Implementation of new standard operating procedures for geriatric trauma patients with multiple injuries: a single level I trauma centre study

Lorenz Peterer, Christian Ossendorf, Kai Oliver Jensen, Georg Osterhoff, Ladislav Mica, Burkhardt Seifert, Clément M L Werner, Hans-Peter Simmen, Hans-Christoph Pape, Kai Sprengel, Lorenz Peterer, Christian Ossendorf, Kai Oliver Jensen, Georg Osterhoff, Ladislav Mica, Burkhardt Seifert, Clément M L Werner, Hans-Peter Simmen, Hans-Christoph Pape, Kai Sprengel

Abstract

Background: The demographic changes towards ageing of the populations in developed countries impose a challenge to trauma centres, as geriatric trauma patients require specific diagnostic and therapeutic procedures. This study investigated whether the integration of new standard operating procedures (SOPs) for the resuscitation room (ER) has an impact on the clinical course in geriatric patients. The new SOPs were designed for severely injured adult trauma patients, based on the Advanced Trauma Life Support (ATLS) and imply early whole-body computed tomography (CT), damage control surgery, and the use of goal-directed coagulation management.

Methods: Single-centre cohort study. We included all patients ≥65 years of age with an Injury Severity Score (ISS) ≥ 9 who were admitted to our hospital primarily via ER. A historic cohort was compared to a cohort after the implementation of the new SOPs.

Results: We enrolled 311 patients who met the inclusion criteria between 2000 and 2006 (group PreSOP) and 2010-2012 (group SOP). There was a significant reduction in the mortality rate after the implementation of the new SOPs (P = .001). This benefit was seen only for severely injured patients (ISS ≥ 16), but not for moderately injured patients (ISS 9-15). There were no differences with regard to infection rates or rate of palliative care.

Conclusions: We found an association between implementation of new ER SOPs, and a lower mortality rate in severely injured geriatric trauma patients, whereas moderately injured patients did not obtain the same benefit.

Trial registration: Clinicaltrials.gov NCT03319381, retrospectively registered 24 October 2017.

Keywords: Algorithm; Geriatrics; In-hospital mortality; Multiple trauma; Standard of care.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Percental proportions in age groups for all trauma patients. Absolute numbers within the bars
Fig. 2
Fig. 2
Flow chart illustrating the patient inclusion and exclusion criteria
Fig. 3
Fig. 3
Percental proportions in age groups for study population. Absolute numbers within the bars
Fig. 4
Fig. 4
Percental proportions of mortality for study population. Percentage within the bars

