Alexander James Ordoobadi

Background: Trauma centers are implementing geriatric‐focused processes of care, including geriatric consult services, to improve outcomes for injured older adults. We hypothesized that trauma centers with a geriatric consult service would have more geriatric‐focused processes of care and improved hospital‐level mortality for injured older adults. Methods: We surveyed US trauma centers regarding compliance with geriatric‐focused processes of care, including presence of geriatric consult service, palliative care consult service, geriatric pharmacists, screening for frailty, screening for potentially inappropriate home medications, and anticoagulation reversal protocols. Using Trauma Quality Improvement Program data, we calculated hospital‐level observed‐to‐expected (O:E) mortality for patients aged ≥ 65 years treated at surveyed trauma centers, controlling for patient demographics, comorbidities, and injury severity. High‐mortality hospitals were defined as those in the highest quartile of O:E ratio for mortality. Multivariable logistic regression was performed to assess the association of geriatric consult service availability with high‐mortality hospitals while controlling for other hospital‐level characteristics, including trauma verification level, number of beds, geriatric trauma volume, teaching status, and compliance with other geriatric‐focused processes of care. Results: Geriatric consult services were available at 49 of the 145 included trauma centers (34%). Hospitals with geriatric consult services were more likely to have Level I verification (61% vs. 12%, p < 0.001), standardized processes for assessing frailty (43% vs. 15%, p < 0.001), and geriatric pharmacists (55% vs. 33%, p = 0.012). On unadjusted analysis, hospitals with a geriatric consult service were less likely to have higher‐than‐expected mortality (17% vs. 44%, p = 0.009). On multivariable logistic regression, the presence of a geriatric consult service was associated with decreased odds of higher‐than‐expected mortality (OR 0.20, 95% CI 0.05–0.73, p = 0.015). Conclusions: Trauma centers with geriatric consult services have improved hospital‐level mortality for injured older adults and have more processes in place to manage these patients. Additional trauma centers should consider implementing a geriatric consult service.

INTRODUCTION: Rehabilitation at inpatient rehabilitation facilities (IRFs) has been shown to improve seriously injured patients' long-term functional independence. However, not all patients with severe injuries are discharged to an IRF. The aim of this study is to examine differences in the proportion of severely injured patients discharged to IRFs across US states and assess the association between the regional supply of IRFs and the likelihood of IRF discharge. METHODS: We performed a retrospective analysis of 2021 Healthcare Cost and Utilization Project State Inpatient Databases across 13 states. We included severely injured (ISS >15) adult patients who survived to hospital discharge. We calculated the marginal probability of discharge to IRF, skilled nursing facility, home health agency, or home without services across states using a multinomial logistic regression model to control for patient demographics, insurance type, injury severity, medical comorbidities, and trauma center level. We also performed a mixed-effects logistic regression to evaluate the association between the supply of IRFs within individual states with the likelihood of discharge to IRF. RESULTS: We identified 104,017 severely injured patients. Across all 13 included states, 13% of patients were discharged to IRFs. There was considerable variation in the adjusted probability of discharge to an IRF across states, ranging from 6.4% in Oregon (95% confidence interval [CI], 5.6–7.1%) to 22.1% in Kentucky (95% CI, 20.8–23.4%), after controlling for potential confounders. The state-level supply of IRFs ranged from 0.49 to 8.63 per 1,000,000 population in Maryland and Arkansas, respectively. Each additional IRF per 1,000,000 population was associated with 11% increased odds of discharge to IRF (95% CI, 1.01–1.21; p = 0.024). CONCLUSION: Severely injured patients face substantial differences in accessing high-level rehabilitation care at an IRF depending on their state of residence. Increasing the availability of IRFs within underserved states may improve access to specialized rehabilitation care for trauma patients. ( J Trauma Acute Care Surg . 2026;100: 722–729. Copyright © 2025 Wolters Kluwer Health, Inc. All rights reserved.) LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

BACKGROUND: Trauma centers are increasingly caring for injured older adults, and a subset of these patients requires surgery for hemorrhage control. Prolonged time to surgery for hemorrhage control is associated with increased mortality. We hypothesized that older adults requiring hemorrhage control surgery have a longer time to surgery than younger adults. METHODS: We analyzed Trauma Quality Improvement Program data (2017–2019) for adult patients taken directly from the emergency department to the operating room for hemorrhage control surgery. We excluded patients who were functionally dependent or had an advanced directive. Multivariable Poisson regression was used to determine the difference in time to surgery between younger adults (aged 18–64 years) and older adults (65 years and older) while controlling for potential confounders. RESULTS: We identified 29,406 adult patients who underwent surgery for hemorrhage control, including 2,586 older adults (8.8%). On unadjusted analysis, older adults had longer median time to surgery than younger adults (83 vs. 55 minutes, p < 0.001). On multivariable Poisson regression, controlling for patient demographics, injury mechanism, Injury Severity Score, trauma center level, and type of surgery, adjusted time to surgery was 9.4 minutes longer for older adults (95% confidence interval, 7.3–11.5; p < 0.001). Adding medical comorbidities to the model decreased the adjusted time difference to 6.2 minutes (95% confidence interval, 4.2–8.2; p < 0.001). Shock index ≥1 was less common in older adults (36% vs. 49%, p < 0.001), and the time to surgery disparity was lower among older adults with shock index ≥1 at presentation compared with those with shock index <1. CONCLUSION: Older adults have a longer time to surgery for hemorrhage control than younger adults. This difference is partially mediated by a higher burden of medical comorbidities and physiologic differences that impact the presentation of shock among older adults. Trauma centers should work to streamline decisions regarding surgical intervention for older adults in hemorrhagic shock. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Background Fall prevention interventions delivered by specially trained emergency medical services (EMS) clinicians in the homes of patients at high risk for falls have been shown to prevent recurrent falls. However, the cost of implementing this ‘community EMS’ approach to fall prevention is a barrier to widespread adoption. The objective of this study was to assess whether a community EMS fall prevention intervention results in overall cost savings for the healthcare system. Methods We performed a cost-effectiveness analysis using a decision-tree model of possible outcomes after an index fall in a simulated population of community-dwelling adults aged ≥65 over a 1-year time horizon. Transition probabilities and costs were obtained through literature review. The intervention, delivered in patients’ homes by specialised EMS clinicians, consisted of environmental modifications, fall prevention education, referral to occupational and physical therapy, and coordination with the patient’s primary care physician. We compared the mean healthcare expenditures per patient among those receiving and not receiving the fall prevention intervention. Results The intervention would result in a net cost savings of $964 per patient compared with no intervention, with an incremental cost-effectiveness ratio of −$22 174 per fall prevented (lower cost and more effective). Holding other variables constant, the programme would remain cost-saving if the effectiveness decreased to a 26% reduction in falls or the programme cost increased to $1634 per patient. Conclusions In this economic modelling analysis, a multifactorial fall prevention intervention delivered by community EMS was cost saving to the healthcare system. Healthcare payors should provide financial support and reimbursement for these programmes.