Where Should You Start Building a Geriatric Trauma Program?

Let's say your trauma center has decided to get serious about geriatric trauma care. You have a sizeable geriatric trauma population and have been tracking some of those patients in the registry. You know that your trauma team can't take care of every injured elderly patient in the hospital, and you know you will get push-back from other specialties when you try to launch the program.

Where should you start?

Well, the good news is that you've completed the first step: acknowledging the need for change. But before you launch a new committee or unveil a new protocol, there are some key steps you can take to reduce barriers and streamline implementation.

So where should a trauma program begin?

1. Start With the Data

The best place to start is to understand your hospital's geriatric trauma population.

Older adults are not a homogeneous group and there is no single intervention that will solve every hospital's geriatric trauma challenges. A successful program should reflect the patients being treated at your hospital, the resources available at your hospital, the problems identified through data at your hospital, and the opportunities for improvement at your hospital.

Since you have to start somewhere, many programs begin with an age cutoff -- often 65 years or older. That's a reasonable starting point, but it shouldn't be the end of the analysis.

Look at your trauma registry and hospital data and characterize your population by:

• Age categories (young-old versus oldest-old)

• Mechanism of injury and injury patterns

• Injury severity

• ICU utilization

• Operative intervention

• Length of stay

• Discharge disposition

• Readmission

• Mortality

Most of these variables should already be in your registry and allow you to get a first look at the size and composition of this homogeneous patient population in your hospital.

2. Find the Problems Hiding in Your Data

Once you understand who your patients are, use some crosstabs and look for patterns.

• How long are your geriatric trauma patients staying in the hospital? Does median length of stay change based on discharge disposition, age (young-old vs. those over age 80 years), admitting service, or type of injury?

• Which geriatric patients are being admitted to the ICU? Does this vary by admitting service or injury type? Does it correlate with injury severity? Are they admitted directly to the ICU from the ED or are they going to the ICU after admission to the floor?

• What complications are geriatric patients experiencing? Do you have high rates of pressure injuries, DVTs, or pneumonia? Do those complications vary by injury type? Are there any complications that could be underreported and under-detected because you are not actively screening for them (e.g. delirium)?

• What are the characteristics of geriatric patients with low injury severity and poor outcomes? Mortality for patients initially admitted to the floor for observation?

Think critically about these patients but don't make assumptions. Use the data to drive the process by asking questions and looking at your data in different ways. This will help you find good places to start in changing care.

3. Establish a Baseline

Before implementing interventions, establish a baseline. This is one of the most frequently overlooked steps in program development.

If you don't know where you started, it becomes difficult to demonstrate whether your interventions actually made a difference.

Depending on your goals, baseline measures might include:

• Geriatric trauma volumes

• Mortality rates

• Complication rates

• ICU utilization and unplanned ICU transfers

• Median length of stay

• Median ventilator days

• 30-day readmission rates

• Consulting services (both from the surgical/medical specialties as well as the ancillary departments like PT, OT, nutrition, etc.)

  
  

Start with a manageable number of metrics that define the current state and will help you measure improvement.

4. Decide What a "Geriatric Trauma Program" Means at Your Hospital

There is no requirement that every hospital build the same model.

For one hospital, a geriatric trauma program may mean a formal geriatric trauma service with dedicated geriatric consultation.

For another, it might mean a trauma-led pathway with standardized screening and targeted consultation.

For another, it could refer to a multidisciplinary team that focuses on frailty, delirium prevention, medication management, mobility, and discharge planning.

And for a smaller or rural hospital, it may mean a standardized approach to identifying high-risk older trauma patients, with clearly defined referral and transfer pathways.

The goal is not to replicate the structure of a large academic medical center or the hospitals presenting posters at conferences. The goal is to build a model that is appropriate for your hospital's size, resources, patient population, and trauma designation level.

5. Start Screening for Geriatric Syndromes That Affect Trauma Outcomes

Use the literature and trauma care best-practices to identify the screening tools that help identify patients at risk and that can help facilitate improvement in patient outcomes. Most commonly, these often include screening tools to identify, assess, document, and monitor issues related to:

• Frailty

• Cognitive impairment

• Pre-injury functional mobility

• Polypharmacy

• Baseline activities of daily living (ADLs)

• Goals of care

It is important to ensure robust processes for these screening tools to make sure they are valid, reliable, and well documented. This allows them to drive geriatric protocols and guidelines.

