Care of Geriatric Patients with Lumbar Spine, Pelvic, and Acetabular Fractures before and after Certification as a Geriatric Trauma Center DGU®: A Retrospective Cohort Study.

Background: More than 750,000 fragility fractures occur in Germany every year, with an expected increase in the following years. Interdisciplinary care pathways for geriatric patients are increasingly established to improve the treatment process and outcome, but there has been only limited evaluation of their use. Objectives: This study aimed to compare patient care before and after the implementation of a geriatric trauma center (GTC) in conformity with the German Society for Trauma Surgery (DGU®). Patients and Methods: We performed a retrospective single-center cohort study, including 361 patients >70 years old with lumbar spine, pelvic, and acetabular fractures, admitted between January 2012 and September 2019. Patients were divided into a usual care cohort (UC, n = 137) before implementation and an ortho-geriatric care cohort (OGC, n = 224) after implementation of the GTC DGU®. We recorded and compared demographic data, fracture type, geriatric assessment and management, therapy, complications, and various clinical parameters, e.g., length of stay, time to surgery, hours admitted to ICU, and change in walking ability. Results: The geriatric assessment revealed significant geriatric co-morbidities and a need for geriatric intervention in 75% of the patients. With orthogeriatric co-management, a significant increase in the detection of urological complications (UC: 25.5% vs. OGC: 37.5%; p = 0.021), earlier postoperative mobilization (UC: 57.1% vs. OGC: 86.3%; p < 0.001), an increased prescription of anti-osteoporotic treatment at discharge (UC: 13.1% vs. OGC: 46.8%; p < 0.001), and lower rates of revision surgery (UC: 5.8% vs. OGC: 3.1%; p = 0.012) could be seen. Conclusions: Our results emphasize the improvement in patient care and clinical outcome by implementing a GTC DGU® and provide opportunities for future improvement in ortho-geriatric patient care.

[120-day follow-up after proximal femoral fractures-first results from the Geriatric Trauma Registry DGU®]. / 120-Tage-Follow-up nach hüftgelenknahen Frakturen ­ erste Daten aus dem AltersTraumaRegister DGU®.

BACKGROUND: Geriatric trauma centers which are certified to the status of a Geriatic Trauma Center DGU® based on the criteria catalogue as outlined by the German Trauma Society (DGU), are required to participate in the Geriatric Trauma Register (ATR-DGU) for quality management and outcome analyses. The evaluation is pseudoanonymous and includes data on all treated hip fracture patients over 70 years old. This has been in regular use since 2016. This study analyzed the postoperative evaluation of gait, mortality, quality of life, hospital readmission and treatment of osteoporosis after 120 days. METHODS: A voluntary retrospective data evaluation of the ATR-DGU 120-day follow-up from 2017 was carried out. Written consent for the analysis and publication of the data was obtained from six clinics that already participated in the follow-up. The primary target parameters were mortality rate, readmission and revision rates, gait quality, osteoporosis treatment and quality of life according to EQ-5D-3L. The patient data were completely pseudonymized and a descriptive analysis was carried out. RESULTS: In this study 957 patients from the 6 hospitals were included. The average age was 84.5 years (±6.8 years). The mortality rate during the acute treatment phase was 5%. The 120-day follow-up could be evaluated in 412 patients, 10% of these required hospital readmission due to complications oft he same fracture and of these 6% required revision surgery. The mortality rate at 120 days was 12%. In 54% of the patients the fracture led to deterioration of mobility and 49% of patients received osteoporosis treatment after 120 days. The results of the EQ-5D-3L at 120 days revealed improvement as compared to the values on postoperative day 7; however, the preoperative status with respect to mobility and quality of life could not be regained. CONCLUSION: Despite the clear advantages of interdisciplinary treatment, the results are still limited concerning mobilization and quality of life. Further analysis of causative and influencing factors is necessary.

[Online survey for assessment of geriatric early rehabilitation complex treatment in geriatric trauma centers of the DGU by the medical services of the health funds]. / Onlinebefragung zur Prüfung der geriatrisch frührehabilitativen Komplexbehandlung durch den Medizinischen Dienst der Krankenversicherung in AltersTraumaZentren DGU®.

