Assessing Older Trauma Patients to Ensure They Get the Specialized Care They Need

Closeup shot of an elderly man holding his wife's hand while she is ill in the hospitalWhen an older person suffers a trauma resulting in multiple broken bones and other injuries, often due to a fall or car accident, ensuring he or she gets appropriate care can be challenging. This is especially true when health care providers don’t have training or experience in geriatrics.

For that reason, Brigham and Women’s Hospital established a program whereby every person aged 65 or above who is admitted for trauma receives a frailty assessment. Frailty is a complex syndrome that’s usually related to age. It is characterized by physical decline and increased vulnerability to external insults such as trauma, infections and other acute illnesses.

“We are possibly the only hospital in the country that has trained our surgical residents to do these frailty assessments at the time of admission,” said Samir Tulebaev, MD, of the Brigham’s Division of Aging, who developed the Geriatric Co-Management Service. “We’ve created a system in which the patients who may need extra care are identified right away. That’s important, because people who are frail are less likely to recover if they don’t get the care they need.”

Any trauma patient who is identified as frail is put into the Frailty Identification and Care Pathway. This program, which was launched in 2016, includes a comprehensive geriatric assessment by Dr. Tulebaev or one of the other two geriatricians on the team.

During this assessment, patients are screened in a number of areas. Experts review a list of all the medications patients regularly take in order to identify anything that may cause harmful interactions or other complications. Patients are also screened for cognitive impairments, psychiatric problems such as depression and the presence of delirium. Nutritional assessments and physical therapy consultations are performed as well.

In addition to physical health, familial and social structures are crucial for the patient’s well-being and recovery after trauma. “A patient’s social domain is just as important as their physical domain,” Dr. Tulebaev said. “That’s something we always take into account. If you’re lacking in family or other social support, that will negatively influence your health.”

Taking care of frail trauma patients is a team effort. “This program is inherently multidisciplinary,” Dr. Tulebaev explained. “When we developed the protocol, we sat down and brainstormed with everyone who is involved in the frailty pathway. This includes nurses, physician assistants, nursing assistants and physical therapists. That’s a big part of what’s made it so successful.”

In May 2018, nurses at the Brigham received Magnet designation from the American Nurses Credentialing Center (ANCC). The Magnet Recognition Program honors organizations where nursing leaders play a key role in improving patient outcomes. The ANCC cited the Geriatric Co-Management Service as one of the factors that set the Brigham nurses apart and led to the designation.

Nurses have also begun to take the Frailty Identification and Care Pathway into other parts of the hospital. “When we developed the program, we envisioned it partly as a research project. And we have begun to show that it does make a difference in measures like readmission rates to the Intensive Care Unit,” Dr. Tulebaev said.

“This has been one of the most important and rewarding programs I’ve ever been a part of,” said Brigham trauma surgeon Zara Cooper, MD, who helped develop the frailty pathway. “Once we recognized that our frail older trauma patients had unique needs that weren’t being addressed, hundreds of clinicians rallied together to learn primary geriatrics and provide care in a person-centered way. This is the wave of the future.”

“One of the things that’s special about our program is that it’s so clinically oriented,” Dr. Tulebaev concluded. “We’re engaged with patients and their family members, as well as with our colleagues. This helps us to make extremely valuable contributions to the care of our patients.”

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