How we’re ensuring better care for older people with traumatic injuries
In 2005, about 20 per cent of patients admitted to major trauma units in England were over the age of 60. Today, more than 50 per cent of those patients are age 60 or older and have incurred traumatic injuries as a result of a fall. These patients tend to be less resilient than younger patients, with multiple, chronic medical conditions – like diabetes, arthritis or asthma – that leave them vulnerable to complications. This change in the patient population is leading to the development of a new kind of specialist care – and Imperial College Healthcare NHS Trust is leading the way. Here, consultant geriatrician Dr George Peck explains how we’re ensuring better care for older patients, and how trauma medicine is evolving to meet changing needs.
Bringing geriatric expertise to trauma care
As a registrar working with consultant geriatrician Dr Michael Fertleman, I was increasingly called to the trauma ward to offer geriatric assessments to patients who struggled with multiple issues. Best practice is to give a patient with suspected frailty a comprehensive geriatric assessment within 72 hours, but the volume of patients we receive who qualify has grown so much that this cannot be done without having a consultant geriatrician embedded in the service full time.
As a result, I became the first geriatrician in London to run a dedicated, embedded service in the trauma department. I will sit in the multidisciplinary team meeting with trauma surgeons, go on joint ward rounds with them throughout the week, and see major trauma patients whenever I am needed. I also help look after our surgical rehabilitation ward, which is for patients who are stable but require a longer period in hospital to recover. It is very rewarding to be able to offer continuity of care to our older trauma patients.
As a geriatrician, I need to understand each patient’s medical and non-medical issues so we can create a care plan that is tailored to them. When an older patient is admitted, the first step is to conduct a comprehensive geriatric assessment as a part of a multidisciplinary team. This means any professionals involved in the patient’s care, including therapists and dieticians, come together to review the patient’s medical history and to talk to their family and carers. We try to understand what the patient’s life was like before they came to hospital and what their challenges are now. This helps us design a holistic care package that takes into account their daily routine and habits, and helps to minimise the risk of complications that could extend their stay in hospital.
Certain injuries are common in our older patients: head injuries, broken ribs, spinal injuries, and broken hips. These can all occur from a relatively trivial fall – it might cause little damage in a younger person, but an older person who takes blood thinners could be at risk of very serious bleeding following a head injury.
We also need to carefully monitor older patients for specific risks in hospital. Patients experiencing pain from rib fractures, for example, tend to take shallow breaths, increasing their risk of developing pneumonia. To prevent this, we must make sure they receive effective pain management. Deconditioning is a risk for any inpatient, but muscle function and strength can deteriorate much more quickly in older people, so we’re careful to ensure they move about as much as is safe. We also need to watch for signs of delirium or acute confusion – we always involve our dementia care team when we feel they could help.
Another challenge is supporting patients who will not survive their injuries. Discussions about what treatments are and aren’t appropriate, and how to manage the care of people coming to the end of their lives, are a really important part of every geriatrician’s work. These conversations can be extremely difficult, but it is very important to have them soon after the patient has been admitted so that there is a clear understanding of what is important to the patient and their family. I work closely with our palliative care team to facilitate these discussions when appropriate.
Treating traumatic injuries in older people is a relatively new challenge, as people are now living longer and more independently with multiple chronic health conditions. At present, there is little research or national guidance on the subject.
That’s why I was pleased to host the first-ever national meeting on major trauma geriatrics at the Royal Society of Medicine in November 2018. Geriatrician representatives from 19 of the nation’s 22 major trauma centres made it to the event, which opened a conversation about geriatric trauma care, what guidance must be developed to support trauma teams to deliver the right care to older patients, and how we can begin collecting and assessing data around treating and supporting older people with traumatic injuries. I look forward to continuing the conversation as we shape and agree practices that will help us better serve our patients.
Working with older patients with major traumatic injuries, as well as complex chronic health issues, can be very challenging. But whether I’m working to help get a patient get home, or helping to make the end of their life comfortable and dignified, it is a role that I find very rewarding.
Dr George Peck became a consultant geriatrician on the major trauma ward in February 2018. He joined the Trust as a registrar in 2015. He trained at Imperial and University College London Hospitals Trust in geriatric and general internal medicine, and worked as a geriatric registrar before joining the major trauma service in 2018.