BACKGROUND: Orthogeriatric co-management of proximal femoral fractures has been proven to effectively reduce mortality rates. This involves extending resources in hospitals treating these patients as well as dealing with the possibility of prolonged periods of hospitalization. The increase in costs of orthogeriatric co-management are best illustrated by the implementation of geriatric early rehabilitation complex treatment. In view of the problems concerning billing this complex treatment, an online survey was carried among certified geriatric trauma centers of the German Trauma Society (DGU®). METHODS: Based on a trauma-geriatric consensus 20 questions were formulated by the Academy of Trauma Surgery (AUC) as an online questionnaire and sent to all 75 certified geriatric trauma centers. Apart from a description of the results, a subanalysis based on the figures presented by the case closing departments (geriatrics or trauma surgery) was included. The questions covered a 2-year period of experiences from 2016 to 2018. RESULTS: A total of 26 of the 75 certified geriatric trauma centers participated (35%). A continuous increase in cost analysis evaluations by the medical services of the health funds was observed. A rise from 38% in 2016 to 45% in 2018 was seen. An analogous rejection trend from 16% to 24% during this period was evident as well. Subanalysis revealed significantly higher cost evaluation by the medical services of the health funds and cost rejection rates if trauma departments were the case closing disciplines. CONCLUSION: The online survey revealed significantly higher assessment and rejection rates when compared to other hospital services. This could prove potentially detrimental to the future of orthogeriatric co-management.

[Challenges of implementing a geriatric trauma network : A regional structure]. / Herausforderung der Implementierung eines Alterstraumanetzwerks : Ein standortübergreifendes Verbundsystem.

BACKGROUND: At present, there is a high percentage and increasing tendency of patients presenting with orthogeriatric injuries. Moreover, significant comorbidities often exist, requiring increased interdisciplinary treatment. These developments have led the German Society of Trauma Surgery, in cooperation with the German Society of Geriatrics, to establish geriatric trauma centers. METHODS: As a conglomerate hospital at two locations, we are cooperating with two external geriatric clinics. In 2015, a geriatric trauma center certification in the form of a conglomerate network structure was agreed upon for the first time in Germany. For this purpose, the requirements for certification were observed. Both structure and organization were defined in a manual according to DIN EN ISO 9001:2015. RESULTS: Between 2008 and 2016, an increase of 70% was seen in geriatric trauma cases in our hospital, with a rise of up to 360% in specific diagnoses. The necessary standards and regulations were compiled and evaluated from our hospitals. After successful certification, improvements were necessary, followed by a planned re-audit. These were prepared by multiprofessional interdisciplinary teams and implemented at all locations. CONCLUSIONS: A network structure can be an alternative to classical cooperation between trauma and geriatric units in one clinic and help reduce possible staffing shortage. Due to the lack of scientific evidence, future evaluations of the geriatric trauma register should reveal whether network structures in geriatric trauma surgery lead to a valid improvement in medical care.

The "Aachen fall prevention App" - a Smartphone application app for the self-assessment of elderly patients at risk for ground level falls.

BACKGROUND: Fall incidents are a major problem for patients and healthcare. The "Aachen Fall Prevention App" (AFPA) represents the first mobile Health (mHealth) application (app) empowering older patients (persons 50+ years) to self-assess and monitor their individual fall risk. Self-assessment is based on the "Aachen Fall Prevention Scale," which consists of three steps. First, patients answer ten standardized yes-no questions (positive criterion ≥ 5 "Yes" responses). Second, a ten-second test of free standing without compensatory movement is performed (positive criterion: compensatory movement). Finally, during the third step, patients rate their subjective fall risk on a 10-point Likert scale, based on the results of steps one and two. The purpose of this app is (1) to offer a low-threshold service through which individuals can independently monitor their individual fall risk and (2) to collect data about how a patient-centered mHealth app for fall risk assessment is used in the field. RESULTS: The results represent the first year of an ongoing field study. From December 2015 to December 2016, 197 persons downloaded the AFPA (iOS™ and Android™; free of charge). N = 111 of these persons voluntarily shared their data and thereby participated in the field study. Data from a final number of n = 79 persons were analyzed due to exclusion criteria (age, missing objective fall risk, missing self-assessment). The objective fall risk and the self-assessed subjective risk measured by the AFPA showed a significant positive relationship. CONCLUSIONS: The "Aachen Fall Prevention App" (AFPA) is an mHealth app released for iOS and Android. This field study revealed the AFPA as a promising tool to raise older adults' awareness of their individual fall risk by means of a low-threshold patient-driven fall risk assessment tool.

