Creating a Geriatric Focused Model of Care in Trauma with ......Aging Population Older Adult: >/=...

© 2015 Lehigh Valley Health Network

Creating a Geriatric Focused Model of Care in

Trauma with Geriatric Education

Kai Bortz MSN, RN-BC, CMSRN, CNL

Learning Objectives

▪ Discuss the growing epidemic of geriatric trauma.▪ Review falls in the elderly population.▪ Provide information on common injuries

seen in the geriatric trauma patient.▪ Review nursing concepts of care in the

geriatric trauma patient.

Disclosure Statement

▪ I have no conflict of interest relative to this educational activity.

This image cannot currently be displayed.

• 5 Campuses• 1 Children’s Hospital• 140+ Physician Practices• 17 Community Clinics• 13 Health Centers• 11 ExpressCARE Locations• 80 Testing and Imaging Locations• 13,100 Employees• 1,340 Physicians• 582 Advanced Practice Clinicians• 3,700 Registered Nurses• 60,585 Admissions• 208,700 ED visits• 1,161 Acute Care Beds

This image cannot currently be displayed.

Aging Population

▪ Older Adult: >/= 65▪ Approximately 12% of current population▪ Expected to be 20% by 2030▪ “Baby Boomer” generation- 1946-1964▪ Trends in Older Adult Population

•Overall world population aging•Life expectancy increasing•>/= 85 fastest growing group

Committee on the Future Health Care Workforce for Older Americans; Institute of Medicine. Retooling for an Aging America: Building the Health Care Workforce. Washington, DC, USA: National Academies Press, 2008, p. 1.

Expected Population Growth 1900-2050

0

10,000,000

20,000,000

30,000,000

40,000,000

50,000,000

60,000,000

70,000,000

80,000,000

90,000,000

100,000,000

1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 2050

Num

ber o

f Per

sons

65+

Population 65+ by Age: 1900-2050Source: U.S. Bureau of the Census

Age65-74

Age75-84

Age85+

Pennsylvania Older Adult Population

▪ Pennsylvania 4th in percentage of population age 65 and over:

• Florida 17.3%• West Virginia 16%• Maine 15.9%• Pennsylvania 15.4%• Iowa 14.9%• US 12.9%

▪ Pennsylvania 3rd in percentage of total population age 85 and over:

• Florida 2.8%• North Dakota 2.7%• Hawaii, Iowa, Pennsylvania, South Dakota 2.5%• Rhode Island 2.4%• US 1.8%

U.S. Census Bureau, 2010

Lehigh Valley PopulationPopulation Changes 2000-2030

28,000

23,000

18,000

13,000

8,000

3,000

‐2,000

0‐4

5‐9

10‐14

15‐19

20‐24

25‐29

30‐34

35‐39

40‐44

45‐49

50‐54

55‐59

60‐64

65‐69

70‐74

75+

0

500

1000

1500

2000

2500

3000

3500

4000

4500

Year

201320142015 (6 mos)

LVHN Trauma Patient Volume2013-2015*

0

200

400

600

800

1000

1200

1400

1600

1800

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015*

65 & upLVHN Trauma Registry 2015

Geriatric Trauma Data:LVHN

(excludes burns)

*2015 is 6 mos.

Percentage of Trauma Patients >=85January 2013-November 2015

0

10

20

30

40

50

60

70

80

Janu

ary, 2013

February

March

April

May

June July

August

Septem

ber

Octob

erNovem

ber

Decembe

rJanu

ary, 2014

February

March

April

May

June July

August

Septem

ber

Octob

erNovem

ber

Decembe

rJanu

ary, 2015

February

March

April

May

June July

August

Septem

ber

Octob

erNovem

ber

# for monthAge >=85

# for monthAge >=85

Linear (# for monthAge >=85)

0

10

20

30

40

50

60

2009 2010 2011 2012 2013 2014LVHN PTOS >=65 All Hospitals PTOS >=65 LVHN PTOS Age >=85 All Hospitals PTOS >=85

LVHN Trauma Registry 2015

Percentage of Trauma Patients Age 65 and Older & 85 and OlderLVHN PTOS vs. All Hospital PTOS

Non-Burn

LVHN 2015 Age >=65(Excludes Burn)

▪ 1,785 patients ▪ Female 58%▪ Male 42%▪ Age: 80.7▪ ISS: 9▪ Blunt: 99.5%▪ Penetrating: 0.5%