References

    1. McNicoll G. World Population Ageing: 1950–2050. New York: United Nations Population Division; 2001.
    1. Population structure and ageing []. Accessed 4 July 2017.
    1. Übersicht []. Accessed 4 July 2017.
    1. Kehoe A, Smith JE, Edwards A, Yates D, Lecky F. The changing face of major trauma in the UK. Emerg Med J. 2015;32:911–915. doi: 10.1136/emermed-2015-205265.
    1. Goodmanson NW, Rosengart MR, Barnato AE, Sperry JL, Peitzman AB, Marshall GT. Defining geriatric trauma: when does age make a difference? Surgery. 2012;152:668–674. doi: 10.1016/j.surg.2012.08.017.
    1. Finelli FC, Jonsson J, Champion HR, Morelli S, Fouty WJ. A case control study for major trauma in geriatric patients. J Trauma. 1989;29:541–548. doi: 10.1097/00005373-198905000-00001.
    1. Champion HR, Copes WS, Buyer D, Flanagan ME, Bain L, Sacco WJ. Major trauma in geriatric patients. Am J Public Health. 1989;79:1278–1282. doi: 10.2105/AJPH.79.9.1278.
    1. Perdue PW, Watts DD, Kaufmann CR, Trask AL. Differences in mortality between elderly and younger adult trauma patients: geriatric status increases risk of delayed death. J Trauma. 1998;45:805–810. doi: 10.1097/00005373-199810000-00034.
    1. Taylor MD, Tracy JK, Meyer W, Pasquale M, Napolitano LM. Trauma in the elderly: intensive care unit resource use and outcome. J Trauma. 2002;53:407–414. doi: 10.1097/00005373-200209000-00001.
    1. Vanzant EL, Hilton RE, Lopez CM, Zhang J, Ungaro RF, Gentile LF, Szpila BE, Maier RV, Cuschieri J, Bihorac A, et al. Advanced age is associated with worsened outcomes and a unique genomic response in severely injured patients with hemorrhagic shock. Crit Care. 2015;19:77. doi: 10.1186/s13054-015-0788-x.
    1. Butcher SK, Killampalli V, Chahal H, Kaya Alpar E, Lord JM. Effect of age on susceptibility to post-traumatic infection in the elderly. Biochem Soc Trans. 2003;31:449–451. doi: 10.1042/bst0310449.
    1. McMahon DJ, Schwab CW, Kauder D. Comorbidity and the elderly trauma patient. World J Surg. 1996;20:1113–1119. doi: 10.1007/s002689900170.
    1. Robinson TN, Walston JD, Brummel NE, Deiner S, Brown CH, Kennedy M, Hurria A. Frailty for surgeons: review of a National Institute on Aging conference on frailty for specialists. J Am Coll Surg. 2015;221:1083–1092. doi: 10.1016/j.jamcollsurg.2015.08.428.
    1. Boltz MM, Podany AB, Hollenbeak CS, Armen SB. Injuries and outcomes associated with traumatic falls in the elderly population on oral anticoagulant therapy. Injury. 2015;46:1765–1771. doi: 10.1016/j.injury.2015.06.013.
    1. Dasgupta M, Rolfson DB, Stolee P, Borrie MJ, Speechley M. Frailty is associated with postoperative complications in older adults with medical problems. Arch Gerontol Geriatr. 2009;48:78–83. doi: 10.1016/j.archger.2007.10.007.
    1. Lehmann R, Beekley A, Casey L, Salim A, Martin M. The impact of advanced age on trauma triage decisions and outcomes: a statewide analysis. Am J Surg. 2009;197:571–574. doi: 10.1016/j.amjsurg.2008.12.037.
    1. New Frontiers in Geriatrics Research: An Agenda for Surgical and Related Medical Specialties []. Accessed 4 July 2017.
    1. STROBE Statement []. Accessed 4 July 2017.
    1. Gennarelli TAWE, Champion HR, MacKenzie EJ, Segui-Gomez M, Augenstein J, Civil I, Cushing B, Esposito T, Mackay M. Abbreviated Injury Scale 2005. Update 2008. Barrington: Association for the Advancement of Automotive Medicine; 2008.
