristina ValiaveettilBarbara Haas

Can J Surg 2016, in press.

S W

O T

Who Is Involved

WEAKNESSES

• regular turnover of trainees

• rotating geriatricians• rotating trauma surgeons

STRENGTHS

• paired leadership• MD-MD• nursing-nursing• research-research• students-students

THREATS

• succession planning for clinical nurse specialist in geriatrics

OPPORTUNITIES

• other hospitals interested in adopting this model

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O T

Funding Sustainability

WEAKNESSES

• funding model is not based on service volumes

STRENGTHS

• incorporated into existing larger service

• publication on sustainability of care model

THREATS

• <speaker censored views on trajectory of health care funding>

OPPORTUNITIES

• research grants to support model evaluation

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Policy Support

WEAKNESSES

• lack of awareness of the policy

STRENGTHS

• hospital-based policy to operationalize the referrals and program

• American College Surgeon guidelines

THREATS

• elder care is not part of the hospital strategic plan

OPPORTUNITIES

• opportunity for Canadian guidelines (Trauma Association of Canada)

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Setting

WEAKNESSES

• geriatric clinicians are not co-located on the trauma ward

STRENGTHS

• co-location of all trauma patients

• high staff retention• academic Level I trauma

centre supports innovation

THREATS

• chaotic physical environment

OPPORTUNITIES

• building of a new patient care tower

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Decision-Making

WEAKNESSES

• some elements are consultative (intentional)

STRENGTHS

• multimodal timely communication between geriatric and trauma teams

• 93% adherence rate

THREATS

• lack of after hours presence of geriatrics

OPPORTUNITIES

• Nurses Improving Care for Healthsystem Elders (NICHE)

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Geriatrician Selection

WEAKNESSES

• rotating geriatricians• rotating trauma

surgeons

STRENGTHS

• the secret sauce is the clinical nurse specialist in geriatrics (consistent)

THREATS

• parental leave

OPPORTUNITIES

• increase in number of new geriatricians trained

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Patient Selection

WEAKNESSES

• triage mechanism is defined by age and trauma, rather than risk stratification by frailty

STRENGTHS

• simple eligibility criteria: 65 years or older admitted to the trauma service

THREATS

• patient identification is done by one individual

OPPORTUNITIES

• current research study on pre-admission frailty and adverse outcomes in geriatric trauma

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AGS Person-Centred Care

WEAKNESSES

• variable integrated, timely communication with primary care

• more than one point of contact

STRENGTHS

• weekly interprofessional care rounds, case manager

• therapeutic harmonization is at the centre of CGA

• delirium education

THREATS

• TQIP quality indicators do not include person-centre outcome reporting

OPPORTUNITIES

• published data on clinical outcomes, but room for patient feedback metrics

• NICHE

You are invitedTO COFFEE WITH TRAUMA.

HALLWAY CONVERSATIONS TO FOLLOW.

What was easy.

Facilitators.

RESEARCH (EVALUATION) DRIVES SUSTAINABILITYWhen you have positive, measurable, published, impact, everyone will want to keep the collaboration model going.

What was challenging.

TRYING TO SPEAK THE SAME LINGO.There is so much to learn about the other field.

TRUST

There must be mutual respect for one another’s domain of expertise.

Elements for success.

Threats.

EVERYONE WANTS IN.geriatric cardiologygeriatric nephrologyperioperative geriatricsgeriatric oncology

Opportunities.

Refinement.Current research focus on using pre-trauma frailty to refine patient selection criteria.

How this model could be more collaborative.

GRASSROOTSAPPROACH

The passion has to come from the FRONTLINE from both sides of the field.

Tip for collaborative care models.

GERIATRIC TRAUMA

… and they lived happily ever after.