Geriatric TraumaMechanism of Injury

▪ Falls #1• Most common method of injury in the elderly• 90% simple falls, such as fall from standing• Far less mechanism to produce injuries

– Weakness– Generalized deconditioning– Loss of visual acuity– Balance and gait instability– Slowed reaction times

▪ Motor Vehicle Collision• Vision changes• Slower reflexes• Cognitive deficits

▪ Suicide• 65 and older-highest suicide rate for all age groups• Nearly 20% of all suicides • Most common method involves firearms• Risk factors: White, male, depression, chronic pain or illness, and social

isolation• Of those who committed suicide:

– 70% PCP within 1 month– 1/3 PCP within 1 week

%

FallMVAOtherPedestrianMCAStruck by

LVHN Trauma Registry 2015

2014 LVHN Trauma Mechanism Age >=65

LVHN Trauma Registry 2015

2014 LVHN Discharge Destination

0102030405060708090

DC Home DC Rehab DC SNF

% Age <65Age >=65

LVHN Trauma Registry 2015

2014 LVHN Trauma Mortality

0 1 2 3 4 5

age <65

age >=65

% Mortality

0

10

20

30

40

50

ISS 1‐8 ISS 9‐12 ISS 13‐15 ISS 16‐24 ISS 25‐40 ISS 41‐49 ISS 50‐74 ISS 75

%

2013 2014 2015

LVHN Geriatric PatientISS Summary

This image cannot currently be displayed.

INJURY PATTERNS IN THE ELDERLY

Why is Geriatric Trauma Care Important?

▪ Trauma is the 5th leading cause of geriatric mortality▪ Increased morbidity … NOT always due to the injury!

• Hospital acquired complications• Exacerbation of co-morbidities

▪ Compared with younger patients with same injuries• Longer hospital stays• Longer inpatient rehab stays• Increased skilled nursing facility requirement• More complications• Increased mortality• Increased dependence for ADL’s

Bonne, S. & Schuerer, D. (2013). Trauma in the older adult: epidemiology and evolving geriatric  trauma principles. Clinical Geriatric Medicine, 29, 137‐150.

High Risk Population▪ Physiological changes in all body systems▪ Less reserve▪ Complex Care

• Susceptible to adverse outcomes from minor trauma• Frailty• Geriatric syndromes

▪ Elderly trauma in hospital complication rate higher • Cardiovascular events (MI, Afib, CHF, etc.)• Pneumonia • Sepsis

▪ Complications lead to poor outcomes and high cost healthcare

Bonne, S. & Schuerer, D. (2013). Trauma in the older adult: epidemiology and evolving geriatric  trauma principles. Clinical Geriatric Medicine, 29, 137‐150.

Physiologic and Functional Preexisting Differences in Older Adults

▪ Vital Signs• Altered response to trauma• Increased mortality if HR>90 bpm or SBP <110mmHg

▪ Neurologic• Baseline deficits (dementia, stroke, hearing loss)• Report less pain thereby limiting injury discovery

▪ Cardiovascular• HTN, medications, CHF

▪ Pulmonary• Decreased functional residual capacity• Decreased vital capacity

▪ Renal• Decreased glomerular filtration rate (GFR)• Decreased excretion and drug clearance• Increased risk of UTI• Decreased response to dehydration

▪ Coagulation• Blood thinners, platelet inhibitors

▪ SkeletalHavens, J., Carter, C., Gu, X., Selwyn, O., & Rogers, J. (2012). Preinjury beta blocker usage does not affect the heart rate response to initial trauma resuscitation. International Journal of Surgery, 10, 518‐521.

Geriatric Considerations during Initial Assessment

▪ ABC – Same for all trauma▪ Spine immobilization▪ Mechanism of injury▪ Age▪ Home medications

• Polypharmacy• Beta Blockers• Anticoagulants

▪ Comorbidities▪ Baseline cognitive status▪ Baseline functional status

Response to Shock▪ Cardiovascular Changes

• Decreased compensatory response• Decreased CO and reserve• Catecholamine insensitivity• Atherosclerosis• Myocyte fibrosis• Conduction Abnormalities

▪ Medications• Beta blockers blunt the stress response to shock and

can mask underlying hypoperfusion• Under-identification of significant blood loss

▪ Decreased ability to survive cardiovascular stress

Musculoskeletal Trauma▪ Decreased overall muscle mass, strength, and endurance▪ Osteoporosis▪ Hip Fractures

