Authors (including presenting author) :
Bosco Ma1, Tony Yau1, Wilson Cheng1, Peter Loo1, Wency Ho1, Daniel Yuk2, Maria Tang2, Elsie Hui2, Danny Chan3
Affiliation :
1 Division of Geriatric Medicine, Department of Medicine and Therapeutics, Prince of Wales Hospital, NTEC
2 Department of Medicine and Geriatrics, Shatin Hospital, NTEC
3 Division of Neurosurgery, Department of Surgery, Prince of Wales Hospital, NTEC
Introduction :
Hong Kong’s healthcare system is grabbling with a growing demand from ageing population. Neurosurgical care for geriatric traumatic brain injury is also on the rise. In NTEC, Prince of Wales Hospital (PWH) is the trauma centre dedicated to acute neurosurgical care. Some of these patients may be transferred to Shatin Hospital (SH) for convalescence care and rehabilitation. There has been a rapid annual surge of neurosurgical admissions for traumatic brain injury in-patients aged 70 years old or above (from 220 in 2014 to 321 in 2018). Over 90% of these patients fell at level ground with underlying risk factors for fall and multiple medical co-morbidities, including diabetes (36%), hypertension (71%), heart problems (34%( and old stroke (24%), among 295 patients in NTEC in 2017. Medical consultations were indicated in 26% of these patients. The average length of stay (LOS) at PWH was 13.1 days and 12.4 days in 2017 and 2018 (January to October) respectively, and that at SH were 41.8 days and 50.6 days in 2017 and 2018 (January to October) respectively. In-patient mortality rates were 11% and 12% in 2017 and 2018 (January to October) respectively.
Objectives :
The Neurosurgical-Geriatric co-care (NGC) model aims to fill the service gap in geriatric traumatic brain injury patients (≥70 years) for seamless transition from acute care to rehabilitation, and to the community by optimisation of co-morbidities and maximisation of functional recovery.
Methodology :
A NGC team has been established at PWH and SH since November 2018. Regular liaison ward rounds (every Monday, Wednesday and Friday) led by specialists in geriatric medicine are conducted at PWH, for optimisation of co-morbidities and investigation of causes of injury (falls and syncope). When in-patient rehabilitation is indicated, patients are transferred to SH for co-care by geriatricians and neurosurgeons. Weekly co-care rounds between neurosurgical team and geriatric rehabilitation team are held, aiming at rehabilitation goal setting and discharge planning, the latter including post-discharge rehabilitation and early community support service arrangements.
Result & Outcome :
A total of 511 patients have been under NGC co-care from November 2018 to November 2020. The average LOS at PWH was reduced from 12.4 days to 10.4 days and that at SH was also reduced from 50.6 days to 27.4 days. At PWH, in-patient mortality rate was also reduced from 12% to 6.5%. At SH, the number of transfers back to acute hospital was significantly reduced, from 82.1% to 32.7%. In terms of rehabilitation outcomes, absolute functional gain, measured by the difference of FIM (functional independence measure) scores on discharge vs admission, was greater in NGC patients (8.35) than in traditional care (6.79). The number of medications on discharge was significantly less in NGC patients (55.8% has no polypharmacy) than those in the pre-NGC care model (35.9%).
Conclusion
This new NGC teamwork for geriatric traumatic brain injury has been shown to be a patient-centred service enhancement model to cope with the growing demand in the population. This model has remarkably reduced hospital LOS, acute bed transfers and in-patient mortality. Polypharmacy was significantly reduced in the NGC model with Geriatrics input. Further audits on functional recovery should be conducted in the future.
