2.6 hours Continuing Education

By Christine L. Cutugno, PhD, RN

The ‘GrayinG’ of Trauma Care: Addressing TrAumATic in Older AdulTs

Evidence-based strategies for managing trauma and its complications in this population.

overview: Trauma is the seventh leading cause of death in older adults. Factors that contribute to the higher rates of morbidity and mortality in geri- atric trauma victims include age-related physio- logic changes, a high prevalence of comorbidities, and poor physiologic reserves. Existing assessment and management standards for the care of older adults haven’t been evaluated for efficacy in geriat- ric trauma patients, and standardized protocols for trauma management haven’t been tested in older adults. Until such specific standards are developed, nurses must be guided by the relevant literature in various areas. The author reviews the mechanisms of traumatic injury in older adults, discusses the effects of aging and comorbidities, reviews assess- ment guidelines and prevention strategies for trauma-related complications, and outlines some evidence-based approaches for improving out- comes. An illustrative case is also provided.

Keywords: geriatric trauma, hospitalized older

adults, older adults, trauma, traumatic injury Photo by Keith Brofsky.

40 AJN ▼ November 2011 ▼ Vol. 111, No. 11 ajnonline.com he “graying” of America is no secret; most of for hospitalized older adults. They are so common in us have heard some version of the statisti- this population that they’re becoming known as “geri- cal projections. In 2010 the U.S. population atric syndromes.”13 T of older adults—people ages 65 and older— What guides current care? The American Geriat- stood at about 40 million; by 2030, their numbers are rics Society (AGS) has proposed wider, standardized use expected to nearly double to more than 72 million.1, 2 of comprehensive geriatric assessment for older adults Most nurses are aware that working with older patients at each entry into the health care system.14 The Amer- poses some challenges not encountered as often with ican College of Surgeons (ACS) and the ACEP have ad- younger patients. Older adults have a higher rate of co- vocated the development of evidence-based clinical morbidity and routinely take more medications than protocols and pathways for both acute care and ongo- do younger ones, and they’re more likely to have unpre- ing management of geriatric patients.9, 15 These proto- dictable responses to treatment and to suffer adverse cols and pathways will undoubtedly draw upon many events during hospitalization.3 of the assessment and treatment standards implemented Trauma is the seventh leading cause of death in through the well-established Nurses Improving Care for older adults.4 Although older adults now constitute Healthsystem Elders initiative (http://nicheprogram. about 13% of the total U.S. population,5 they account org). But although such standards for geriatric patients for more than 25% of all hospital trauma admissions,6 have been developed, they’ve yet to be evaluated for and it’s likely that as the proportion of older adults rises, efficacy with those suffering from traumatic injury. And that percentage will also rise. Indeed, it’s been estimated although several standardized protocols for trauma that by 2050, about 40% of all trauma patients will be management exist, they were developed primarily for over age 65.6, 7 Falls are known to be the leading cause younger patients and haven’t been tested in older adults. of injury in older adults. Other common causes of in- Thus, until assessment and management standards spe- jury in this age group include motor vehicle collisions, cific to geriatric trauma patients are developed and widely pedestrian–motor vehicle collisions, assault, and ther- implemented, nurses will need to be guided by measures mal . For any injury of a given severity level, older known to prevent iatrogenic complications in other pa- adults are more likely to suffer complications and die tient populations. than are younger ones. These statistics and projections are alarming, not only because of the personal costs to patients and fam- by 2050, about 40% of all ilies, but also because of the financial impact on our health care system. For example, in 2000 McMahon trauma patients will be and colleagues reported that the geriatric population consumed 33% of U.S. health care spending and 25% over age 65. of all trauma dollars.8 A 2008 report by the American College of Emergency Physicians (ACEP) noted that al- though older adults represent 