6. Identify the Patients Who Need More Than "Routine" Trauma Care

Once you have good baseline data, you can start to stratify risk and identify patient populations who may need more than the routine standard of care. You can write guidelines so that a certain screening result or an accumulation of risk factors defines a consult to the geriatrician or the deployment of a risk-reducing protocol.

Some examples of criteria that might identify patients at higher risk:

• Frailty score

• Number of rib fractures

• Traumatic brain injury

• Anticoagulant use

• Cognitive impairment

• Pre-existing functional limitations

• Multiple comorbidities

• Polytrauma

• High risk for delirium

• Substance use

  
  

These criteria can help determine which patients need additional assessment or intervention. Importantly, the criteria should be specific enough to identify meaningful risk without creating an unmanageable workload.

7. Create the Right Partnerships

A geriatric trauma program cannot be built by the trauma service alone. Identify the departments and disciplines that already touch these patients.

Potential partners include:

• Geriatricians

• Trauma surgery

• Emergency medicine

• Orthopedic surgery

• Hospital medicine

• Nursing

• Pharmacy

• Physical therapy

• Occupational therapy

• Speech therapy

• Respiratory therapy

• Case management

• Social work

• Palliative care

• Nutrition

• Rehabilitation

• Home health

• Skilled nursing facilities

  
  

Determine who needs to be at the table and how you can collaboratively elevate care for patients. If you form a committee that meets monthly, make sure it is data-driven, focused, and can define improvement or meaningfully change in patient care.

8. Define Geriatric Consults or Care Pathways

Depending on the hospital's resources, most hospitals cannot dedicate time and resources for every single patient over the age of 65 years to get a geriatric consult. So you need a targeted approach that is reassessed regularly through the performance improvement process.

For example, geriatric consultation or deployment of a geriatric guideline could be triggered by:

• Positive frailty screen

• Development of delirium

• Polypharmacy

• Recurrent falls

• Functional decline

• Complex discharge needs

• Multiple comorbidities

• Goals-of-care concerns

• High-risk injury patterns

The important thing is to define the trigger clearly. A program should be able to identify which patients should receive additional geriatric expertise, who should identify them, and what happens next.

9. Build Geriatric Trauma Into PI

This is where the program becomes more than a clinical initiative. Geriatric trauma should become part of the trauma program's existing Performance Improvement and Patient Safety (PIPS) structure. Hopefully this already started in Steps 1 and 2, but now that you've implemented some changes you can start to measure progress and (hopefully) improvement.

10. Don't Forget About Discharge Practices

One of the biggest mistakes in geriatric trauma program development is focusing almost entirely on the acute hospitalization. Part of the reason for this is lack of information from the post-hospitalization period, but trauma programs can develop processes to obtain some of these data points.

Ask:

• Did the patient return to their previous living situation?

• Did they return to their previous level of independence?

• Did they require skilled nursing?

• Did someone explain their medication changes to them at discharge?

• Was fall prevention addressed?

• Did they have appropriate follow-up?

• Did they return to the emergency department?

• Were they readmitted?

  
  

A trauma program that successfully gets an older patient through surgery but sends them home with a major, unrecognized loss of function has not necessarily achieved the best possible outcome. Survival matters. Function matters, too.

What Does a Mature Geriatric Trauma Program Look Like?

A mature program isn't necessarily found at the hospital with the largest team or the most elaborate protocols. It is the program that can easily answer several fundamental questions:

• Who are our older trauma patients?

• How do we identify the patients at greatest risk?

• What interventions are we providing?

• Are those interventions happening reliably?

• Are outcomes improving?

• What have we learned from our PI data?

• What else do we have to change to continue improving geriatric trauma care?

The Bottom Line

Building geriatric trauma capability doesn't have to begin with a new service line, a large committee, or an expensive program.

• Start with the data.

• Identify the problems.

• Choose a manageable opportunity.

• Build the right interdisciplinary response.

• Measure the results.

Then let the findings guide what comes next.