Severely Injured Elderly Patients May Not Always Receive The Same High-Quality Care as Younger Patients

Newswise — As elderly citizens represent an ever growing proportion of the population, trauma centers are being challenged to provide them with same quality of care that younger patients receive during a medical emergency. A recent study by researchers using the American College of Surgeons (ACS) National Trauma Databank (NTDB) published in the January 2011 issue of Annals of Surgery reveals that trauma centers that excel in the care of severely injured young patients do not necessarily provide the same quality of care to elderly ones.

The study also cited growing evidence that elderly injured patients have unique needs and helped the investigators identify some ways in which trauma centers can improve their care of the elderly. The researchers analyzed data on 87,754 trauma patients of all ages treated at 132 facilities. One trauma center was located in Canada, and the rest were located in the United States. About one in four patients were elderly.

The study compared the performance of these 132 facilities, and identified centers with both the highest and lowest death rates. When patients in all age groups were studied together, 14 centers were high performers, with lower than expected rates of death. When young and elderly patients were considered separately, seven centers were high performers for young patients, and nine were high performers for the elderly. However, there was little overlap: only two centers were high performers for both the young and the elderly.

“In the study we showed that although some centers demonstrate high performance overall, these same centers might not be providing the same high-quality care to the elderly,” according to investigator Barbara Haas, MD, of St. Michael’s Hospital, University of Toronto. “We’ve shown that elderly patients have different needs from young patients. Centers need to focus on the needs of the elderly specifically in order to improve their quality of care.”

Many trauma centers got their start in the 1980s in response to drug-related violence and then developed more experience caring for car crash victims, two types of injuries that primarily involve young adults, according to lead investigator Avery B. Nathens, MD, PhD, FACS, also of St. Michael’s Hospital, University of Toronto. “Today trauma centers are seeing a lot more elderly patients, and what we’ve shown is that taking the same approach to care for young patients doesn’t necessarily benefit the elderly patient,” Dr. Nathens said.

Elderly patients, for example, are more likely to have coexisting diseases than younger patients, Dr. Nathens explained. “The elderly patients often have heart disease, lung disease, diabetes, and might be on blood thinners,” he said. “All of these things need to be addressed at the same time the injuries are cared for.” Elderly persons are also more likely to have reduced organ function, what physicians describe as “physiologic reserve,” he said, further complicating their ability to recover from injuries.

The researchers found that elderly patients seen in trauma centers were mostly women and were more likely to have blunt injury, specifically from falls. Severe head and leg injuries were also more predominant in the elderly.

Dr. Nathens pointed to two potential approaches that may lead to better results among elderly trauma patients. One involves putting intensive care patients under the care of an intensive care specialist, or an intensivist, once he or she is moved from the emergency room to the intensive care unit. The second involves more frequent use of the expertise of geriatricians who specialize in the care of the elderly. “The collaboration between a trauma surgeon, intensivist and a geriatric specialist would provide all the critical resources to ensure the best possible care for these patients,” Dr. Nathens said. “These factors, along with an understanding that these patients have unique needs, would go a long way to improving their quality of care.”

Future studies would help to identify specific processes that can improve trauma care for the elderly, according to Dr. Haas. “We speculated as to what the reasons might be for the differences between trauma centers, but actually identifying those processes is going to require a lot more work, potentially going directly to the hospitals and observing what they do,” she said. Future analysis should also concentrate on what happens to elderly trauma patients after they’re discharged from the hospital, Dr. Nathens added.

In addition to Drs. Haas and Nathens, the research team included David Gomez, MD; Wei Xiong MSc; and Najma Ahmed, MD, PhD, FACS, all with St. Michael’s Hospital and the University of Toronto.

The study was supported by the Canada Research Chair Program. The National Trauma Data Bank (NTDB) of the American College of Surgeons is the largest aggregation of trauma registry data ever assembled. NTDB collects trauma registry data from participating trauma centers on an annual basis.

The American College of Surgeons is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and to improve the care of the surgical patient. The College is dedicated to the ethical and competent practice of surgery. Its achievements have significantly influenced the course of scientific surgery in America and have established it as an important advocate for all surgical patients. The College has more than 77,000 members and is the largest organization of surgeons in the world. For more information visit: www.facs.org (.)

CITATION: Haas B, Gomez D, Xiong W, Ahmed N, Nathens AB. External benchmarking of trauma center performance: Have we forgotten our elders. Ann Surg. 2011;144-150.