15% of all patients seen This article reviews the mechanisms of traumatic in EDs, they account for 48% of ICU admissions and injury in older adults, discusses the effects of aging and use 50% more diagnostic resources.9 Such dispropor- comorbidities, reviews assessment guidelines and pre- tionate usage of resources is also likely to become greater vention strategies for trauma-related complications, as the population ages. It behooves us to examine what and outlines some evidence-based approaches for im- is being done—and to ask what more can be done— proving outcomes in geriatric trauma patients. A pa- to address these trends. tient case is also provided (see An Illustrative Case). While advanced age is associated with increased risks Terms defined. Although various lay definitions ex- of morbidity and death,4, 10 it’s not an independent pre- ist, this article uses the definition of serious injury or dictor of trauma outcome and “should not be used as trauma as stated by Richmond and colleagues: “the the sole criterion for denying or limiting care.”4 One anatomical and physiological derangements induced early study of geriatric trauma patients found that pre- by the application of external physical forces to the ventable complications contributed to over 30% of all body, resulting in injuries that threaten limb loss or deaths11; but more recent studies attribute many post- death.”10 Older adults here refers to people ages 65 trauma complications to preexisting conditions and or older; geriatric patients refers to patients in that age age-related physiologic changes.10, 12 Regardless, hospi- group. talizations for trauma are often prolonged, and recovery delayed, by many of the same iatrogenic complica- AGE AND COMPENSATORY RESPONSES TO TRAUMA tions addressed by the Institute of Medicine (IOM) in Why is trauma so much more “traumatic” for older peo- its 1999 report, To Err Is Human: Building a Safer Health ple? Factors that contribute to the higher rates of mor- System. These include adverse drug events, falls, pres- bidity and mortality in geriatric trauma victims include sure ulcers, inadequate nutrition, incontinence, and de- age-related physiologic changes, a greater prevalence lirium, and they contribute to unfavorable outcomes of comorbidities, and poorer physiologic reserves. [email protected] AJN ▼ November 2011 ▼ Vol. 111, No. 11 41 Physiologic changes associated with normal ag- maintain fluid and electrolyte balance.3, 18 Once they’re ing can predispose some older adults to serious injury injured, compensatory responses may be inadequate and make recovery of function less likely.8, 16 For exam- to stabilize older adults physiologically. Changes in vi- ple, advancing age is associated with diminished vision tal signs are less reliable indicators of instability. For and , slower reflexes, and poorer balance. Older example, in a person with chronic hypertension, a seem- adults also tend to have more mobility limitations, re- ingly normal blood pressure reading may actually be in- duced muscle mass and strength, and less joint flexibil- dicative of hypotension. The “fight or flight” responses ity. Age-related changes in bone density and decreasing associated with injury are less robust in older people. lean muscle mass can make bone fractures more likely, Compensatory increases in heart rate may be impos- with hip fracture being the most prevalent. sible if the patient has an implanted pacemaker. The Comorbidities are very common in older adults. normal tachycardic response to injury may be blunted Approximately 80% of people ages 65 and older have or diminished in patients with chronic cardiac arrhyth- one or more chronic diseases17; the most common mias, such as atrial fibrillation. Although an older adult include hypertension, arthritis, heart disease, cancer, with atrial fibrillation might be able to achieve ade- diabetes, stroke, asthma, and chronic bronchitis or em- quate tissue perfusion under ordinary circumstances, physema.2 And comorbid illness is more often the ini- a traumatic injury can overwhelm the person’s com- tiating event for trauma in older adults than it is in pensatory abilities. Tissue hypoxia can in turn cause younger ones.8 other arrhythmias, such as premature ventricular con- Older adults generally have poorer physiologic re- tractions, that can further alter cardiac output. This cy- serves and are less able to maintain homeostasis, re- cle of tissue and organ hypoxia can have predictably sulting in poor temperature control and less ability to negative effects.

