Association Between Implementation of a Geriatric Trauma Clinical Pathway and Changes in Rates of Delirium in Older Adults With Traumatic Injury

Key Points

Question

Is the establishment of a geriatric-centered clinical pathway associated with improved outcomes in older adults with traumatic injury?

Findings

In this case-control study of 712 older adults with traumatic injury in a single level I trauma center, outcomes before and after implementation of a novel clinical pathway were compared. Reductions in delirium in unadjusted analyses and adjusted analyses were noted.

Meaning

In this case-control study, implementation of a multidisciplinary care pathway was associated with improved rates of delirium.

Abstract

Importance

Older adults (age ≥65 years) are at risk for high rates of delirium and poor outcomes; however, how to improve outcomes is still being explored.

Objective

To assess whether implementation of a geriatric trauma clinical pathway was associated with reduced rates of delirium in older adults with traumatic injury.

Design, Setting, and Participants

A retrospective case-control study of electronic health records of patients aged 65 years or older with traumatic injury from 2018 to 2020 was conducted at a single level I trauma center. Eligible patients were age 65 years or older admitted to the trauma service and who did not undergo an operation.

Intervention

The implementation of a clinical pathway based on geriatric best practices, which included order sets, guidelines, automated consultations, and escalation pathways executed by a multidisciplinary team.

Main Outcomes and Measures

The primary outcome was delirium. The secondary outcome was hospital length of stay. Process measures for pathway compliance were also assessed.

Results

Of the 859 eligible patients, 712 patients were included in the analysis (442 [62.1%] in the baseline group; 270 [37.9%] in the postimplementation group; mean [SD] age: 81.4 [9.1] years; 394 [55.3%] were female). The mechanism of injury was not different between groups, with 247 in the baseline group (55.9%) and 162 in the postimplementation group (60.0%) (P = .43) experiencing a fall. Injuries were minor or moderate in both groups (261 in baseline group [59.0%] and 168 in postimplementation group [62.2%]; P = .87). The adjusted odds ratio for delirium in the postimplementation cohort was 0.54 (95% CI, 0.37-0.80; P < .001). Goals of care documentation improved significantly in the postimplementation cohort vs the baseline cohort with regard to documented goals of care notes (53.7% in the postimplementation cohort [145 of 270] vs 16.7% in the baseline cohort [74 of 442]; P < .001) and a shortened time to discussion from presenting to the emergency department (36 hours in the postimplementation cohort vs 50 hours in the baseline cohort; P = .03).

Conclusions and Relevance

In this study, implementation of a multidisciplinary clinical pathway for injured older adults at a single level I trauma center was associated with improved care and clinical outcomes. Interventions such as these may have utility in this vulnerable population, and findings should be confirmed across multiple centers.

This case-control study assesses whether implementation of a geriatric trauma clinical pathway was associated with reduced delirium in patients aged 65 years and older with traumatic injury.

Introduction

As the US population of older adults is rapidly increasing, the number of older adults 65 years and older is projected to nearly double from 49 million in 2016 to 95 million by 2060, comprising approximately 23% of the total population.¹ This population experiences high rates of injury, and this rate continues to increase.² In 2019, unintentional injury ranked as the seventh leading cause of death for those older than 65 years in the US.³ The proportion of patients with traumatic injury in this age category is estimated to reach to more than 40% by 2050.^4,5

Traumatic injury in those older than 65 years has been associated with worse outcomes compared with younger populations.^6,7,8 Furthermore, these poor outcomes can occur after even minor injuries. The management of injuries in older adults requires an attentive holistic approach across the continuum of care. A thoughtful care redesign framework incorporates multiple factors such as chronic comorbidities, pharmaceuticals, geriatric syndromes, and frailty. Frailty is highly prevalent in geriatric patients with traumatic injury, such that many (up to 50%) of those admitted with a ground-level fall have been shown to be frail.^9,10 Similarly, preinjury frailty has been found to be a factor in recovery and outcomes, with higher incidence than age and injury severity.¹⁰

Improvements for the care of hospitalized older adults have been achieved through different intervention types. Programs such as the Acute Care for Elders, Hospital Elder Life Program, and Nursing Improving Care of Healthsystem Elders have shown to reduce incidence of delirium, hospital length of stay, and complications while improving function and likelihood of a home discharge.^11,12,13

In addition, a geriatric medicine consultation-based service has shown improvement in advance care planning documentation, decreased delirium, and decreased mortality,¹⁴ improvement in prevention of functional decline,⁶ as well as reductions in long-term care needs.¹⁵ A 2019 study¹⁴ similarly demonstrated that a frailty-based multidisciplinary pathway for patients with traumatic injury aged 65 years and older resulted in decrease in delirium and 30-day readmission rates. However, this work represents a single center and has not been validated. Furthermore, the study focused on those individuals who met specific criteria and therefore might miss opportunities in populations vulnerable to poor outcomes.

