Organization of medical services for trauma patients: current requirements and best practices of cooperation between traumatologists and therapists

Shahnoza F. Davlyatova, Murad M. Muradov, Polina S. Afanase-va. Organization of medical services for trauma patients: current requirements and best practices of cooperation between traumatologists and therapists. Cardiometry; Issue No. 33; November 2024; p. 44-49; DOI: 10.18137/cardiometry.2024.33.4449; Available from:

The available data strongly suggest that joint or-thogeriatric treatment improves outcomes in debilitated elderly patients with a fracture, but there is insufficient data on how to implement this treatment model in daily clinical practice. In this article, we first describe the implementation process and the choice of strategies for implementing an orthogeriatric joint management program in the trauma department at one of the clinics. Secondly, we report the results of the feasibility study using several methods. This study measures adherence to the main components of the program, quantifies the feasibility and acceptability perceived by health professionals, and identifies the factors that determine implementation.

The purpose of the work is to consider the specifics of working with traumatology patients as part of the joint work of a traumatologist, a therapist and specialists of different profiles.

MATERIALS AND METHODS

The implementation strategies were implemented based on the Recommendations of the Change Implementation Experts (RCIE). In the feasibility study, fidelity to the main components of the program was measured in a group of 15 patients aged 75 years and older using electronic medical records. Feasibility and acceptability from the point of view of the medical professionals involved were assessed using a survey of 15 questions on a 5-point Likert scale. The factors determining implementation were thematically mapped based on seven focus group discussions and two semi-structured interviews focusing on the experience of medical professionals.

RESULTS

We observed low accuracy in completing the screening questionnaire for mapping the premorbid situation (13%), but high accuracy in relation to other main components of the program: multidimensional assessment (100%), development of an individual care plan (100%) and systematic treatment. observation (80%). Of the 50 respondents to the survey, 94% agreed with the program, and 62% considered it feasible. Important factors determining implementation were feasibility, awareness and awareness, as well as improved interaction between medical professionals, which positively influenced the commitment to the program.

DISCUSSION

The fidelity, acceptability and feasibility of the or-thogeriatric collaborative management program were high as a result of an iterative process of selecting implementation strategies with intensive stakeholder participation from the very beginning.

Weakened elderly people, who often suffer from functional dependencies, concomitant diseases and polypragmasia, are more prone to repeated falls [1]. About a third of people over the age of 65 experience at least one fall per year, and among people over the age of 80, this figure increases to half [2]. As a result, hospitalization is often necessary [3]. The impact of fall-related fractures on quality of life is enormous due to complications after fractures such as delirium, functional decline and mortality [4].

Comprehensive geriatric assessment (CGA) was introduced to prevent adverse outcomes in hospitalized debilitated patients.

CGA is a process of risk screening in debilitated elderly patients, multidimensional assessment, development of an individual care plan and systematic monitoring by a multidisciplinary medical team, including a team with therapists and traumatologists.

CGA is considered the gold standard in providing high-quality geriatric care and is the foundation of all interdisciplinary models of care for debilitated elderly patients. In many hospitals, elderly patients with fractures are admitted to the emergency trauma unit, followed by surgical follow-up and a more fracture-oriented approach without much attention to geriatric needs. In some hospitals, mobile geriatric consultation groups are available at the request of the non-geriat-ric care team [5]. These teams provide CGA-based care recommendations for elderly patients admitted to non-geriatric wards. However, studies have shown that the influence of the advisory model on patient treatment outcomes is limited due to its rather reactive and recommendatory nature [6].

Proactive geriatric co-management has proven to be a potential solution to overcome the limitations of the counseling model. Co-management is characterized by joint decision-making and responsibility sharing between the geriatric and non-geriatric care team, from admission to discharge. The beneficial effect of joint geriatric and surgical treatment on patient outcomes, such as hospital-acquired mortality and length of stay, has been repeatedly confirmed in the course of research [7].