AN ILLUSTRATIVE CASE rank Jones, age 83, was brought by paramedics to a local it was noted that his hematocrit hadn’t been reassessed since Ftrauma center after falling down a short flight of stairs in admission, so routine blood tests, including a complete blood his home. (This case is a composite based upon the author’s count and a metabolic panel, were also ordered at 4 pm. At experience). He was accompanied by his 82-year-old wife. 4:15 pm he became bradycardic and developed ventricular On arrival in the ED, Mr. Jones was awake and alert and fibrillation. He was resuscitated, but subsequently demonstrated complaining of pain in the right side of his chest, right wrist, signs of severe cerebral anoxia, later confirmed by neurology and right ankle. His vital signs on admission were as follows: consultation. The blood tests ordered just before the code pulse, 72 beats per minute; respiration, 30 breaths per minute was called revealed a hematocrit level of 18%. Because Mr. Jones and shallow; and blood pressure, 140/90 mmHg. He was was on a β-blocker, he had not developed tachycardia, and afebrile and his oxygen saturation was 93%. his worsening anemia had gone unrecognized. After the team Mr. Jones had a history of atrial fibrillation, for which he and Mr. Jones’s wife had discussed the patient’s known pref- was taking the β-blocker atenolol (Tenormin) daily, and mild erences for end-of-life care and the options available, a deci- congestive , for which he was taking furosemide sion was made to withdraw life support. Mr. Jones was (Lasix) daily. He had no known allergies. His X-rays in the taken off the ventilator the next day and died soon thereafter. ED revealed two fractured ribs on the right side, a fractured What went wrong? In trauma centers, all trauma-related right ulna, and a fractured right tibia. His electrolytes were deaths are reviewed to see if the care that was provided met within normal limits; his hematocrit and hemoglobin were quality standards. In this case, the quality issue was the failure 28% and 9.2 g/dL, respectively; and his coagulation profile to recheck the patient’s hematocrit. Mr. Jones was anemic on and white blood cell count were normal. Because of his admission, and the team should have recognized that, given advanced age and multiple fractures, he was admitted to the his multiple fractures, he was likely to continue to bleed into surgical ICU at 8 pm on the day of his arrival. His orders and around each fracture. The case was subsequently referred included morphine sulfate (as patient-controlled analgesia), to the surgical chief of service for physician quality review atenolol, furosemide, normal saline at 100 mL per hour iv, and for discussion at surgical monthly morbidity and mortality and 4 L nasal O2. His vital signs remained stable throughout rounds. The case was also referred to the nursing service the night and the following morning. director for review with critical care staff. Corrective actions On the following afternoon, Mr. Jones developed rapid atrial included staff education; in particular, the importance of fibrillation and became increasingly unstable. An immediate repeating hematocrit and hemoglobin assessment in patients cardiology consultation was called; the cardiologist ordered with multiple fractures and of considering the masking effects diltiazem (Cardizem) 10 mg iv. The trauma physicians began of β-blockers on shock symptoms was addressed. Follow-up assessment and stabilization measures. His arterial blood also included monthly chart review of geriatric trauma cases gases revealed a significant metabolic acidosis. At this point to confirm that such measures were being taken.

42 AJN ▼ November 2011 ▼ Vol. 111, No. 11 ajnonline.com Poorer physiologic reserves can be exacerbated by age-related physiologic changes are likely to affect the the drugs taken to manage comorbidities. For exam- various body systems to some degree. The complica- ple, β-blockers, which are used to manage various con- tions associated with those changes are more common ditions including hypertension and cardiac arrhythmias, in older people than in younger ones. It’s beyond the directly alter physiologic responses to shock. Clinicians scope of this article to review the effects of all major often rely on tachycardia as an indicator of physio- trauma conditions on all body systems; rather, the fo- logic distress; but this warning sign can be masked by cus will be on what distinguishes geriatric trauma vic- β-blockers, which slow the heart rate. In my career in tims from younger ones and what endangers them critical care nursing, I’ve had numerous experiences more. (For a list of some common age-related phys- in which a patient on β-blockers was bleeding inter- iologic changes and associated complications, see nally but didn’t develop tachycardia and thus didn’t Table 1.3, 18, 23) receive early intervention. Bleeding may not become evident until tissue hypoxia has already resulted in considerable damage to end organs. This can be espe- Changes in vital signs are cially dangerous when the bleeding is retroperitoneal or intracranial, where it isn’t as evident as bleeding else- less reliable indicators of where. Large amounts of blood can collect in the retroperitoneal space with