Midlevel Providers Focusing on Geriatrics Improve Care and Outcomes of Fall-Related Injuries Among the Elderly

Key Takeaways

Increasing age and anticoagulant use increased length of stay and mortality in patients over 65 years of age with a fall-related injury in our 327-patient sample size (both with P<.05).

Introduction

In the setting of an area health system consolidation of 21 hospitals and 3 trauma centers in rural eastern Tennessee and southwest Virginia, a level 1 trauma center with fellowship-trained trauma surgeons and surgical residents was re-designated to a level III trauma center with experienced senior general surgeons and midlevel providers (nurse practitioners and physician assistants) staffing the trauma service. We hypothesized that elderly patients with fall-related injuries would continue to be frequently admitted to our trauma center and that improved outcomes could be obtained using a geriatric-focused care model by midlevel providers.

Methods

The Ballad Health Institutional Review Board approved this study to include a trauma registry review of all patients over 65 years of age admitted to the hospital trauma service with a fall-related injury for the previous 3 years from 2018 through 2020, approval number [1706037-1]. Demographics and injury-related data included date of admission, age, GCS (Glasgow Coma Scale) score, admission disposition to floor, intensive care unit (ICU) or operating room, nature of injuries, Injury Severity Score (ISS), Abbreviated Injury Score (AIS) for body regions, hospital and ICU lengths of stay, anticoagulant use, patient comorbidities, types of falls including ground level fall or falls from ladders or steps, complications, patient functional level on discharge, discharge disposition to home or rehab, and death.

Fall-related injury outcome data from the early 2019 study period which included patient care under the level 1 trauma center designation with critical care–certified surgeons and surgical residents were compared to the later 2020 study period under the level III designation with senior general surgeons and midlevel providers using a geriatric-focused care model. Four general surgeons on the call panel in the later study period were senior general surgeons with over 25 years of experience in trauma of which two were fellowship-trained trauma surgeons currently board certified in surgical critical care. Midlevel providers included nurse practitioners and physician assistants who had several years of ICU experience with credentials for central line insertions and other procedures. Surgical critical care is provided for the patients by the trauma team. The network system level 1 trauma center is located 20 miles away.

Trauma attending and midlevel providers interviewed patients and family members using a trauma prevention checklist including medications reconciliation, frailty scores, history of previous falls, nutrition, and home environment fall risks in an effort to prevent further falls. This process encompassed the geriatric-focused care model utilized in this study.

Statistical data analysis included t-test and regression analysis. P-value < .05 was considered significant. Microsoft® Excel® for Microsoft 365 MSO version 2107 was used for the analysis.

Results

There were 327 patients admitted with fall-related injuries over the entire study period with 177 seen in the early period and 150 patients seen in the latter period (NS: non-significant), as shown in Table 1. Injury Severity Scores (ISS) were similar throughout the study period (NS). Abbreviated Injury Scores (AIS) including head and neck, chest, abdominal, and extremity were similar in both study periods (NS). Average age (79 years) was similar (NS). Mortality rate was improved (P = .01), and patient functional level of independence scores were improved in the latter period with midlevels (P = .03). Hospital length of stay trended to shorter stays (P = .1) with midlevels. Patient use of anti-coagulants (45%), complications (15%), and presence of comorbidities (80%) were similar.

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Table 1.

Demographics of 327 Fall-Related Injuries (2019 and 2020).

Variable	2019 (n = 177)	2020 (n = 150)	P value
Admissions, n (% of total)	177 (54.1%)	150 (45.8%)
AIS head/neck	1.7	1.8	0.8
AIS chest	0.6	0.5	0.5
AIS extremities	0.7	0.7	0.7
AIS abdomen	0.2	0.2	NS
Average age (years)	79.1	79.4	NS
Male gender, n (%)	47%	40%	0.2
ISS*	10.2	9.8	0.9
GCS**	14.2	14.2	NS
LOS	5.3	4.9	0.1
ICU LOS	2.2	2	0.8
% Ground level fall	64%	63%	NS
Outcome death (%)	12.5%	8.7%	.01 a
% Taking anti-coagulants	45%	44%	NS
% With comorbidities	75%	87%	NS

Ground level falls were the predominant mechanism of falls (63%), while falls off ladders (4%), falls from steps (4%), and patients found down (3%) were less common. Overall, 37% of patients had closed head injuries, 21% had spinal injuries, 16% had rib fractures, 8% had pelvic or hip fractures, 11% had facial fractures, 17% had extremity fractures, and 11% of patients died. 80% of patients who died suffered closed head injuries.