Despite extensive evidence of the effectiveness of collaborative geriatric management, few hospitals have implemented geriatric collaborative management models. The problem is related to the fact that at the moment there are no prescriptions and methodological recommendations on which strategies to use and how to successfully implement an orthogeriatric program.

In 2017, a joint geriatric disease management program was implemented in the cardiology departments of the University Hospital of Leuven in Belgium [9]. Using a hybrid Type I efficiency and implementation scheme, this collaborative management model has proven effective in improving hospital care processes and preventing functional deterioration and complications. Moreover, this model of care was perceived by medical professionals as acceptable and feasible [10]. Based on these results, the care model was adapted and implemented in the trauma department of the same hospital on an ongoing basis. This joint geriatric and surgical treatment program, called G-COMAN, is currently being evaluated using a hybrid Type II efficacy study design [11].

Although the effectiveness assessment will be reported upon completion of data collection, the purpose of this document on the implementation of

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G-COMAN is not unambiguous. First, we describe the implementation process, including the choice of an implementation strategy. Secondly, we report the results of a multi-method feasibility study in which we measured commitment to the core components of the program, quantified the feasibility and acceptability perceived by health professionals, and identified the determining factors of implementation.

It can be emphasized that for sure the implemented system will lead to an increase in time for decision-making by specialists of different profiles: therapists and traumatologists. Thanks to the G-COMAN program, therapists and traumatologists can exchange information and make decisions faster, which reduces patient waiting times and increases satisfaction levels.

The study was conducted in the trauma department of one of the clinics. About 53,000 patients are admitted to this hospital annually, of which 22.0% are patients aged 75 years and older. In the trauma department, 30.5% of hospitalized patients are over 75 years old. A multidisciplinary team provides daily care in the 56-bed trauma unit. This team consists of several full-time trauma surgeons, assisted by eight surgical residents and a therapist.

The joint work of a traumatologist and a therapist is of key importance for providing comprehensive and effective medical care to patients with traumatic conditions. The traumatologist specializes in the diagnosis and treatment of injuries, while the therapist has extensive knowledge in the field of internal diseases and general medical practice.

The department is managed by two full-time senior nurses who supervise the department’s staff nurses and other medical staff (i.e. junior nurses and logistics staff). There are also four part-time advanced practice nurses specializing in trauma care. These trained nurses are clinical experts in nursing and trauma care and ensure continuity of care and treatment for patients on weekends. They also play a coordinating role in the implementation of quality improvement initiatives in the department and monitor the clinical treatment pathways for patients with fractures. Related medical professionals in the trauma department include physiotherapists, a therapist, occupational therapists, a psychologist, a speech therapist, a nutritionist, and a social worker.

It should be noted that the work of a traumatologist and a therapist is still of key importance, since close communication between these specialists allows 46 | Cardiometry | Issue 33. November 2024

patients to provide a full range of medical care: from initial examination and diagnosis to treatment and rehabilitation. The traumatologist and the therapist can interact to determine the optimal treatment tactics, take into account all concomitant diseases and characteristics of the patient’s body, as well as to monitor the patient’s condition throughout the recovery process.

Prior to the implementation of the G-COMAN program, the usual care for elderly patients admitted to the trauma department consisted of the assistance of a multidisciplinary trauma team. An inpatient geriatric consultation group, including geriatric nurses under the guidance of geriatricians, was available at the request of a surgical resident or a traumatologist. The Geriatric Consultation Group conducted a multidimensional assessment and formulated individual recommendations based on the identified geriatric problems. The trauma team was responsible for implementing these recommendations without systematic oversight by the geriatric advisory group.

The G-COMAN program includes preventive geriatric care with automated protocols for all patients aged 75 years and older and a screening questionnaire for all patients aged 75 years and older to map the premorbid situation followed by multidimensional assessment and interdisciplinary interventions with systematic follow-up [12].

Firstly, all patients aged 75 years and older receive preventive geriatric care with an emphasis on functional, somatic, psychological and social spheres. To do this, various medical care plans are automatically programmed into the electronic medical record. For example, nurses receive a patient’s bowel care plan three times a day. In addition, the removal of the urinary catheter is planned within 24 hours after surgery, after which the electronic medical record automatically launches a plan for the care of the remaining volume of the bladder after emptying using a bladder scan.