few outward signs other than instability in older adults. back pain. A high index of suspicion is required for the recognition of retroperitoneal bleeding, especially in patients on β-blockers. Airway and breathing. In all trauma patients, the Similarly, the development of traumatic subdural cervical spine is first stabilized and then assessed for hematomas can also escape timely recognition. Many possible injury. Since many older adults have osteopo- older adults take (Coumadin), an anticoag- rosis, which makes them more susceptible to fractures, ulant, for various conditions including atrial fibrilla- extreme care must be taken in stabilizing an older pa- tion. The normal physiologic in an aging brain tient’s spine. Age-related loss of muscle mass and strength creates more intracranial space; in a trauma patient, may also contribute to weaker gag and cough reflexes. significantly more blood can accumulate before symp- This makes it harder for the older patient to clear her toms become evident.19 Delayed recognition of the de- or his airway, increasing the risk of aspiration. The use terioration of such patients will lead to predictably of suction, which increases intrathoracic (and there- negative outcomes. fore central venous) pressure and can exacerbate bleed- Undertriage. Optimum management of any trauma ing, should be kept to a minimum, both in the amount patient involves expert field stabilization, minimal trans- of negative pressure used (since an older person’s tis- port time, and to the appropriate level of trauma sues are more delicate) and in duration (since it suctions care. But complicating the management of geriatric out oxygen as well). It should also be kept in mind that trauma patients is undertreatment both at the scene suctioning can cause coughing and gagging, which and in the ED.9 Studies that have looked specifically at can also raise intrathoracic pressure. If there is any undertriage—defined as “when trauma patients were chance that the cribriform plate—the cartilage sepa- not transported to a state-designated trauma cen- rating the nose from the brain—has been damaged, ter”20—have found that older patients are consistently neither suction nor intubation can be attempted na- less likely to be so transported.20, 21 One study found sally. Prophylactic intubation may be necessary if there’s that undertriaged geriatric trauma patients had four any indication (such as decreased level of conscious- times the mortality and discharge disability rates of ness or diminished gag reflex) that the patient can’t undertriaged younger patients.22 Based on these and maintain her or his airway. The standard is to admin- other outcome studies, the ACS now recommends ister oxygen to any trauma patient with apparent sig- that trauma patients over the age of 55 be transported nificant injury.24 Although denture removal is also a to trauma centers based on that criterion alone.15 standard airway-protective measure, this will make it harder to achieve a good seal with a bag-valve-mask TRAUMA ASSESSMENT AND PREVENTION device. OF COMPLICATIONS The chest wall becomes less compliant and the lungs Regardless of patient age, trauma care priorities don’t less elastic with advancing age. In a patient with bro- change. Initial assessment and efforts fol- ken ribs or pulmonary injuries, the work of breathing low the “ABCs”: airway, breathing, and circulation. can be just that: work. It’s important to note whether What distinguish geriatric trauma victims from younger a patient is tiring from the effort to breathe, even if ox- ones are their generally poorer physiologic reserves ygen saturation levels are normal. The effort to breathe and the greater likelihood of comorbidities. It’s im- may not be sustainable; and if pain is present, it may be portant to remember that individual health status var- nearly impossible for the patient to maintain adequate ies markedly, even for patients of the same age. That said, ventilation, increasing the risk of atelectasis. Because [email protected] AJN ▼ November 2011 ▼ Vol. 111, No. 11 43 pain medications can depress respiration, the use of Circulation. For any trauma patient, fluid resusci- analgesia may require a pain consultation. tation begins with iv administration of crystalloid so- Once adequate ventilation is assured, measures to lutions, either Ringer’s lactate or normal saline. Typically prevent atelectasis and pneumonia are essential. Mea- one to two liters are given initially; if more volume is sures to prevent atelectasis may include elevation of needed, packed red blood cells are considered. (Most the head of the bed (unless contraindicated), incentive adults have four to five liters of blood, so if replacing spirometry, and early ambulation. Older patients on essentially half the person’s blood volume with crys- ventilators and positive end-expiratory pressure are talloids isn’t effective, it’s time to consider blood and especially prone to complications of barotrauma, such blood products.) Any additional fluid challenges may as and decreased cardiac output; and need to involve smaller volumes and more frequent those with malnutrition or age-compromised immune assessment; but maintaining adequate circulatory vol- systems are at higher risk for ventilator-associated pneu- ume is imperative. Inadequate perfusion in a geriatric monia (VAP). Additional measures to prevent VAP in- trauma patient can lead to myocardial ischemia or in- clude early extubation, frequent oral care, and peptic farction. Since heart rate and blood pressure may not ulcer and deep vein thrombosis prophylaxes. (For more be reliable indicators of an older patient’s stability, fre- on preventing VAP, visit www.cdc.gov/HAI/vap/vap. quent evaluation of hematocrit and hemoglobin levels, html). lung sounds, urine output, oxygen saturation levels,

