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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
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The Toronto Star, August 2 2011
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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
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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
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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
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GERIATRIC TRAUMA
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.
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Medication review
Sensory impairment
Pain
NutritionMood
Mobilization
Other medical complications
ContinenceRestraints
Discharge planning
ComorbiditiesFall risk
Beers criteria
Decubitus risk
Cognition
Delirium
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Ann Surg 2012;256: 1098–1101.
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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.
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Camilla L. WongRaghda Al AtiaAmanda McFarlanHolly Y. LeeChristina ValiaveettilBarbara Haas
Can J Surg 2016, in press.
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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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S W
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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S W
O T
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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S W
O T
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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S W
O T
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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S W
O T
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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S W
O T
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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S W
O T
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
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You are invitedTO COFFEE WITH TRAUMA.
HALLWAY CONVERSATIONS TO FOLLOW.
What was easy.
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Facilitators.
RESEARCH (EVALUATION) DRIVES SUSTAINABILITYWhen you have positive, measurable, published, impact, everyone will want to keep the collaboration model going.
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What was challenging.
TRYING TO SPEAK THE SAME LINGO.There is so much to learn about the other field.
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TRUST
There must be mutual respect for one another’s domain of expertise.
Elements for success.
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Threats.
EVERYONE WANTS IN.geriatric cardiologygeriatric nephrologyperioperative geriatricsgeriatric oncology
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Opportunities.
Refinement.Current research focus on using pre-trauma frailty to refine patient selection criteria.
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How this model could be more collaborative.
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GRASSROOTSAPPROACH
The passion has to come from the FRONTLINE from both sides of the field.
Tip for collaborative care models.
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GERIATRIC TRAUMA
… and they lived happily ever after.