• Outcomes improved with multidisciplinary team • Protocols that promote early operative intervention (<48hrs)• Early ambulation• Early physical therapy

▪ Pelvic Fractures• Pubic rami most common • Acetabulum

▪ Elderly less likely to have “severe” pelvic fractures, yet have far higher mortality

▪ Higher rates of hemorrhage despite lower fracture severity

Neurological Changes with Aging

▪ Brain weight decreases • 10% between age 30-70

▪ Decreased number of neurons▪ Slower reflexes▪ Decreased speed of nerve impulse travel▪ Sensory and motor decline▪ Dementia and cognitive impairment may delay

treatment ▪ Patient presents with mild mechanism- may

have a significant underlying SDH or Epidural

Head Injuries in the Elderly▪ 2 major risk factors:

• Dura becomes adherent to the skull with aging• Anticoagulant use

– Approximately 11-20% on Coumadin at the time of injury– New anticoagulants

– Direct thrombin inhibitors – Factor Xa inhibitors

▪ Low threshold for CT with any neuro changes• Occult injuries common• Minimal risk of radiation

▪ Mortality rates 2-5x’s younger with matched GCS & intracranial pathway

▪ Falls- most common cause of TBI in elderly▪ Increased age is an independent predictor of worse

outcome from TBI

Cervical Spine Fractures▪ Odontoid Fractures most common ▪ Geriatric patients more upper C-spine fx

• Non-geriatric more lower C-spine fx• Initially the most mobile segment of C4-C7 stiffens

with age ▪ Increased risk of cervical spine injury

• DJD, osteoporosis• Less muscle and ligament support

▪ Central Cord Syndrome• More common in the elderly• Hyperextension injury• High risk of depression

▪ Nonoperative vs Surgical Management

Rib Fractures▪ Osteoporosis decreases rib durability▪ Increased incidence of

• Rib fractures• Sternal fractures• Pulmonary contusions

▪ Weakened respiratory muscles• Alveolar surface area loss• Decreased chest wall compliance• Decreased vital capacity, functional residual capacity

▪ Rib fractures and flail chest have a significantly higher morbidity and mortality in elderly

Rib Fractures▪ Poor outcomes related to physiologic changes with

aging▪ Increased splinting leads to

• Hypoventilation, atelectasis and pneumonia▪ Increase in number of rib fractures…..

Increase in complication risk!▪ Nursing interventions

• Pain Control• Aggressive pulmonary toileting• Mobilization• Protocols

▪ Rib Plating

Facial Fractures in the Elderly▪ Typically minimally displaced fractures▪ Surgical vs. Non-surgical intervention▪ LOS and mortality increased when

compared to younger patients▪ Nursing Care

•Airway• Ice•Pain control•HOB elevated•Mobilize

Atypical Presentation of Illness

▪ Presentation is vague, altered or not presented at all

▪ Signs of 1 disease hidden by signs of another▪ Common conditions

• Infections• Falls•Urinary incontinence•MI•CHF

Mitty, E.(2010). Iatrogenesis, frailty, and geriatric syndromes. Geriatric Nursing, 31(5), 368‐374.

Cascade Iatrogenesis

▪ A series of adverse events or effects caused by a medical or nursing intervention that was initially used to solve a prior symptom▪ Difficult to reverse▪ Associated with poor prognosis after

hospital discharge

Mitty, E.(2010). Iatrogenesis, frailty, and geriatric syndromes. Geriatric Nursing, 31(5), 368‐374.

Factors that Increase Risk of Iatrogenesis

▪ Polypharmacy•Adverse Drug Event most common cause

▪ Atypical presentation of illness▪ Many comorbid chronic illnesses▪ Impaired cognitive and functional capacity▪ Reduced physiologic reserve▪ Altered compensatory mechanisms

Mitty, E.(2010). Iatrogenesis, frailty, and geriatric syndromes. Geriatric Nursing, 31(5), 368‐374.

Frailty▪ Combination of age-related changes and

assorted medical problems•Exhaustion•Unintentional weight loss (>10lbs)•Muscle weakness•Walking slowly•Low physical activity level

▪ High Risk for Iatrogenesis▪ Trauma-Specific Frailty Index

Mitty, E.(2010). Iatrogenesis, frailty, and geriatric syndromes. Geriatric Nursing, 31(5), 368‐374.