Table 1. Complications Associated with Age-Related Physiologic Changes3, 18, 23

System Affected Age-Related Changes Associated Complications Pulmonary weaker gag reflex aspiration weaker cough mechanism hypoventilation chest wall less compliant atelectasis lungs less elastic barotrauma if ventilated decreased muscle mass and strength Circulatory less responsive sympathetic nervous system inability to maintain homeostasis poorer temperature control tissue hypoxia less cardiac reserves arrhythmias hypothermia Neurologic diminished hearing decreased ability to avoid injury diminished sight falls poorer balance fractures poorer slower reflex response Musculoskeletal decreased bone density falls decreased muscle mass and strength fractures decreased joint flexibility limited mobility Gastrointestinal decreased gastrointestinal motility aspiration decreased sphincter tone constipation, incontinence Renal decreased glomerular filtration rate fluid and electrolyte imbalances poorer drug clearance acute renal failure Hepatic decreased hepatic clearance poorer drug clearance coagulation problems Immunologic less responsive immunologic system infections poorer healing Integumentary loss of connective tissue poorer increasingly friable skin pressure ulcers

44 AJN ▼ November 2011 ▼ Vol. 111, No. 11 ajnonline.com and capillary refill time can all be valuable, especially injuries should not be allowed to sleep for long periods in the absence of more sophisticated hemodynamic and must be assessed frequently. Confusion, especially monitoring. Most clinicians who are experienced in in older adults, requires close monitoring and frequent trauma care are acutely aware of the challenges of reorientation. Restraints should be used only as a last keeping a patient hydrated while avoiding fluid over- resort to ensure patient safety. Their use can be frighten- load. ing to patients who might not remember receiving an The importance of frequent assessment of hemato- explanation for why they’re necessary, and can cause logic status cannot be overemphasized, especially in pa- further agitation. If restraints are absolutely necessary, tients with multiple fractures or crush injuries. In such in my experience, patients with traumatic brain inju- cases, bleeding can continue for more than 24 hours, ries seem to find vest or mitt restraints less objection- and over time a patient can bleed one to two units into able than more restrictive limb restraints. and around each fracture. Cardiac arrhythmias must be Renal. Age-related decreases in the glomerular fil- evaluated, as they may be associated with injury, elec- tration rate can wreak havoc in the geriatric patient. trolyte imbalance, or preexisting cardiac disease, and Renal clearance can deteriorate further as a result of hy- may signify a worsening condition. In patients with crit- poxemia, nephrotoxic drugs (such as aminoglycosides, ical injuries, blood lactate and base levels are fre- diuretics, contrast media, and others), or age-related quently monitored. These values are considered more slower drug metabolism. Drug dosage adjustments may accurate for detecting metabolic acidosis than moni- be indicated and drug levels should be checked peri- toring blood bicarbonate alone. A base deficit is indica- odically, especially for drugs with long half-lives. In- tive of inadequate tissue oxygenation and is associated travenous contrast media can precipitate severe fluid with significantly higher mortality.25 and electrolyte imbalances or even acute renal failure in Lastly, although temperature isn’t one of the ABCs, a geriatric trauma patient. Careful follow-up is required it’s a crucial consideration in initial trauma care. Trauma in such cases. In older patients with kidney injuries, a patients are undressed for examinations, often given high index of suspicion for retroperitoneal bleeding solutions at room temperature, and kept on relatively is called for. cold trauma stretchers, sometimes for extended peri- Diabetes insipidus may result from traumatic brain ods. Hypothermia places older patients at higher risk injury: damage to the posterior pituitary gland can for several temperature-related complications, among disrupt secretion of antidiuretic hormone (ADH, also them premature ventricular contractions and ventric- called vasopressin), resulting in severe diuresis and ular tachycardia. Hypothermia also slows oxygen de- fluid and electrolyte imbalances. Management requires livery to the tissues. Using heated blankets and warming fluid and electrolyte replacement therapy and treat- iv solutions and blood products becomes more vital ment with synthetic vasopressin (Pitressin) to replace the longer the resuscitation efforts last. ADH.

