Elderly Adults With Isolated Hip Fractures- Orthogeriatric Care Versus Standard Care: A Practice Management Guideline From the Eastern Association for the Surgery of Trauma

BACKGROUND: Elderly patients commonly suffer isolated hip fractures, causing significant morbidity and mortality. The use of orthogeriatrics (OG) management services, in which geriatric specialists primarily manage or co-manage patients after admission, may improve outcomes. We sought to provide recommendations regarding the role of OG services. METHODS: Using GRADE methodology with meta-analyses, the Practice Management Guidelines Committee of the Eastern Association for the Surgery of Trauma conducted a systematic review of the literature from January 1, 1900 to August 31, 2017. A single PICO question was generated with multiple outcomes: Should geriatric trauma patients aged 65+ with isolated hip fracture receive routine OG management, compared to no routine OG management, to decrease mortality, improve discharge disposition, improve functional outcomes, decrease in-hospital medical complications, and decrease hospital length of stay. RESULTS: Forty-five manuscripts were evaluated. Six randomized controlled trials and seven retrospective case-control studies (RCCS) met criteria for quantitative analysis. For critical outcomes, RCCS demonstrated a 30-day mortality benefit with OG (OR 0.78[0.67, 0.90]), but this was not demonstrated prospectively or at one year. Functional outcomes were superior with OG, specifically improved score on the Short Physical Performance Battery at four months (MD 0.78 [0.28, 1.29]), and improved score on the Mini Mental Status Exam with OG at 12 months (MD 1.57 [0.40, 2.73]). Execution of activities of daily living was improved with OG as measured by two separate tests at four and twelve months. There was no difference in discharge disposition. Among important outcomes, the OG group had fewer hospital-acquired pressure ulcers (OR 0.30 [0.15, 0.60]). There was no difference in other complications or length of stay. Overall quality of evidence was low. CONCLUSIONS: In geriatric patients with isolated hip fracture, we conditionally recommend an OG care model to improve patient outcomes. LEVEL OF EVIDENCE: Level III evidenceSystematic Review/Meta-Analysis

Evidence-based review of trauma center care and routine palliative care processes for geriatric trauma patients; a collaboration from the American Association for the Surgery of Trauma (AAST) Patient Assessment Committee, the AAST Geriatric Trauma Committee, and the Eastern Association for the Surgery of Trauma Guidelines Committee

Background Despite an aging population and increasing number of geriatric trauma patients annually, gaps in our understanding of best practices for geriatric trauma patients persist. We know that trauma center care improves outcomes for injured patients generally, and palliative care processes can improve outcomes for disease-specific conditions, and our goal was to determine effectiveness of these interventions on outcomes for geriatric trauma patients. Methods A priori questions were created regarding outcomes for patients age 65+ with respect to care at trauma centers versus non trauma centers and use of routine palliative care processes. A query of MEDLINE, PubMed, Cochrane Library, and Embase was performed. Letters to the editor, case reports, book chapters, and review articles were excluded. GRADE methodology was used to perform a systematic review and create recommendations. Results: We reviewed 7 articles relevant to trauma center care and 9 articles reporting results on palliative care processes as they related to geriatric trauma patients. Given data quality and limitations, we conditionally recommend trauma center care for the severely injured geriatric trauma patients, but are unable to make a recommendation on the question of routine palliative care processes for geriatric trauma patients. Conclusion As our older adult population increases, injured geriatric patients will continue to pose challenges for care, such as comorbidities or frailty. We found that trauma center care was associated with improved outcomes for geriatric trauma patients in most studies, and that utilization of early palliative care consultations was generally associated with improved secondary outcomes, such as length of stay, however inconsistency and imprecision prevented us from making a clear recommendation for this question. As caregivers, we should ensure adequate support for trauma systems and palliative care processes in our institutions and communities and continue to support robust research to study these and other aspects of geriatric trauma