Geriatric Syndromes

▪ Can result as an outcome of iatrogenesisand frailty▪ Impact morbidity and mortality

•Sleep Disorders•Problems with Eating or Feeding• Incontinence•Delirium•Falls •Skin Breakdown

Mitty, E.(2010). Iatrogenesis, frailty, and geriatric syndromes. Geriatric Nursing, 31(5), 368‐374.

Functional Status

▪ Functional Status•Ability to perform basic self-care activities•Strong predictor of poor outcomes• Indicator of Quality of Life• Baseline status

▪ Functional Assessment Tools

Padula, C., Hughes, C., & Baumhover, L. (2009). Impact of a nurse‐driven mobility protocol on functional decline in hospitalized older adults. Journal of Nursing Care Quality, 24(4), 325‐331.

Functional Decline

▪ Prevention of Functional Decline• 34%-50% of hospitalized older adults•Many do not regain lost function

▪ Increased• LOS•Mortality• Institutionalization• Longer rehab and home health services•Healthcare resources

▪ Minimal research in trauma….

Comorbid ConditionsLVHN vs. TQIP 2013

Comorbid Condition TQIP – ALL (%) LVHN (%)

CHF 8.9 12HX ANGINA 0.3 0.1MI 3.2 4.7STROKE 5.9 13.3HTN 62.2 79.4P VAS. D. 0.8 3.2DISSM CA 1.7 1.5ALCOHOLISM 4.2 3.1SMOKER 6.3 7.3DRUGS 0.4 0

BLEEDINGDISORDER

16.3 31.2

DEMENTIA 8.8 21PSYCH 6.3 28DIABETES 23 26.3RENAL 1.8 1.5RESP 11.5 17.5FUNC DEP 5.4 28STEROIDS 1.1 4.5

This image cannot currently be displayed.

IMPROVING GERIATRIC TRAUMA CARE

Geriatric Trauma Care at LVHN

▪ 2004 Established first Geriatric Trauma Program

▪ Monthly Geriatric Trauma Conference

▪ Injury Prevention

▪ Community Outreach

Geriatric Consultation

▪ Proactive consultation model▪ Comprehensive geriatric assessment

•Prevention and management of geriatric syndromes

•Function preservation•Discharge planning

▪ Improved outcomes▪ Decreased hospital-acquired complicationsLenartowicz, M., Parkovnick, M., McFarlan, A, Haas, B., Straus, S., Nathens, A., & Wong, C. (2012). An evaluation of a proactive geriatric trauma consultation service. Annals of Surgery, 256(6), 1098‐1101.

Recognizing the Problem▪ Complex care▪ Lack of geriatric education for trauma nurses▪ Nursing care not specific to geriatric trauma

patients▪ Geriatrician Recommendations not acted on

• Lack of understanding of importance•No standard communication•Delay in care

▪ Recognized need for including Geriatric Resource Program in trauma care

•Geriatric specific education• Look at nursing interventions to reduce

complications

Overall, are we prepared?

▪ Geriatric Education limited▪ <1% of RN’s are certified in

gerontology nursing▪ Evidence indicates

•patient outcomes improve when older adults receive care from nurses with geriatric training

▪ GeriatriciansWendel, V., Durso, S., Cayea, D., Arbaje, A., & Tanner, E. (2010). Implementing staff nurse geriatric education in the acute hospital setting. MedSurg Nursing, 19(5), 274‐280.

A Plan for Improved Geriatric Care Recognized

▪ Only 8.8% of Trauma Centers in the U.S. incorporate Geriatric Resource Programs

•Mostly Level I Trauma Centers▪ 17 of 26 Trauma Centers in PA

are Geriatric Resource Program Sites (65%)

▪ Extent of incorporation of Geriatric Resource Programs unknown

Maxwell, C., Mion, L, & Minnick, A. (2013). Geriatric Resources in acute care hospitals and trauma centers. Journal of GerontologicalNursing, 39(12), 33‐42.

