PI Metrics for Geriatric Trauma -- Insight from Trauma Program Managers
Geriatric trauma is often discussed as though it were a single patient population. It isn't.
And because of that, trauma center Performance Improvement (PI) processes can't treat older adults as a single patient population, either.
A common starting point is to create a geriatric trauma PI filter based on age (typically patients 65 years and older) and monitor some basic demographics or measures of care. That's a reasonable place to begin. But a mature trauma program shouldn't stop there.
The most effective geriatric trauma PI programs use a combination of common, evidence-informed filters and program-specific filters designed around the problems their own data reveal.
I spoke with several Trauma Program Managers (TPMs) and asked them how they have used unique, program-specific PI filters to take geriatric PI to the next level.
#1. Patients with Relatively Minor Injury
A TPM from an adult Level I trauma center indicated that some of their most meaningful geriatric PI work has come from reviewing patients with relatively minor anatomic injury who experience unexpectedly prolonged hospitalizations. As the TPM noted, “These cases often uncover issues related to frailty, polypharmacy, functional decline, hypotension in the OR, or discharge planning that traditional trauma metrics may miss.”
How to do it: Start with your trauma registry and identify geriatric patients with an ISS < 8. Calculate the median LOS for this cohort, then filter to patients whose LOS exceeded the median. These cases become a targeted PI cohort for further clinical review -- patients whose hospital course was more prolonged than their relatively minor injury severity alone might suggest. Then go beyond the registry variables and reconstruct the patient's clinical trajectory to understand why the hospital course was prolonged and whether there was an opportunity for the trauma system to intervene earlier.
#2. Goals-of-Care Conversations
Another TPM at an adult Level I trauma center indicated that their hospital tracks whether and when goals-of-care conversations occur and are documented. The goal is not simply to achieve 100% documentation. The goal is to determine whether the right patients are being identified and whether meaningful conversations are occurring early enough to influence the plan of care. These conversations are an important component of geriatric trauma care because pre-existing health conditions, functional limitations, cognitive status, and personal values may significantly influence treatment decisions and desired outcomes. Early, thoughtful conversations with patients and families help ensure that the trauma plan of care reflects the patient's goals, values, preferences, and acceptable quality of life rather than focusing solely on survival or injury treatment.
How to do it? The trigger should be defined by the hospital's existing goals-of-care process and patient population. Follow compliance with established goals-of-care processes to evaluate whether these conversations are occurring consistently, in a timely manner, and appropriately for patients who may benefit from them. Reviewing compliance allows the trauma program to identify gaps in recognition, documentation, communication, and interdisciplinary coordination and to determine whether those gaps affect patient-centered outcomes, resource utilization, disposition, or the patient's ability to achieve their desired goals of care.
#3. Time-Sensitive Care Pathways
Timely operative management is particularly important for older trauma patients with hip fractures, making time to OR a useful hospital-specific PI measure. A PI nurse at a Level II trauma center described several hospital-specific metrics they use to identify and address potentially preventable delays in operative care.
How to do it? Rather than simply measuring whether a patient went to the OR within an identified time frame, the program looks more closely at what happened between arrival and operative intervention—and why.
Hip Fractures:
Time to OR: Percentage of hip fracture patients taken to the OR within 24 hours.
Anticoagulation reversal: Whether reversal was required and, when applicable, whether reversal contributed to the timing of operative intervention.
Cardiology consultation: Timing of cardiology consultation when needed, with attention to whether the consultation contributed to a potentially avoidable delay to the OR.
Cause of delay: For cases exceeding 24 hours, identify the reason for the delay, such as OR scheduling, consent, medical clearance, or cardiac clearance.
Case exclusions: Exclude periprosthetic and complicated pelvic fractures when the clinical circumstances make the 24-hour benchmark inappropriate.
This approach moves the PI review beyond simply reporting a percentage of patients who met the 24-hour target. It allows the trauma program to determine where in the process delays are occurring and which delays are potentially modifiable. For example, if a substantial proportion of delays are attributed to cardiac clearance, the program can examine whether cardiology consultation is being requested appropriately and early enough, whether there are opportunities for standardized preoperative assessment, or whether the clearance process itself can be streamlined.
