Program Description
After a collaborative, transparent review of quality metrics, opportunities for improvement in the care of trauma patients were identified, and the Trauma/Acute Care Surgery Hospitalist Comanagement Program was created at our institution at the end of 2016. The focus of the program was based on the American College of Surgeons Trauma Quality Improvement Program (TQIP) Geriatric Trauma Management Guidelines.17
A group of five dedicated hospitalists were assembled as members of the comanagement team. A single hospitalist rotates for two weeks at a time and has no other clinical responsibilities. The hospitalist attends daily morning rounds with the trauma and acute care surgery team, at which time the overnight surgical attending, the day surgical attending, residents, advanced care providers, and administrators are present to discuss patients. During this time, patients who are appropriate for comanagement are identified by the team. Inclusion criteria for comanagement include age over 65, presence of multiple chronic medical conditions, and/or being on high risk medications such as anticoagulants, antiplatelets, insulin or psychotropic medications. The most common admitting diagnoses for this population of patients are hip or femoral fracture, intracranial hemorrhage, rib fracture, syncope or fall, other fractures, bowel obstruction, motor vehicle collision, and cholecystitis.
Patients are followed by the hospitalist for the duration of their hospitalization. On average, ten comanagement patients are seen daily from Monday to Friday. On weekends, high-risk patients are identified collaboratively to be seen by the hospitalist, as well as initial evaluations for high-risk patients (i.e., those presenting with acute medical issues). Overnight, patients are primarily managed by the surgical team, with in-house hospitalist coverage available as back-up. After admission by the surgery team, the hospitalist manages chronic medical conditions and medications, as well as acute medical conditions and perioperative complications. The hospitalist places orders, determines the need for subspecialty consultation, and facilitates transitions of care to the outpatient setting. The hospitalist communicates with the trauma surgery team throughout the day regarding the management of patients. Disagreements in opinion or management are resolved by attending level discussion.
Based on the American College of Surgeons Trauma Quality Improvement Program (TQIP) Geriatric Trauma Management Guidelines, the following assessment and practices were integrated into initial and daily electronic health record notes: 1. Establish and document baseline cognitive and functional status; 2. Perform a comprehensive medication reconciliation to discontinue nonessential medications, dose adjust medications when necessary, continue medications with withdrawal potential, and limit potentially inappropriate medications as per the Beers Criteria; 3. Discuss and document the patient’s priorities and preferences, decision making capacity, advance directives and goals of care; 4. Engage and inform family members; 5. Screen for cognitive impairment including delirium; 6. Assess for fall risk, develop a plan for early mobilization and engage physical therapy; 7. Remove any unnecessary lines and devices; 8. Optimize pain management while limiting the use of opiates and ensuring appropriate bowel regimen; 9. Use non-pharmacologic interventions to prevent and manage delirium (maintain sleep-wake cycle, hydration, early mobility, and use of hearing and vision devices); and 10. Ensure there is an early and comprehensive discharge plan. These principles were discussed on daily multidisciplinary rounds.
Study Design
This was a retrospective cohort study of the outcomes of geriatric trauma and acute care surgery patients who were co-managed by a hospitalist (intervention group), compared with propensity score-matched patients admitted to the trauma and acute care surgery service prior to the creation of the comanagement program (pre-intervention control group). The study and design were approved by our institutional review board.
Setting and Patients
This study was conducted at a 738-bed academic tertiary care hospital, a Level I trauma center with more than 1200 admissions to the trauma surgery service annually. The trauma service is staffed by a dedicated group of trauma and acute care surgeons. Patients were included in the study if they were over the age of 59 and were on the trauma surgery service. The comanagement program was developed at the end of 2016 and was implemented in January of 2017. We defined the pre-intervention control group as patients on the trauma surgery service between January 1, 2015 and June 30, 2016. We defined the intervention group as trauma surgery patients who were comanaged by a hospitalist between March 1, 2017 and July 31, 2018. The intervening period was excluded as a period of transition between models of practice.
Outcomes and Measures
Baseline patient characteristics collected included age, gender, race, body mass index, coverage by Medicare and Medicaid, Charlson comorbidity score, initial Injury Severity Score (ISS), and whether patients were initially admitted to the intensive care unit (ICU). The primary outcomes examined were hospital mortality, hospital length of stay (LOS), ICU LOS, 30-day readmissions, and readmissions to the ICU after being discharged to the floor. Secondary outcomes included the proportion of patients receiving an order for geriatric-focused quality indicators, including fall risk, aspiration risk, physical therapy, bed rest, dietary restrictions (nil per os), constant observation, enhanced observation and restraints, as well as the time to these orders or the total duration of such orders outside the intensive care unit (ICU). Duration outside the ICU was chosen due to expected greater impact by the hospitalist outside the ICU setting. Additional secondary outcomes included proportion of patients with a do-not-resuscitate order and a palliative care consult order. We also examined doses of potentially inappropriate medications (PIMs), i.e. benzodiazepines, antipsychotics, and pain medications (acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), morphine, oxycodone, tramadol, hydromorphone) received, as well as proportion of patients receiving different forms of venous thromboembolism (VTE) prophylaxis.
Data Acquisition and Statistical Analysis
The Charlson comorbidity score was calculated using ICD-9 data as previously described.18 The ISS was obtained from a trauma registry prospectively populated by a research coordinator. The remaining data were queried from the Allscripts Sunrise electronic health records (EHR) system database, with subsequent processing in Microsoft Excel. Data pertaining to orders were available readily from the EHR database. Medication dosing was extracted from the electronic medication administration record. LOS and ICU LOS were rounded to the nearest number of days. Baseline patient characteristics were compared between pre- and post-intervention groups, which revealed large between-group differences. To create balanced groups with similar characteristics, one-to-one propensity score matching (PSM) was performed based on age, gender, ISS, Charlson comorbidity score, and initial admission to the ICU.
PSM and statistical analysis were performed using SAS release 3.8 (SAS Institute Inc., Cary, NC). Between group differences in continuous variables (hospital LOS, ICU LOS, doses of medications) were evaluated using Wilcoxon Rank Sum tests. Chi-square or Fisher’s Exact test was used in univariate analysis to determine whether there was a difference in the distribution of demographics, medical history, and clinical characteristics between treatment groups. Generalized Linear Model with repeated measures was performed to determine whether there was an association between in hospital mortality, 30-day readmission, upgrade to the ICU and group effect. Generalized Linear Model with repeated measures was also performed to determine whether there was an association between each order and group effect. Mixed Linear Model with repeated measures was performed to determine whether there was a difference in the dose of various medications and the time to each type of order between the two groups.