A standardized interdisciplinary clinical pathway to identify and manage frailty in older patients has reduced the rate of one of the most debilitating complications for older patients– delirium and kept patients from returning to the hospital within 30 days of treatment for traumatic injury. The pathway is being adapted for other surgical services as trauma surgeons from Brigham and Women’s Hospital, Boston, focus attention on the specific needs of elderly surgical patients.
A study describing the pathway and its effects on outcomes appears as an “article in press” on the Journal of the American College of Surgeons website in advance of print publication. As the U.S. population continues to age; increasing numbers of elderly patients will have a need for trauma surgery. By 2050, 40% of all trauma patients will be over age 65.
While the elderly are at increased risk for morbidity and mortality after trauma; age itself is not the sole reason for poor outcomes. Frailty is a major contributor. Frail patients are more likely to have complications and loss of function after hospital care and require readmission for repeat trauma than more robust patients. As many as 50% of older trauma patients are frail; and 78%are functionally impaired.
Interdisciplinary inpatient care protocols involving consultation with geriatricians have improved outcomes for elderly hospitalized patients. However; there is a nationwide shortage of geriatricians. Because “It’s just not feasible to have a geriatrician available for consultation all the time. Therefore We needed to become better equipped to provide dedicated geriatric-focused care on our own.
So we put some processes in place to screen elderly trauma patients for frailty and stratify and direct our resources to provide the best possible care for them;” said Zara Cooper, MD, FACS, an associate professor of surgery; Harvard Medical School, and corresponding author of the study.
Since Brigham and Women’s Hospital’s trauma surgery service hired a geriatrician to consult on the care of elderly injury victims in 2014; it documented fewer complications; mortalities; readmissions and extended hospital stays. However; the surgeons noticed gaps in care when the geriatrician was not available and lack of overall uniformity in the way recommendations from the geriatric team were instituted.
The pathway for frail elderly trauma patients was created in 2016 to standardize processes of care a geriatrician would typically recommend: early ambulation, therefore bowel and pain regimens; non-pharmacological delirium prevention, nutrition, physical therapy, and geriatric assessments.
Surgeons at Brigham and Women’s Hospital developed the Frailty Identification and Care Pathway over a six-month period with input from geriatrics, nursing, nutrition; physical and occupational therapy, speech and language pathology, social work, and care coordinators. Because The pathway makes use of the five-item FRAIL scale to identify vulnerable elderly trauma patients; a standardized set of orders for geriatric-focused care and consultations; family meetings, and fall prevention education.