NICHE at Lehigh Valley Health Network (LVHN)

▪ April 2010, LVHN designated as official NICHE hospital

▪ LVHN Network Wide:•>100 Geriatric Resource Nurses (GRN)•24 Geriatric Patient Care Assistants (GPCA)

▪ Geriatric Certification

Nurses Improving Care for Healthsystem Elders (NICHE)

▪ Nurse Driven program designed to help hospitals improve the care of older adults

▪ VISION•All patients 65-and-over to be given sensitive

and exemplary care

▪ MISSION•Provide principles and tools to stimulate a

change in the culture of healthcare facilities to achieve patient-centered care for older adults

Nurses Improving Care to Healthsystem Elders (NICHE). (2013). About NICHE. Retrieved from http://www.nichprogram.org

Nurses Improving Care for Healthsystem Elders (NICHE)

▪ Core components•Guiding principles•Leadership•Organizational structures•Physical environment•Patient and family centered approaches•Aging sensitive practices•Geriatric staff competence• Interdisciplinary resources and processes

Geriatric Resource Nurse Model(GRN)

▪ Evidence-based geriatrics within clinical practice▪ Prepares nurses as clinical resource

leaders on geriatric issues▪ Considered the foundation for improving

geriatric care▪ Patient Care

Associate (GPCA)

Nurses Improving Care for Healthsystem Elders (NICHE)

▪ Benefits of NICHE designation:• Improved clinical outcomes

•Positive fiscal results

•Enhanced nursing competencies

•Community recognition

•Greater patient, family, and staff satisfaction

Incorporating Geriatric Education in Trauma

▪ NICHE Rollout to Trauma Units in November 2013

•19 Geriatric Resource Nurses in Trauma– 11 Transitional Trauma Unit– 8 Trauma-Neuro Intensive Care Unit

•2 Geriatric Patient Care Associates

•Trauma Neuro Intensive Care Unit 1st ICU to participate in NICHE education at LVHN

What can NICHE do for Trauma?

▪ How does this work for trauma?

▪ How do we incorporate NICHE concepts in trauma care?

▪ Physician Champions•Dr. Joseph Stirparo & Dr. Jayme Lieberman

▪ Geriatric Trauma Process Improvement

▪ Geriatric Trauma specific education

▪ Develop Geriatric Resources

Trauma NICHE Meetings Scheduled

▪ GRN’s from TTU & TNICU▪ Focus on Geriatric Trauma care▪ Data updates▪ Education▪ Process Improvement projects▪ Unit Champions▪ ED Nurse involvement

Geriatric Trauma: Key Concepts in Care

▪ Prevention of falls▪ Pain▪ Delirium▪ Mobility▪ Nutrition▪ Sleep

Preventing Recurrent Falls▪ Consider cause of fall

▪ Orthostatic Blood Pressures• All patients 65 and older admitted s/p fall• Medications• Dehydration

▪ Fall Precautions

▪ Patient and Family Education

▪ Environmental Adaptations

Pain Control▪ Assessments

• Appropriate pain scale• Non-verbal signs

▪ More likely to tolerate pain then report it▪ Barriers:

• Cognitive impairment• Fear of addiction• Side effects• Sensory impairment• Under-reporting

▪ Uncontrolled Pain• Delirium• Decreased mobility • Decreased participation in ADL’s• Respiratory compromise

▪ Elderly may not verbalize their injury as “pain”• Ache, hurt, discomfort

Pain Control▪ Treat it…..

•Start low, go slow!• 50%-75% of normal dose and titrate

▪ Variations in levels of pain▪ Acute and Chronic Pain▪ Appropriate medications▪ Non-pharmacological pain interventions▪ Cognitively impaired most vulnerable▪ Bowel regimen▪ Pain Medication Resource developed with

recommended medications and doses

Geriatric Pain RecommendationsMedication Dose Route Frequency CAUTION

SEVERE PAIN

Morphine 1‐2 mg IV 2 hours RENALFentanyl 12.5‐25mcg IV 1 hour Rapid, fast reliefHydromorphone  0.1‐0.2 mg IV 4 hoursPCA NO BASAL RATE

MILD‐MODERATE PAINTylenol  500mg PO QID LIVER DYSFUNCTIONIbuprofen 200mg PO TID RENALOxycodone 2.5‐5mg PO 4 hoursTramadol 25 mg PO 6 hours <200mg per dayCapsaicin cream, EMLALidocaine Patches 1 patch topical dailyBengay topical**Robaxin NOT recommended (highly anticholinergic)  *Start bowel regimen with any narcotic use**Do not give Oxycodone and Tramadol at the same time *Do NOT use Valium**Only use ONE IV opiate and ONE ORAL opiate‐ If not providing adequate pain control,DISCONTINUE and replace with an alternative 

Delirium▪ Frequently seen in Geriatric Trauma patients- “confusion”▪ Increased:

– LOS, functional and cognitive decline, re-admissions, mortality, facility placement, and falls