    1. Baker SP, O’Neill B, Haddon W, Long WB. The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma. 1974;14:187–196. doi: 10.1097/00005373-197403000-00001.
    1. Osler T, Baker SP, Long W. A modification of the injury severity score that both improves accuracy and simplifies scoring. J Trauma. 1997;43:922–925. doi: 10.1097/00005373-199712000-00009.
    1. Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet. 1974;2:81–84. doi: 10.1016/S0140-6736(74)91639-0.
    1. Callaway DW, Shapiro NI, Donnino MW, Baker C, Rosen CL. Serum lactate and base deficit as predictors of mortality in normotensive elderly blunt trauma patients. J Trauma. 2009;66:1040–1044. doi: 10.1097/TA.0b013e3181895e9e.
    1. Salottolo KM, Mains CW, Offner PJ, Bourg PW, Bar-Or D. A retrospective analysis of geriatric trauma patients: venous lactate is a better predictor of mortality than traditional vital signs. Scand J Trauma Resusc Emerg Med. 2013;21:7. doi: 10.1186/1757-7241-21-7.
    1. Braun BJ, Holstein J, Fritz T, Veith NT, Herath S, Mörsdorf P, Pohlemann T. Polytrauma in the elderly: a review. EFORT Open Rev. 2016;1:146–151. doi: 10.1302/2058-5241.1.160002.
    1. Coleman J, Baldawi M, Heidt D. The effect anticoagulation status on geriatric fall trauma patients. Am J Surg. 2016;212:1237–1242. doi: 10.1016/j.amjsurg.2016.09.036.
    1. Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Crit Care Med. 1985;13:818–829. doi: 10.1097/00003246-198510000-00009.
    1. Boyd CR, Tolson MA, Copes WS. Evaluating trauma care: the TRISS method. Trauma score and the injury severity score. J Trauma. 1987;27:370–378. doi: 10.1097/00005373-198704000-00005.
    1. Advanced Trauma Life Support (ATLS) Student Course Manual. Ninth Edition. Chicago: American College of Surgeon; 2012.
    1. Stein P., Kaserer A., Sprengel K., Wanner G. A., Seifert B., Theusinger O. M., Spahn D. R. Change of transfusion and treatment paradigm in major trauma patients. Anaesthesia. 2017;72(11):1317–1326. doi: 10.1111/anae.13920.
    1. Grimshaw JM, Russell IT. Effect of clinical guidelines on medical practice: a systematic review of rigorous evaluations. Lancet. 1993;342:1317–1322. doi: 10.1016/0140-6736(93)92244-N.
    1. Rice TW, Morris S, Tortella BJ, Wheeler AP, Christensen MC. Deviations from evidence-based clinical management guidelines increase mortality in critically injured trauma patients*. Crit Care Med. 2012;40:778–786. doi: 10.1097/CCM.0b013e318236f168.
    1. Schoeneberg C, Schilling M, Burggraf M, Fochtmann U, Lendemans S. Reduction in mortality in severely injured patients following the introduction of the “treatment of patients with severe and multiple injuries” guideline of the German society of trauma surgery--a retrospective analysis of a level 1 trauma center (2010-2012) Injury. 2014;45:635–638. doi: 10.1016/j.injury.2013.11.024.
    1. Huber-Wagner S, Lefering R, Qvick LM, Körner M, Kay MV, Pfeifer KJ, Reiser M, Mutschler W, Kanz KG. Society WGoPotGT: effect of whole-body CT during trauma resuscitation on survival: a retrospective, multicentre study. Lancet. 2009;373:1455–1461. doi: 10.1016/S0140-6736(09)60232-4.
    1. Jiang L, Ma Y, Jiang S, Ye L, Zheng Z, Xu Y, Zhang M. Comparison of whole-body computed tomography vs selective radiological imaging on outcomes in major trauma patients: a meta-analysis. Scand J Trauma Resusc Emerg Med. 2014;22:54. doi: 10.1186/s13049-014-0054-2.