Secondly, the premorbid functional, somatic, psychological and social status of the patient is documented using a screening questionnaire. This questionnaire is sent to the patient or the person caring for him through the hospital’s mobile application upon admission to the trauma department. Alternatively, the questionnaire can be offered by e-mail, using a QR code or on interactive screens available in all wards of the hospital. Subsequently, a multidisciplinary trauma team or geriatric counseling group conducts a more in-depth multidimensional assessment at the patient’s bedside to identify potential geriatric problems. The results of the screening questionnaire and the multidimensional assessment make it possible to develop an individual interdisciplinary care plan through daily consultations between the G-COMAN trauma nurse and the responsible nurse of the department, as well as during weekly meetings with the multidisciplinary care team of the trauma department. This care plan, based on the individual needs of the patient, is implemented by a multidisciplinary trauma department team with the support of a geriatric counseling group and a geriatric resident. Twice a week, the surgical resident consults with the geriatric resident to discuss acute medical problems or geriatric syndromes.

The implementation of the new care program involves changing the existing organization of care and behavior of medical workers. For implementation efforts to be successful, implementation strategies are needed to overcome local barriers and contribute to the achievement of implementation results [13]. Based on our assessment of the implementation in the cardiology department, we invested in intensive stakeholder engagement from the very beginning of the implementation process and a thorough contextual analysis. We used an iterative process of choosing G-COMAN implementation strategies at each stage of the project, as defined in Prochaska and Veliser’s theory of change [14].

They describe the process of changing health behaviors over five stages: the preliminary review stage (people are not aware of the problem and are not ready to change their behavior), the contemplation stage (people are aware and aware of the problem), the preparation phase (people take small steps to change behavior), the action phase (people change their behavior) and maintenance phase (continuation of actions and prevention of relapses). In this article, we describe the strategies for implementing G-COMAN in stages. We synthesized these strategies based on the recommendations of the Change Implementation Experts (ERIC) [15], consisting of 73 implementation strategies divided into nine categories and indicating for each strategy which implementation outcome is the goal.

To get an idea of the results and the factors determining implementation, we conducted a comprehensive assessment at the action stage of the implementation process. First, a quantitative assessment of loyalty was performed on a small group of patients to determine how well the main components and care pro- cesses of the G-COMAN program were implemented. A study was also conducted to assess the perceived feasibility and acceptability of this solution on the part of medical professionals. The last stage was a qualitative descriptive assessment using discussions and interviews in focus groups to collect the experience of medical professionals during implementation and assess the factors determining implementation [16].

We recruited fifteen consecutive patients aged 75 years and older who were admitted to the trauma department and enrolled in the G-COMAN program.

In the study cohort of fifteen patients, the average age was 84.2 years, and the ratio of women to men was 2:1. Most patients were hospitalized with a fracture of the proximal femur (46.7%), followed by a fracture of the distal femur (13.3%) and a pelvic fracture (13.3%). The patients had an average Katz index of 8.6, an average Parker mobility index of 7.2, and an average MNA of 10.6 [17].

Compliance with the main components of the G-COMAN program was as follows: filling out a screening questionnaire (13%), multidimensional assessment (100%), development of an individual care plan (100%) and systematic observation (80%). Of the fifteen patients, 73.3% received physical therapy within 24 hours after surgery, and 86.7% were free from physical limitations. One third of the patients did not have a permanent urinary catheter within 24 hours after surgery. Almost every patient (90.0%) received an oral laxative if he did not have a stool for three days. During the first three postoperative days, none of the patients were evaluated three times a day using the delirium monitoring scale, and only 75.0% during this period assessed pain using a numerical rating scale or pain in progressive dementia. At discharge, 87.5% of patients who had not yet taken calcium/vitamin D supplements at admission received a prescription.