Age, ISS, AIS head and neck, and use of anti-coagulants were predictors of death (P < .05). Age predicted worse head injuries, worse chest injuries, longer lengths of stay, and lower likelihood of discharge to home.

Discussion

Due to dramatic changes in health care both politically and technologically, communities and hospitals are faced with increasingly complex patient populations without associated financial reimbursements. It is in this dynamic setting that the role of the advanced practice providers continues to evolve. Nurse practitioners and physician assistants were conceptualized in the early 1960s and have since helped expand the scope of midlevel provider practice. ¹ Today’s midlevel practitioner works in a variety of settings and specialties. It is evident from the literature that more trauma programs are beginning to utilize midlevels in various capacities. As a result, midlevels quickly have become valuable members of trauma teams. They provide comprehensive medical care complimented by a holistic nursing approach. As more and more trauma programs turn toward utilizing physician extenders to augment their programs, studies have shown that midlevels are capable of these challenging roles. ²

A level 1 trauma center is a regional resource and tertiary care facility capable of providing immediate definitive and comprehensive care to all injured patients, regardless of severity and complexity. ³ All level II centers include the specialty services needed to provide care to the severely injured, although clinical capabilities may not be as comprehensive as at level 1 centers.

The level III center is an entry point to the regional trauma system usually in communities that are remote from major trauma centers. The presence of general surgery capability differentiates the level III from the level IV center with the expectation that a general surgeon will be present in the emergency department to lead resuscitation upon arrival of every major trauma patient. The level III center provides definitive care to the moderately injured and initial stabilization for the major trauma patient, which may include operative hemorrhage control to ensure safe transfer to a major trauma center.^4,5 Pre-defined plans for transfer of patients to the major trauma centers are essential.

In 2013, 2.5 million nonfatal falls among older adults were treated in emergency departments, and more than 734,000 patients were hospitalized. In addition, approximately 25,000 older adults died from unintentional fall-related injuries in the same year. ⁶ For older trauma patients many of these falls are from a standing height but still lead to significant injuries requiring hospitalization. ⁷ Pre-existing medical conditions, medications, and other variables play a significant role in ground level falls. ⁸ Unfavorable discharge dispositions and mortality are significant in this group of patients.

A study from Harborview Medical Center examined 1,352 elderly patients admitted to their trauma center after a ground level fall. ⁹ Deaths occurred in 12% of the patients during the index admission. Of the survivors, 50% were discharged to a skilled nursing facility (SNF) and only 6% were discharged home. Nearly 45% were readmitted within 1 year following discharge, with patients requiring an admission to the ICU during the index admission to be at highest risk for readmission. The overall 1-year mortality for the entire group, including those who died during the index admission, was 33%. Patients discharged to a SNF were 3 times more likely to die than patients discharge home.

Fall prevention programs aim to detect individuals at high risk for falls and to remove those risk factors that can lead to falls. ¹⁰ Because the societal and financial impact of older adults sustaining falls is significant, developing effective prevention measures is mandatory. Optimizing medications to prevent hypotension and hypoglycemia; encouraging physical exercise to prevent osteoporosis and prevent skeletal muscle loss; instituting environmental modifications, such as grab bars and clutter removal; and reducing environmental hazards all play a significant role in preventing falls.

Elderly patients with fall-related injuries are increasingly seen in trauma systems that may include level I, II, or III designated trauma centers. Trauma surgeons experienced in trauma working with midlevel practitioners in level III centers may provide high quality efficient care including trauma prevention efforts with clinical outcomes comparable to level I and level II centers with surgical resident staffing. The major limitation of this study was the sample size. As this care model is further developed and implemented, more patient data will become available to include and allow for drawing broader conclusions. Opportunities for the progression of this research include using frailty score as a predictor of outcomes, implementing propensity matching for a higher level of statistical analysis, and granulation of the data looking at specific comorbidities and medications the patients may be on which could influence their course of treatment and outcomes.