Given these findings and the clinical necessity in this patient population, we sought to create a Stanford Geriatric Trauma Care Pathway using a roadmap and infrastructure that meets the needs of the patient through the continuum of care. We hypothesized that delirium and length of stay would be improved with implementation of the pathway.

Methods

This case-control study was approved by the Stanford Institutional Research Board with a waiver of informed patient consent on the basis of retrospective data. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline for case-control studies.

Participants

Eligible patients were age 65 years or older admitted to the trauma service and who did not undergo an operation. Race and ethnicity information was collected from the electronic medical record and so was recorded by admissions staff. The options included were Asian, Black, White, and other. For reporting, Black and other were combined to avoid presenting population numbers less than 10. No further clarification of categories comprising other was available in the EHR.

Pathway Development

The Stanford Quality Pathways team led a multidisciplinary steering committee with representation from the following subspecialties: trauma, geriatric medicine, emergency department, critical care, nursing, physical and occupational therapy, speech and language pathology, case management, social work, pharmacy, nutrition, transitional care, quality, and the patient family advisory council. Current state process mapping was done, which included the patient continuum from the emergency department through discharge. Barriers to consistency in care were identified, and opportunities to use evidence-based geriatric principles and processes were identified. The Institute for Healthcare Improvement Age-Friendly Health Systems framework (medication, mentation, mobility, what matters; hereinafter 4M framework) was used to prioritize interventions.¹⁶ A care pathway was designed incorporating all of these features, as well as what has been shown to be effective from the literature.

Assessment and measures were conducted by the multidisciplinary team. Every patient received a comprehensive geriatric assessment by a geriatric medicine clinician (MD or advanced practice clinicians) as well as assessments by nurses, physical therapists, occupational therapists, and social workers. As part of the geriatrician-administered comprehensive geriatric assessment, evaluations included the following: (1) functional assessment using both the Katz Index of Independence in Activities of Daily Living¹⁷ and the Lawton and Brody Instrumental Activities of Daily-Living Scale¹⁸; (2) a cognitive assessment using the Mini-Cog screening for early dementia; and (3) depression screen using the Patient Health Questionnaire-2 depression module.¹⁹ In addition to the comprehensive geriatric assessment, nurses performed a Confusion Assessment Method (CAM) test every shift.²⁰ Physical and occupational therapists assessed mobility and determined baseline and current functional needs. In addition, social workers assessed social barriers as needed.

To support the pathway, electronic health record (EHR) and workflow needs were identified, which included the identification of multidisciplinary assessment, actions, documentation, and escalation algorithms. Escalation algorithms enabled all members of the care team to manage commonly expected symptoms such as pain, bowel, and sleep regulation. Order sets were created incorporating evidence-based age-appropriate nonpharmacological interventions and pharmacological dosages and formulations.

Our strategy was inspired by others’ strategies¹¹ in developing inpatient geriatric efforts (eg, Acute Care Elder Units). We focused on organizing and coordinating existing resources to minimize costs. We also used existing hospital infrastructure for changes. For example, we used our information technology department to develop EHR documents and order sets. Physical and occupational therapy resources were already in place, but our efforts refined their focus. We also used our quality department to help develop clinical pathway guidelines and develop electronic outcome dashboards. By reorganizing our resources and making new use of existing hospital support structures, we were able to avoid costly investments in new hires or infrastructure.