Of the 50 medical professionals who took part in the survey (response rate = 58%), 98% knew about the program, 88% indicated that they have theoretical knowledge about geriatric syndromes, and 78% of medical professionals indicated that they know how to prevent geriatric syndromes. The perceived acceptability and feasibility of the program was 94% and 62%, respectively. Almost all medical professionals (96%) believed in the added value of the program, and 86% were motivated to work in accordance with the program. The majority (65%) believed in the sustainability of the program, but only 35% of medical pro fessionals believed that the program had already been implemented into their daily clinical practice.

The first area for which important factors determining implementation were identified were the guiding factors. Medical staff were satisfied with the availability of orthogeriatric protocols (availability of recommendations). Therapists emphasized the need to adapt geriatric protocols to the trauma patient population (compatibility), since not all components of geriatric intervention could be performed in a traumatology setting (feasibility). Efforts were perceived as minimal as soon as they observed an improvement as a result of their actions (observability). As a result, protocol execution was no longer perceived as an additional burden (effort).

The second area contains individual occupational health factors. Before the implementation, the medical staff of the trauma department indicated that their geriatric knowledge was limited and required improvement (knowledge of the subject area). They were assisted in this by therapists with broader knowledge in this field. The joint work of various specialists helped to identify and prevent complications in a timely manner, provided more effective and targeted treatment, as well as improved the quality of life of patients after injury [18].

Awareness and familiarity with the program, both among people already working in the department and among new people starting during implementation and in the future, were important factors determining implementation. In addition, the decisive factor in the implementation of the program was the intentions and motivation of each person. Demotivation on the part of colleagues was perceived as a barrier, as it affected the motivation of others. At the same time, the exchange of information between traumatologists and therapists contributed to more successful and full-fledged rehabilitation results of patients, a positive atmosphere within the team, which indicates a good level of program implementation.

Medical professionals stressed that the program should eventually become routine due to the frequent implementation of protocols (the nature of behavior) [19].

The third domain covers patient factors, with patient needs being an important determining factor. The revealed barrier was the perception of patients’ needs by medical professionals, which did not always correspond to the actions of the program. For example, it was supposed to introduce a fixed moment for 48 | Cardiometry | Issue 33. November 2024

urination training, but medical workers considered this a violation of the patient’s independence.

The fourth area contains professional interactions. Since the launch of the program, communication between medical staff of the geriatric, therapeutic and trauma teams has improved, which has had a positive impact on treatment adherence. During the implementation, the referral process has changed in a positive way. Consequently, all disciplines worked more closely with each other and considered this their strong point.

The fifth area is the ability to make organizational changes [20]. Medical professionals agreed that in a time of change, an able leader is needed who is actively involved in the implementation process. The importance of a recommendation person from the nursing staff who can motivate medical workers and provide them with feedback has been emphasized many times. The process of adapting the work of different medical teams to work together, despite a number of difficulties, can be called positive.

Despite convincing evidence of the impact of or-thogeriatric collaborative management models on patient and organizational outcomes, the implementation of these models into routine clinical practice remains a difficult task [21]. In this study, we have shown that a step-by-step approach to implementation based on careful contextual analysis and ongoing stakeholder involvement has led to the successful implementation of an orthogeriatric collaborative management program. This program was perceived by the medical professionals involved as feasible and acceptable, and also led to positive results for patients, as working together made the rehabilitation process faster.

CONCLUSIONS

In conclusion, this article provides important information about the process of implementing the CGA-based orthogeriatric care model, which can serve as a guide for other physicians and researchers. The iterative process of choosing implementation strategies with the intensive participation of various specialists, including therapists, has become the key to the success of this medical program.

This is reflected in the high acceptability and feasibility perceived by healthcare professionals, as well as the high level of rehabilitation process in patients. This program will have a beneficial effect on patient outcomes and inpatient treatment costs. At the moment, testing of similar techniques is not complete.

Thanks to the G-COMAN program, it was possible to make the information exchange process more efficient and transparent, which contributes to more accurate diagnosis and rapid treatment.