SECONDARY ASSESSMENT: PREVENTING FURTHER DISABILITY Inadequate perfusion in a geriatric Once the ABCs are assured, a secondary, head-to-toe assessment is performed. This is done to identify and trauma patient can lead to myocardial evaluate any injuries that aren’t immediately apparent or life threatening, with the goal of preventing further ischemia or infarction. disability. Additional tests may also be needed, depend- ing on the type and mechanism of injury found and other assessment findings. Even with the advanced technolo- Gastrointestinal. Maintaining adequate nutrition gies available today, injuries can be missed; ongoing can be a consistent and challenging problem with older nursing vigilance is essential. The issues that are recog- trauma victims. In general, older adults often have de- nized and addressed as a result of this secondary as- creased appetites, reduced metabolism, and decreased sessment can have considerable impact on the patient’s colonic motility; these factors as well as the presence eventual outcome. The following is a system-by-system of comorbidities can put them at higher risk for under- look at some of these issues. or malnutrition. They are thus prone to complications Neurologic. Cognitive impairments may have pre- such as compromised immune function, slow wound cipitated the traumatic injury, result from it, or both. healing, and loss of skin integrity. Many ICUs now mon- A change in level of consciousness is the first symp- itor serum prealbumin, rather than albumin, as it is a tom of deterioration in cases of , much better indicator of nutritional status.26 Research regardless of the patient’s age. It may manifest as con- supports giving early enteral nutrition to trauma pa- fusion, agitation, somnolence, or a combination of these. tients whenever possible, as this helps offset stress- But these same symptoms can be the result of an en- induced hypermetabolism, helps to maintain the gut’s tirely different problem, such as pain, and should be mucosal integrity, and minimizes bacterial entrance differentiated. Patients with suspected traumatic brain into the portal and systemic circulation.27, 28 [email protected] AJN ▼ November 2011 ▼ Vol. 111, No. 11 45 Consultation with a dietician and incorporating nu- • first- or second-degree over more than 10% tritional measures into the plan of care are also essen- total body surface area tial in such cases. • third-degree burns Musculoskeletal and integumentary. Advancing • inhalation injury age is associated with loss of muscle mass and strength; • chemical or electrical injury and many older adults, especially women, also have os- • burns with associated trauma teoporosis, a skeletal disease characterized by low bone • injuries in patients with any preexisting co- density and strength. These conditions put older adults morbidities (such as diabetes, hypertension, chronic at higher risk for bone fractures. In geriatric trauma obstructive pulmonary disease, heart failure) that patients, once a fracture has been diagnosed, further as- might complicate management sessment of the “zone of injury”—an area including • burns of the hands, face, feet, genitalia, perineum, the joints immediately above and below a fracture— or major joints is necessary. Certain fractures are often concomitant There are several initial fluid resuscitation formulas with others; for example, hip fractures resulting from for burn victims in the literature, of which the Park- a fall can be associated with wrist or shoulder fractures land formula (www.mdcalc.com/parkland-formula- incurred when the person tries to break that fall. Upper- for-burns) is probably the best known. Most use body extremity fractures can be particularly devastating for weight and burn surface area in calculating the amount older adults, impairing their ability to care for them- of fluids to infuse over a 24-hour period. However, no selves and manage activities of daily living. Discharge existing formula takes advanced age into account.31 planning should include assessment of bone density and There’s evidence of a trend toward using end-point mon- balance. A home environment evaluation might also be itoring (of end points such as urine output and blood helpful in preventing future injuries. pressure) and administering fluids to keep these within All fractures can result in bleeding and edema in a target ranges.32 This might help prevent complications closed area; patients with fractures require assessment that can result from using standard treatments in ge- for . The resulting pressure and riatric trauma patients. For example, an older adult with neurovascular compromise can result in one or more chronic heart failure and a traumatic