Resuscitation and Transfusion
The same program also evaluates resuscitation and transfusion practices in geriatric trauma patients. The PI review includes trending hemoglobin and hematocrit (H&H) during resuscitation and evaluating transfusion decisions using the program's established criteria, including transfusion for hemoglobin below 8 g/dL or a significant hemoglobin decline, such as a three-point drop, when accompanied by symptoms or other clinical concerns. The goal is not simply to determine whether a transfusion occurred. The program reviews the clinical context, timing, laboratory trends, symptoms, ongoing blood loss, and response to resuscitation to identify potential opportunities to improve care. This type of filter can reveal problems that may not be apparent through traditional registry measures alone.
Rib Fracture Management
Rib fractures provide another opportunity to evaluate a time-sensitive geriatric trauma care pathway. The program uses its rib fracture guidelines and PIC score to evaluate whether patients are receiving the appropriate level of care and timely interventions. PI measures include:
Appropriate level of care: Was the patient admitted to the appropriate unit based on the PIC score and clinical condition?
Multimodal pain management: Was an appropriate multimodal pain regimen initiated in a timely manner?
Regional anesthesia: When appropriate, was an anesthesia block considered and provided in a timely manner?
Rib plating evaluation: Was the patient appropriately evaluated for surgical stabilization of rib fractures?
Time to rib plating: When rib plating was indicated, was it performed within 72 hours?
Together, these measures allow the program to examine whether delays at one point in the pathway contribute to downstream complications or prolonged hospitalization.
#4. Overtriage of Geriatric Patients
In our well-intentioned effort to reduce undertriage in the geriatric population, efforts to broaden activation criteria can also create unintended consequences. While it is important to have generous activation criteria to avoid missing critical injury, trauma programs must also be mindful of resource utilization and workflow when those criteria are too broad.
How to do it? I'll use my experience at a Level I trauma center as an example. When the Orange Book standards came out in 2014, the trauma center cast a broad net and added a criterion that every fall (no height limitation) for a patient aged 55+ on an anticoagulant would receive a partial-activation. This doubled the number of activated patients but had no statistically significant impact on mortality, hospital length of stay, or ICU days. The hospital successfully reduced undertriage in this population from 13% to 2%, but in the process, overtriage increased from 21% to 60%. (Published paper)
The trauma program then used its data to revise the protocol, creating a third-level response in the ED that reduced trauma team involvement and decreased ED disposition time without prolonging timeliness of anticoagulation reversal for those patients who needed it. The program continued to monitor and annually evaluate outcomes, resource utilization, and timeliness of care for this activation response. (Published paper)
This is the PI cycle in action: identify an unintended consequence, modify the process, measure the result, and continue monitoring to ensure the change produces the intended outcome.
The Importance of Hospital-Specific PI Filters for Geriatric Trauma
A trauma program should not simply copy a list of geriatric PI indicators from another hospital and consider the PI process complete.
One of the strongest indicators of a mature PI program is the ability to move from generic filters to locally relevant filters.
A developing program: Patients ≥65 years old.
A more sophisticated program: Patients ≥65 years old with a ground-level fall and anticoagulant use.
A mature program might ultimately develop a filter based on something the program's own data revealed: Patients ≥75 years old with ground-level falls who are discharged home and return to the emergency department within 30 days, with review of whether the return was potentially preventable.
That represents a very different level of PI thinking. The program has identified a specific vulnerability in its trauma population and is using PI to understand and address it. The filter itself is not the measure of maturity. The ability to use data to identify, investigate, and address a previously unrecognized problem is.
That is performance improvement.
The Bottom Line
Geriatric trauma is changing. The number of older adults requiring trauma care is increasing, but more importantly, trauma programs are developing a better understanding of the complexity of caring for these patients. Geriatric PI should evolve with that understanding.
Start with the common filters. Use age, mechanism, injury pattern, anticoagulation, frailty, complications, and disposition to establish a foundation.
Then go further. Use your own data to identify the problems that are most relevant to your patients and your system. Develop targeted filters. Audit them consistently. Implement interventions. Measure whether the interventions worked. Then refine the filters again when the data tell you to.
That progression—from standardized PI to data-driven, hospital-specific PI—is one of the clearest signs of a trauma program that is not simply maintaining compliance, but using PI to lead improvement.