▪ 3 Types of Delirium• Hyperactive• Hypoactive• Mixed

▪ Predisposing Risk Factors• Age, cognitive impairment, history of delirium, dementia,

stroke, visual/hearing impairment, lives alone or in a facility, alcohol abuse

▪ Precipitating Risk Factors• Environmental- foleys, restraints, medications, surgery, pain,

immobilization, change in surroundings

Delirium Prevention▪ Baseline assessment

▪ Routine Screening (CAM/CAM-ICU)

▪ 30-40% of cases are preventable

• Avoid inappropriate drugs• Avoid use of restraints• Reorientation and behavioral interventions• Clear instructions• Minimize sensory impairments• Environmental • Nonpharmacological sleep protocols• Geriatric consultation

Delirium Treatment

▪ Prevention is key!

▪ Treat as a medical emergency!

▪ Treat underlying cause!

▪ Patient and Family Education

▪ Delirium Protocols

Immobility

▪ Loss of muscle mass and strength ▪ Orthostasis▪ Falls▪ SNF placement ▪ As early as day 2 of hospitalization functional

decline can start▪ Mobility inadequate overall in hospitals▪ Older adults spend >80% of their day in bed

during hospitalization

Mobility▪ Spine clearance ▪ Determine baseline functional status▪ Encourage participation in ADL’s▪ Early mobilization

•Within first 48 hours▪ PT/OT consult▪ Assistive devices ▪ Progressive mobilization▪ Ambulate!

▪ Patients age 65 and older▪ Nurse Driven Mobility Protocol▪ Levels of mobility to determine activity level▪ Education for all TTU staff

• Importance of mobility during hospitalization•Progressive mobility• Functional status/functional decline• Function-Focused-Care•Documentation of mobility•Documentation of Functional status-

Prior/Current•GPCA’s will champion the project

Mobility Project

Malnutrition in the Geriatric Population

▪ Diminished senses of taste and smell▪ Changes in dental status and decreased ability to chew or swallow certain foods

▪ Reduced visual and auditory senses▪ Medication use that may have an adverse effect on appetite

▪ Confusion from delirium or dementia▪ Depression▪ Eating aloneCampbell, J., Degolia, P., Fallon, W., & Rader, E. (2009). In harm’s way: moving the older trauma patient toward a better outcome. Geriatrics, 64(1), 8‐13.

Nutrition▪ Malnutrition can contribute to functional decline▪ Trauma Patients at high risk of malnutrition

• Head injuries• Hypermetabolism•Malnutrition pre‐injury • NPO• Collars • Facial injuries • Dysphagia• Immobility• Pain

Campbell, J., Degolia, P., Fallon, W., & Rader, E. (2009). In harm’s way: moving the older trauma patient toward a better outcome. Geriatrics, 64(1), 8‐13.

Nutritional Support

▪ Supplements with meds▪ Nutrition Consultation

•Supplements•Calorie Counts•Weights

▪ Encourage OOB for meals▪ Socialization ▪ Ensure hydration▪ Speech Therapy

Sleep▪ Important to overall physical and psychological

well-being▪ Sleep often disrupted during hospitalization▪ Impacts healing and health recovery▪ Adverse Outcomes

• Delirium• Decreased glucose tolerance• Changes in thermoregulation• Increased levels of inflammatory

cytokines• Increased anxiety• Impaired cognitive performance

Faraklas, I., Holt, B., Tran, S., Lin, H., Saffle, J., & Cochran, A. (2013). Impact of a nursing‐ driven sleep hygiene protocol on sleep quality. Journal of Burn Care & Research, 34(2), 249‐254.

Sleep Hygiene Protocol

▪ Noise Reduction▪ Dim lights▪ Aromatherapy▪ Massage▪ Snack▪ Toileting▪ Protected sleep time

•Neuro checks•Vital Signs• Labs

Geriatric Sleep/Agitation/Delirium Recommendations

Medication Dose Route  Frequency Use Nursing Considerations

Haldol 0.5‐1mg IV q3 hrs DeliriumDOCUMENT RESPONSE in1‐2hrs

Home Benzodiazepine Use1. Determine how much patient takes at home2. Cut dose in half if taken routinely

Ativan‐ start with small doses 0.25mg PO DOCUMENT RESPONSE

SLEEP AIDSMelatonin 3‐5mg PO BedtimeTrazodone 25mg PO BedtimeMirtazepine 7.5mg PO Bedtime