    1. Huber-Wagner S, Biberthaler P, Häberle S, Wierer M, Dobritz M, Rummeny E, van Griensven M, Kanz KG, Lefering R, DGU T. Whole-body CT in haemodynamically unstable severely injured patients--a retrospective, multicentre study. PLoS One. 2013;8:e68880. doi: 10.1371/journal.pone.0068880.
    1. Sierink JC, Treskes K, Edwards MJ, Beuker BJ, den Hartog D, Hohmann J, Dijkgraaf MG, Luitse JS, Beenen LF, Hollmann MW, et al. Immediate total-body CT scanning versus conventional imaging and selective CT scanning in patients with severe trauma (REACT-2): a randomised controlled trial. Lancet. 2016;388:673–683. doi: 10.1016/S0140-6736(16)30932-1.
    1. Huber-Wagner S, Lefering R, Kanz KG, Biberthaler P, Stengel D. The importance of immediate total-body CT scanning. Lancet. 2017;389:502–503. doi: 10.1016/S0140-6736(17)30232-5.
    1. Wurmb TE, Bernhard M. Total-body CT for initial diagnosis of severe trauma. Lancet. 2016;388:636–638. doi: 10.1016/S0140-6736(16)30933-3.
    1. Gordic S, Alkadhi H, Hodel S, Simmen HP, Brueesch M, Frauenfelder T, Wanner GA, Sprengel K. Whole-body CT-based imaging algorithm for multiple trauma patients: radiation dose and time to diagnosis. Br J Radiol. 2015;88:20140616. doi: 10.1259/bjr.20140616.
    1. Rossaint R, Bouillon B, Cerny V, Coats TJ, Duranteau J, Fernández-Mondéjar E, Filipescu D, Hunt BJ, Komadina R, Nardi G, et al. The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition. Crit Care. 2016;20:100. doi: 10.1186/s13054-016-1265-x.
    1. Spahn DR, Spahn GH, Stein P. Evidence base for restrictive transfusion triggers in high-risk patients. Transfus Med Hemother. 2015;42:110–114. doi: 10.1159/000381509.
    1. Rotondo MF, Schwab CW, McGonigal MD, Phillips GR, Fruchterman TM, Kauder DR, Latenser BA, Angood PA. ‘Damage control’: an approach for improved survival in exsanguinating penetrating abdominal injury. J Trauma. 1993;35:375–382. doi: 10.1097/00005373-199309000-00008.
    1. Taeger G, Ruchholtz S, Waydhas C, Lewan U, Schmidt B, Nast-Kolb D. Damage control orthopedics in patients with multiple injuries is effective, time saving, and safe. J Trauma. 2005;59:409–416. doi: 10.1097/01.ta.0000175088.29170.3e.
    1. Pape HC, Tornetta P, Tarkin I, Tzioupis C, Sabeson V, Olson SA. Timing of fracture fixation in multitrauma patients: the role of early total care and damage control surgery. J Am Acad Orthop Surg. 2009;17:541–549. doi: 10.5435/00124635-200909000-00001.
    1. Gubler KD, Davis R, Koepsell T, Soderberg R, Maier RV, Rivara FP. Long-term survival of elderly trauma patients. Arch Surg. 1997;132:1010–1014. doi: 10.1001/archsurg.1997.01430330076013.
    1. Fleischman RJ, Adams AL, Hedges JR, Ma OJ, Mullins RJ, Newgard CD. The optimum follow-up period for assessing mortality outcomes in injured older adults. J Am Geriatr Soc. 2010;58:1843–1849. doi: 10.1111/j.1532-5415.2010.03065.x.
    1. Wong TH, Nadkarni NV, Nguyen HV, Lim GH, Matchar DB, Seow DCC, King NKK, Ong MEH. One-year and three-year mortality prediction in adult major blunt trauma survivors: a National Retrospective Cohort Analysis. Scand J Trauma Resusc Emerg Med. 2018;26:28. doi: 10.1186/s13049-018-0497-y.
    1. Kozar RA, Arbabi S, Stein DM, Shackford SR, Barraco RD, Biffl WL, Brasel KJ, Cooper Z, Fakhry SM, Livingston D, et al. Injury in the aged: geriatric trauma care at the crossroads. J Trauma Acute Care Surg. 2015;78:1197–1209. doi: 10.1097/TA.0000000000000656.