injury could be of the five “Ps”: pain, pallor, paresthesia, pulselessness, propelled into fluid overload by a typical rapid fluid and paralysis. Splitting the cast, if the area is casted, or challenge of 500 to 1,000 mL; assessing that patient’s performing a fasciotomy may be necessary to relieve lungs after each bolus of 250 mL is probably a safer the pressure. Crush injuries in particular are known management strategy. to cause compartment syndrome and these can also result in myoglobinuria and subsequent renal fail- A CALL FOR CHANGE ure. As the proportion of older Americans increases, sim- ply being aware of how older trauma victims differ from younger ones and practicing vigilant care may Upper-extremity fractures can be particularly not be enough to prevent us from being overwhelmed by their numbers. If we subscribe to the philosophy devastating for older adults, impairing their of the trauma care community that most trauma is preventable, then we must ask what more can be done. ability to care for them selves. Upon discharge, many patients will be returning to the same environment in which the traumatic injury occurred—or possibly to one even less safe. Experts The skin of older adults tends to damage easily and have recommended interdisciplinary care for geriat- to heal slowly. Certified wound care nurses, if available, ric trauma patients that involves ongoing assessment can assist with managing skin-related complications and management from admission through discharge, in geriatric trauma patients. There are evidence-based and even afterward, if possible. (As with any patient, treatments for most kinds of skin damage, including it’s essential to involve family members and friends in pressure ulcers and shear injuries. these matters as well.) Some successful measures have Older adults who suffer thermal injuries are at much been identified for broader implementation and fur- higher risk for long-term disability and death than are ther study. younger ones.29 Inhalation burns should be suspected The recommendations of the AGS, the ACS, and in patients with facial burns and singed nasal mucosa the ACEP center around three broad categories: early or soot in the nares. Carboxyhemoglobin levels must screening for all high-risk older patients; prevention be assessed when a burn was incurred in an enclosed and early recognition of complications; and interdis- area. Burns are complicated systemic injuries requir- ciplinary discharge planning.9, 14, 15, 33 Many of the rec- ing management by experts. The American Burn As- ommendations in each category are already standard sociation’s criteria for transferring a patient to a burn current nursing practice, although not necessarily spe- unit include the following30: cific to geriatric trauma patients.

46 AJN ▼ November 2011 ▼ Vol. 111, No. 11 ajnonline.com THE ROLE OF NURSING IN IMPROVING OUTCOMES follow-up, using an ED team trained in geriatric as- Nursing’s role in proactive intervention is well docu- sessment, performing functional assessments before dis- mented. Falls risk assessment, skin assessment, pro- charge, making greater use of home care services, and motion of early ambulation, incentive spirometry, and providing better education to ED staff. Another group measures to prevent nosocomial infections (such as uri- of researchers developed a standardized geriatric con- nary tract infections, ventilator-associated pneumonia, sultation for patients admitted to a trauma service; this and central line–related bloodstream infections) are evaluated the patient’s pretrauma social situation, clin- patient safety measures now expected by regulatory ical condition, physical and cognitive function, mood agencies like the Joint Commission (and some are also (depression), use of potentially inappropriate medica- nursing-sensitive quality indicators). As evidence-based tions, and control of pain.39 In another study of hospital- clinical protocols and pathways for both acute care and ized older adults, investigators studied the effectiveness ongoing management of geriatric trauma patients are of an advanced practice nurse (APN)–centered dis- developed, such measures will undoubtedly be included. charge planning and home follow-up intervention.40 Education of nursing staff and quality-of-care monitor- They found that the intervention led to lower readmis- ing will also be needed to ensure compliance. sion rates, longer times between discharge and readmis- Overall, the importance of nursing to the prevention sion, and decreased costs of care. Given the projected of complications in and the improvement of functional shortage of 25,000 gerontologists by 2030,9 this suc- outcomes for hospitalized older adults has been