Clinically, the geriatric medicine services were standardized to incorporate a comprehensive geriatric assessment within 48 hours of admission, which included addressing goals of care and baseline cognition, function, social, polypharmacy, and frailty assessments. The 4M framework¹⁶ was applied, and patient and family caregiver preferences during the hospitalization were documented within the goals of care note and communicated to the care team. The goals of care discussions were conducted by the geriatrics team and when clinically appropriate in partnership with the primary trauma service. Results from the discussion were entered in the EHR as a standardized goals of care note, which included a template to document the 4M framework questions. They were available for the entire team to view. The template also included patient and family caregiver priorities for the hospitalization and advance care planning information including health care durable power of attorney and previous advance directive. Relevant findings were also communicated to the trauma team during the daily multidisciplinary rounds if they had not been present in the meeting. Rehabilitation services were standardized to promote early mobility within 24 hours of presentation to the emergency department.

The workflow uniting these features began with admission to the emergency department with the geriatric trauma care admission order set being automatically triggered. Services caring for the patient were provided according to the guidelines and order sets. A multidisciplinary team meeting was held daily during the week on the non–intensive care trauma unit with the geriatric clinician included to reinforce and assist with proactive management of geriatric syndromes. Prior to discharge, a transitional care team was consulted if deemed appropriate for postdischarge follow-up or a home visit. Those presenting with a ground-level fall as the cause for injury were provided with a home-based fall prevention program postdischarge for secondary fall prevention.²¹

Education and orientation for the pathway, guidelines, and order sets were similarly multidisciplinary. Champions within each specialty were used to reinforce teaching. Patient family educational materials were created to engage them in care and better prepare them for the hospitalization and recovery period. The educational content was individualized based on specific patient needs. Most commonly, the content centered on the principles of delirium and disability prevention during hospitalization. Additional areas of focus included safe transitional care planning. Geriatric-specific best practice models informed these discussions, such as the Institute for Healthcare Improvement Age-Friendly Health Systems 4M framework. Injury-specific educational materials for injuries common in the older adult population were provided. For example, materials were created for those with rib fractures, focusing on managing pain and mobility during the recovery process. Quarterly reviews of the program used to reinforce teachings and iterate plans were conducted by leadership from geriatric medicine, trauma surgery, and nursing. Learnings were distributed from leadership to frontline clinicians. Outcomes were tracked using an automated dashboard created to report on core process and outcome measures monthly, to be reviewed by the leadership team. The pathway was formally launched on November 1, 2018. The eTable in the Supplement contains essential elements of the Geriatric Trauma Care Pathway.

Results obtained from the these assessments were used in several different ways, including to guide the multidisciplinary care and discussions with patients and families, and to help establish transitions of care when necessary. Any new results were communicated to the trauma team during daily multidisciplinary rounds. Where appropriate, such as when facilitating transitions of care, communications were established with the patient’s physician or postacute care team. Results were shared with other home-based intervention programs when the patient expressed an interest in participation.

Statistical Analysis

A case-control analysis was performed comparing outcomes from baseline and postimplementation. The time from September 2015 through April 2018 was used as the preimplementation baseline and from January 2019 through January 2020 as the postimplementation period. The 8-month gap from May 2018 through December 2018 was excluded as a wash-out period from the analysis because this time was during the development and implementation of the pathway when practice patterns were changing because of the discovery process. Data after January 2020 were not included because Stanford moved into a new hospital, which required retooling of pathways to adapt to a new physical plant in February 2020.

During these times, patients were identified from the EHR for adults older than 65 years, admitted to the trauma service with injuries. Only patients without a major operation were included because patients undergoing surgical procedures were often treated through other care pathways, confounding the analysis. Data from the Stanford Trauma Registry were used to supplement EHR data, including injury patterns and severity.

The primary outcome was delirium, and the secondary outcome was length of stay. Delirium was determined to be present if the patient had a CAM positive score or was diagnosed with delirium by the clinician team. Mortality numbers were too low for analysis at the time the study was collected and are expected to be reported in subsequent follow-up analyses.

Process metrics identified by the geriatric trauma leadership team to mark successful implementation of program guidelines were also analyzed. These metrics included achieving adequate pain control (score of 4 or lower on verbal pain score, where 0 indicates no pain and 10 indicates maximal pain) within the first 24 hours, first mobilization within 24 hours, and advance care planning note documentation within 48 hours if the stay was greater than or equal to 2 days. First mobilization was defined as the first time a mobility assessment led to dangling legs or getting out of bed and standing on the floor, as performed by a team member, typically the nurse or a physical therapist. The first goals of care note was defined as the first note that shared patient’s and/or family caregiver’s 4M framework goals for the hospitalization, escalation intent in case of a sudden decompensation, code status, health care proxy, and previous advance directive.