    1. Olufajo OA, Tulebaev S, Javedan H, Gates J, Wang J, Duarte M, Kelly E, Lilley E, Salim A, Cooper Z. Integrating geriatric consults into routine Care of Older Trauma Patients: one-year experience of a level I trauma center. J Am Coll Surg. 2016;222:1029–1035. doi: 10.1016/j.jamcollsurg.2015.12.058.
    1. Middleton M, Wan B, da Assunçao R. Improving hip fracture outcomes with integrated orthogeriatric care: a comparison between two accepted orthogeriatric models. Age Ageing. 2017;46:465–470.
    1. Havens JM, Olufajo OA, Tsai TC, Jiang W, Columbus AB, Nitzschke SL, Cooper Z, Salim A. Hospital factors associated with care discontinuity following emergency general surgery. JAMA Surg. 2017;152:242–249. doi: 10.1001/jamasurg.2016.4078.
    1. DGU(®) T 20 years of trauma documentation in Germany--actual trends and developments. Injury. 2014;45(Suppl 3):S14–S19.
    1. Helling TS, Watkins M, Evans LL, Nelson PW, Shook JW, Van Way CW. Low falls: an underappreciated mechanism of injury. J Trauma. 1999;46:453–456. doi: 10.1097/00005373-199903000-00019.
    1. Richmond TS, Kauder D, Strumpf N, Meredith T. Characteristics and outcomes of serious traumatic injury in older adults. J Am Geriatr Soc. 2002;50:215–222. doi: 10.1046/j.1532-5415.2002.50051.x.
    1. Schönenberger A, Billeter AT, Seifert B, Neuhaus V, Trentz O, Turina M. Opportunities for improved trauma care of the elderly - a single center analysis of 2090 severely injured patients. Arch Gerontol Geriatr. 2012;55:660–666. doi: 10.1016/j.archger.2012.02.013.
    1. Matsushima K, Schaefer EW, Won EJ, Armen SB, Indeck MC, Soybel DI. Positive and negative volume-outcome relationships in the geriatric trauma population. JAMA Surg. 2014;149:319–326. doi: 10.1001/jamasurg.2013.4834.
    1. Zafar SN, Obirieze A, Schneider EB, Hashmi ZG, Scott VK, Greene WR, Efron DT, MacKenzie EJ, Cornwell EE, Haider AH. Outcomes of trauma care at centers treating a higher proportion of older patients: the case for geriatric trauma centers. J Trauma Acute Care Surg. 2015;78:852–859. doi: 10.1097/TA.0000000000000557.
    1. Olufajo OA, Metcalfe D, Rios-Diaz A, Lilley E, Havens JM, Kelly E, Weissman JS, Haider AH, Salim A, Cooper Z. Does Hospital Experience Rather than Volume Improve Outcomes in Geriatric Trauma Patients? J Am Coll Surg. 2016;223:32–40.e31. doi: 10.1016/j.jamcollsurg.2016.02.002.
    1. Caterino JM, Valasek T, Werman HA. Identification of an age cutoff for increased mortality in patients with elderly trauma. Am J Emerg Med. 2010;28:151–158. doi: 10.1016/j.ajem.2008.10.027.
    1. Bochicchio GV, Joshi M, Knorr KM, Scalea TM. Impact of nosocomial infections in trauma: does age make a difference? J Trauma. 2001;50:612–617. doi: 10.1097/00005373-200104000-00004.
    1. Blot S, Koulenti D, Dimopoulos G, Martin C, Komnos A, Krueger WA, Spina G, Armaganidis A, Rello J, Investigators E-VS. Prevalence, risk factors, and mortality for ventilator-associated pneumonia in middle-aged, old, and very old critically ill patients*. Crit Care Med. 2014;42:601–609. doi: 10.1097/01.ccm.0000435665.07446.50.
    1. Hazeldine J, Lord JM, Hampson P. Immunesenescence and inflammaging: a contributory factor in the poor outcome of the geriatric trauma patient. Ageing Res Rev. 2015;24:349–357. doi: 10.1016/j.arr.2015.10.003.
    1. Abstracts 105. Jahreskongress der Schweizerischen Gesellschaft für Chirurgie. Swiss Knife. 2018;15(Special Edition):52.
    1. ECTES Abstracts 2018. Eur J Trauma Emerg Surg. 2018;44(Suppl 2):430–431.

Source: PubMed

Szponzorok és közreműködők

Egészségi állapot

Kábítószer-beavatkozások

3
Iratkozz fel