*Benadryl is NEVER recommended as a sleep aid in geriatric patients*Non‐pharmacological Interventions 1st*Avoid Ambien*Home PRN Benzo use can vary from 3x's/day to 3x's/week‐must ask patient*Determine cause of Delirium

Diversional Activities

▪ A form of recreation which helps individuals by turning their attention away from their illness to another interest

▪ Occupies the individual’s mind and fosters their return to health

▪ Helps a person to regulate emotions, thoughts, and behaviors by self soothing

• Pain• Anxiety• Frustration• Confused• Hungry• Tired

Diversional Activities

▪ Music▪ Puzzles▪ Games▪ Fabric- different textures▪ Stress balls▪ Massagers▪ Coloring Pages

Pet Therapy

Geriatric Focused Collaborative Rounds

▪ Coordination of Care▪ Geriatric Resource Nurse▪ Trauma Team▪ Geriatrician▪ Case Management▪ Registered Dietician▪ Physical Therapy/Occupational Therapy

Geriatric Considerations in Collaborative Rounds

▪ Early mobilization▪ Orthostasis▪ Medication Changes▪ Pain Control▪ Nutrition▪ Delirium prevention and recognition▪ Family▪ Disposition

Process Improvement Projects

▪ Geriatric Focused Collaborative Rounds▪ Initiation of Geriatric Recommendations

•Orthostatic Blood Pressures▪ Geriatric Pain Control

•Cognitive Impairment•ATC dosing

▪ Reducing Inappropriate Medication Use•Pain/Agitation/Sleep Recommendations

▪ Delirium recognition and treatment▪ Nutrition

Continuing Staff Engagement

▪ Project Champions

▪ Continuing Education specific to geriatric trauma

▪ Geriatric Trauma Hours- 2 hours year/2015•Geriatric Trauma Conference•Fleming Lecture Series•NICHE Webinars

Geriatric Trauma Protocol Development

▪ Geriatric Consultation• Injury doesn’t matter??

▪ Delirium Protocol

▪ Pain Protocol• Acute pain management

▪ Rib Fractures• Patient Placement• Respiratory Therapy

Outcomes Following NICHE

▪ Percentage of hospital falls in patients age 65 and older decreased•FY14 61.5%, FY15 26.7%

▪ Pressure ulcers- minimal change▪ HCAHPS survey improved

•Transitions of care•Pain Management

▪ Change in Culture!!

0

1

2

3

4

5

6

2011 2012 2013 2014 2015

LOS Age <65 LOS Age >=65 LOS Age >=85

LVHN Geriatric Trauma LOS2011-2015

Analyzing the Data▪ Increasing number of functionally dependent patients

• 2011- 25.3%• 2012- 28.7%• 2013- 38.6%• 2014- 43.7%• 2015- 51.1%

▪ Increased percentage of patients >84▪ Average Injury Severity Score

• 2013- 9• 2014- 10• 2015- 9

▪ Comorbidity Average• 2013- 4.20• 2014- 4.34• 2015- 4.41

Focus Groups on Geriatric Trauma▪ AAST Geriatric Trauma Coalition

• Multidisciplinary group• Improve geriatric trauma care

– Injury Prevention– Transport and Triage– Initial assessment and Hospital Management

– Establish guidelines/protocols– Transitions of Care

– Community Resources

▪ Society of Trauma Nurses• Geriatric Special Interest Group• Fall Prevention, Protocols, Geriatric Trauma Program

▪ EAST

Plans for the Future▪ NICHE Education for all TTU Nurses▪ Continue incorporation of NICHE concepts in

trauma care•Prevent complications post trauma•Decrease Geriatric Syndromes

▪ Develop Geriatric Trauma Protocols/Guidelines▪ Research▪ More Trauma Centers must consider integrating

Geriatric Resource Programs•Optimize care of the Geriatric Trauma Population

– Geriatric Education– Specialized care

▪ Monitor Outcomes

References▪ Bonne, S. & Schuerer, D. (2013). Trauma in the older adult: epidemiology and evolving geriatric trauma principles. Clinical Geriatric Medicine, 29, 137-150.▪ Boltz, M.(2011). Nurses improving care for healthsystem elders (NICHE). In Nursing leadership. Retrieved from

http://search.credoreference.com.ezproxy2.library.drexel.edu/content/entry/spnurld/nurses_improving_care_for_healthsystem_elders_niche/0▪ Campbell, J., Degolia, P., Fallon, W., & Rader, E. (2009). In harm’s way: moving the older trauma patient toward a better outcome. Geriatrics, 64(1), 8-13.▪ Callaway, D. & Wolfe, R. (2007). Geriatric Trauma. Emergency Medicine Clinics of North America, 25, 837-860.▪ Capezuti, E., Boltz, M., Cline, D., Dickson, V., Rosenberg, M., Wagner, L, Shuluk, J., & Nigolian, C. (2012). Nurses improving care for healthsystem elders- a

model for optimising the geriatric nursing practice environment. Journal of Clinical Nursing, 21, 3117-3125.▪ Committee on the Future Health Care Workforce for Older Americans; Institute of Medicine. Retooling for an Aging America: Building the Health Care Workforce.