estab- cessful use of APN-centered care for at-risk older adults lished. However, experts have recommended further seems particularly promising. research specific to older victims of trauma.10, 12, 34 Areas in which more study is warranted include early mobi- lization, assessment of cognition, prevention of respi- only a third of baccalaureate ratory complications, assessment of nutritional status, pain control, attention to sleep disturbances, fall pre- nursing programs re quire a vention, and skin integrity. More physiologic studies are also needed. One study examined oxygen debt in course in . adult trauma patients in a surgical ICU, and confirmed that older patients had significantly lower levels of oxy- gen delivery and consumption.35 The researchers called BETTER PREPARATION for further study on how the pacing and adjustment In its 2008 report Retooling for an Aging America: of nursing interventions should be modified for older Building the Health Care Workforce, the IOM re- trauma patients. In my experience, the use of nursing ported that the proportion of recommended care that judgment to assess patient status and determine timeli- patients receive decreases with age, and recommended ness of treatment is routine. For example, in patients with a new health care model to address the challenges of head trauma, when possible, the nursing staff would an aging population.41 Although not specific to geriat- suspend or delay any treatments (such as suctioning) ric trauma patients alone, the report’s findings and rec- that might result in sustained increases in intracranial ommendations are certainly relevant here. The IOM’s pressure. proposed model includes more education for all dis- Some promising results. One large study at an ur- ciplines involved in the care of older adults, including ban investigated whether admission to emergency responders and nurses. The report noted the step-down unit, which offered increased patient that only a third of baccalaureate nursing programs re- monitoring and low patient-to-nurse ratios, affected the quire a course in geriatrics and that less than 1% of RNs outcomes of 255 geriatric patients with hip fractures.36 are certified in geriatrics.41 Other recommendations in- National mortality rates for such fractures in older adults clude interdisciplinary team care, transitional care as reportedly range from 6% to 30%; at this trauma patients move between health care settings, proactive center, the mortality rate had previously been 20%. But rehabilitation, pharmaceutical management, and pre- the study found that with admission to the step-down ven tive home visits. Given the critical role nurses play unit, mortality fell to 2%. Although the researchers didn’t in the assessment and management of geriatric trauma specifically examine nursing measures, they pointed patients and the prevention of iatrogenic complications, to research by others demonstrating “that high patient- better educational preparation for nurses in these areas to-nurse ratios translate to higher risk-adjusted 30-day is essential. t mortality for surgical patients.”36, 37 Others have studied interventions aimed at improv- ing outcomes in geriatric patients and, in the case of trauma victims, restoring them to preinjury status. A For 72 additional continuing nursing educa- systematic review considered the evidence for interven- tion articles on geriatric topics, go to www. tions designed to improve outcomes in geriatric patients nursingcenter.com/ce. after ED discharge.38 These included using telephone [email protected] AJN ▼ November 2011 ▼ Vol. 111, No. 11 47 19. Callaway DW, Wolfe R. Geriatric trauma. Emerg Med Clin Christine L. Cutugno is an assistant professor of nursing at the North Am 2007;25(3):837-60, x. Hunter-Bellevue School of Nursing in New York City. A CCRN for over 30 years, she was most recently the director of the Criti- 20. Chang DC, et al. Undertriage of elderly trauma patients to cal Care Division at St. Joseph’s Regional Medical Center in Pat- state-designated trauma centers. Arch Surg 2008;143(8):776- erson, NJ, from 2003 to 2009 and at Jacobi Medical Center, Bronx, 81; discussion 782. NY, from 1999 to 2003. Contact author: [email protected]. 21. Lane P, et al. Geriatric trauma patients—are they receiving edu. The author has disclosed no potential conflicts of interest, fi- trauma center care? Acad Emerg Med 2003;10(3):244-50. nancial or otherwise. 22. Lehmann R, et al. The impact of advanced age on trauma triage decisions and outcomes: a statewide analysis. Am J REFERENCES Surg 2009;197(5):571-4; discussion 574-5. 1. Administration on Aging. Aging statistics. Projected future 23. 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