[Living will, durable power of attorney and legal guardianship in the trauma surgery routine : Data from a geriatric trauma center]. / Patientenverfügung, Vorsorgevollmacht und gesetzliche Betreuung im unfallchirurgischen Alltag : Zahlen aus einem alterstraumatologischen Zentrum.

BACKGROUND: Due to the increasing number of elderly patients, trauma surgeons are often confronted with end-of-life treatment decisions. Advance directives can help reduce the lack of clarity in those situations. OBJECTIVES: The aim of this study was to identify the presence of living wills, durable power of attorney, legal guardianship and appointment of guardianship in the geriatric trauma center of a university hospital. MATERIALS AND METHODS: The data of all patients treated in our geriatric trauma center from 01/01/2013 to 03/31/2014 were analyzed regarding the presence of a living will, durable power of attorney, legal guardianship and appointment of guardianship as well as the procedure of documenting those items. RESULTS: Out of 181 patients, 63 % (n = 114) had one or more of these documents. Most frequently used was the durable power of attorney in 33 % (n = 59), followed by a living will in 27 % (n = 48), legal guardianship in 20 % (n = 37) and appointment of guardianship in 7 % (n = 12). The existence of those documents was recorded in 88 % (n = 100) of patients within 24 h after admission; documentation in the medical records was found in 58 % (n = 66). CONCLUSION: A large proportion of patients had one or more of the documents named above. In this respect, standardized documentation of advance directives in the medical record is an important issue for all persons involved.

Geriatric Fracture Centre (German Trauma Society): guidelines and certification to improve geriatric trauma care.

Because of demographic changes and the increasing proportion of orthogeriatric patients, the German Trauma Society (DGU) established a certification process for geriatric fracture centres (AltersTraumaZentrum DGU®). This article is a detailed illustration of the certification process and the related Registry. The main goal of the certification is to support orthogeriatric comanagement and to improve the quality of care for geriatric patients. The requirements of the Criteria Catalogue force participating centres to continuously survey and improve their standards and structures. As a result, the requirements should lead to a high quality of care. To prove that the certification leads to higher quality of care, the DGU started a Geriatric Fracture Registry (AltersTraumaRegister DGU®) in 2016, which is obligatory for all certified centres. Studies on comanaged care and the improvement of quality by certified geriatric fracture centres are planned. Further health-care research will also be possible with the collected data.

The 'Aachen Falls Prevention Scale' - development of a tool for self-assessment of elderly patients at risk for ground level falls.

BACKGROUND: The incidence of falls in the elderly population is difficult to determine and therefore potentially underestimated. Screening algorithms usually have in common that the evaluation is undertaken by trained individuals in a hospital setting. This leads to the inclusion of a high proportion of low-risk people and a waste of resources. It would be advantageous to pretest the individuals at risk in their own environment using a simple self-assessment approach. METHODS: The consensus process of our group of clinicians and physical therapists included: 1. a preparative literature review about risk profiles and assessment tools for ground level falls; 2. a selection of appropriate questions that cover all health aspects involved in an increased risk for falling; and 3. a selection of a simple physical test that can be used at home without the need of a health care professional. We thus searched to develop a scale that can be used by older citizen at higher risk of falling. The current manuscript summarizes the results of this review, consensus and selection process. RESULTS: The literature search was undertaken between March and August 1, 2013. The selection process for the questions used (Part I) lasted between March 2013 and January 2014. Among all tests evaluated the 20 second standing test (Part II) was deemed to be safe to be performed even by an individual at risk for a fall, as it closely resembles activities of daily living. The `Aachen Falls Prevention Scale` finally uses a self-assessment tool grading falls risk on a scale of 1 to 10 by the individual itself after completion of Part I and Part II. In summary, we present a scale that might offer a self-assessment option to improve the measures of falls prevention pass for elderly citizens. CONCLUSIONS: The introduction of the `Aachen Falls Prevention Scale` which combines a simple questionnaire with a safe and quick balance tool, meets the criteria to identify whether or not a balance problem exists - the first step in evaluation of falls risk. Further studies will have to assess the ability of an individual to estimate his or her individual falls risk on a longitudinal basis and possibly trigger the necessity for the assessment by a physician.