Washington, DC, USA: National Academies Press, 2008, p. 1.▪ Havens, J., Carter, C., Gu, X., Selwyn, O., & Rogers, J. (2012). Preinjury beta blocker usage does not affect the heart rate response to initial trauma

resuscitation. International Journal of Surgery, 10, 518-521.▪ Faraklas, I., Holt, B., Tran, S., Lin, H., Saffle, J., & Cochran, A. (2013). Impact of a nursing-driven sleep hygiene protocol on sleep quality. Journal of Burn Care &

Research, 34(2), 249-254.▪ Inouye, S., Foreman, M., Mion, L, Katz, K., & Cooney, L. (2001). Nurses’ recognition of delirium and its symptoms. Archives of Internal Medicine, 161(20), 2467-

2473. ▪ Kozar, R., Arbabi, S., Stein, D., Shackford, S., Barraco, R., Biffl, W., Brasel, K., Cooper, Z., Fakhry, S., Livingston, D., Moore, F., & Luchette, F. (2015) Injury in

the aged: Geriatric trauma care at the crossroads. Journal of Trauma Acute Care Surgery, 78(6), 1197-1209.▪ Lenartowicz, M., Parkovnick, M., McFarlan, A, Haas, B., Straus, S., Nathens, A., & Wong, C. (2012). An evaluation of a proactive geriatric trauma consultation

service. Annals of Surgery, 256(6), 1098-1101.▪ Maxwell, C. (2015). Trauma in the geriatric population. Critical Care Nurse Clinics of North America, 1-15.▪ Maxwell, C., Mion, L, & Minnick, A. (2013). Geriatric Resources in acute care hospitals and trauma centers. Journal of Gerontological Nursing, 39(12), 33-42.▪ Mitty, E.(2010). Iatrogenesis, frailty, and geriatric syndromes. Geriatric Nursing, 31(5), 368-374.▪ Nurses Improving Care to Healthsystem Elders (NICHE). (2013). About NICHE. Retrieved from http://www.nichprogram.org▪ Phillips, L. (2013). Delirium in geriatric patients: identification and prevention. MedSurg Nursing, 22(1), 9-12. ▪ Padula, C., Hughes, C., & Baumhover, L. (2009). Impact of a nurse-driven mobility protocol on functional decline in hospitalized older adults. Journal of Nursing

Care Quality, 24(4), 325-331.▪ Smith, J., Kepler, C., Kopjar, B., Harrop, J., Arnold, P., Chapman, J., Fehlings, M., Vaccaro, A., & Shaffrey, C. (2013). Effect of type II odontoid fracture nonunion

on outcome among elderly patients treated without surgery. Spine, 38(26), 2240-2246. ▪ Staus, R. (2011). Delirium in the older adult orthopaedic patient. Orthopaedic Nursing, 30(4), 231-238. ▪ Thompson, H. & Bourbonniere, M. (2006). Traumatic injury in the older adult from head to toe. Critical Care Nurse Clinics of North America, 18, 419-431.▪ Wendel, V., Durso, S., Cayea, D., Arbaje, A., & Tanner, E. (2010). Implementing staff nurse geriatric education in the acute hospital setting. MedSurg Nursing,

19(5), 274-280.▪ Winters, B. (2009). Older adults with traumatic rib fractures: an evidence-based approach to their care. Journal of Trauma Nursing, 16(2), 93-97.▪ Zelken, J., Khalifian, S., Mundinger, G., Ha, J., Manson, P., Rodriguez, E., & Dorafshar, A. (2014). Defining predictable patterns of craniomaxillofacial injury in the

elderly: analysis of 1,047 patients. Journal of Oral Maxillofacial Surgery, 72, 352-361.

Contact Information:

Kai Bortz MSN, RN‐BC, CMSRN, CNLKai_L.Bortz@lvh.com