Unadjusted and adjusted analyses were performed. Continuous variables were compared using t test when data were parametric and Mann-Whitney test when data were nonparametric. Categorical data were compared using χ² tests, and Fischer exact test in cases with small cell values. Logistic and linear regression analyses were performed taking into consideration patient demographic characteristics, injury characteristics, and process measures. Injury severity was dichotomized into minor or moderate (Injury Severity Score [ISS] <15) and severe injury (ISS >15) (ISS range, 0-75; ≥16 indicates serious overall injury). Statistical significance was set at 2-tailed P < .05. Analyses were conducted using Stata version 16.1 (StataCorp).

Results

A total of 859 patients were identified from the Stanford EHR that met inclusion criteria. After excluding patients transferred from the service and those admitted during the implementation and wash-out phases, a total of 712 patients were included (442 [62.1%] in the baseline group; 270 [37.9%] in the postimplementation group; mean [SD] age: 81.4 [9.1] years; 394 [55.3%] were female) (Table 1). There was a significant difference in the proportion of patients who identified as White in the baseline group vs postimplementation group (60.9% [269 of 442] in the baseline group vs 67.4% [182 of 270] in the postimplementation group; P = .03). The mechanism of injury was similar between groups, with 247 in the baseline group (55.9%) and 162 in the postimplementation group (60.0%) (P = .43) experiencing a fall. The ISS was similar for both groups. Injuries were minor or moderate in both groups (261 in baseline group [59.0%] and 168 in postimplementation group [62.2%]; P = .87).

Table 1. Characteristics of the Baseline and Postimplementation Cohorts.

Characteristic	No. (%)		P value for difference
	Baseline	Postimplementation
No. (%)	442 (62.1)	270 (37.9)	NA
Demographic
Sex
Female	247 (55.9)	147 (54.4)	.68
Male	194 (43.9)	123 (45.6)
Age, mean (SD), y	81.8 (9.3)	81.6 (8.8)	.91
Age categories, y
65-70	60 (13.6)	31 (11.5)	.88
71-80	132 (29.9)	82 (30.4)
81-90	158 (35.7)	100 (37.0)
>90	92 (20.8)	57 (21.1)
Race and ethnicity
Asian	86 (19.5)	44 (16.3)	.03
White	269 (60.9)	182 (67.4)
Othera	87 (19.7)	44 (16.3)
Language
Non–English speaking	75 (17.0)	40 (14.8)	.45
English speaking	367 (83.0)	230 (85.2)
Injury
Mechanism
Fall	247 (55.9)	162 (60.0)	.43
MVC	34 (7.7)	18 (6.7)
Bicycle	21 (4.8)	6 (2.2)
Other or missing	140 (31.7)	84 (31.1)
ISSb
<9	78 (17.6)	50 (18.5)	.87
9-15	183 (41.4)	118 (43.7)
>15	58 (13.1)	33 (12.2)

Abbreviations: ISS, Injury Severity Score; MVC, motor vehicle collision; NA, not applicable.

^a Race information was collected from the electronic medical record and so was recorded by admissions staff. The options included were Asian, Black, White, and other. For reporting, Black and other were combined to avoid presenting population numbers less than 10. No further clarification of categories comprising other was available.

^b For statistical analysis, injury severity was dichotomized into minor or moderate (ISS <15) and severe injury (ISS >15) (ISS range, 0-75; ≥16 indicates serious overall injury).

The presence of delirium was significantly lower in the postimplementation group compared with the baseline group (18.5% [50 of 270] in the postimplementation group vs 28.3% [125 of 442] in the baseline group; P = .002) (Table 2). Patients with minor or moderate injuries experienced the most notable decrease in rates of delirium (15.6% [69 of 442] in the baseline group vs 8.5% [23 of 270] in the postimplementation group; P = .001). Stratifying for other patient characteristics, significant reductions in rates of delirium postimplementation were observed for female patients (43% reduction), for those who experienced a fall (50% reduction), and those with an ISS less than 15 (45% reduction) (Figure). This reduction was also statistically significant in logistic regression after controlling for patient demographic characteristics and injury characteristics (OR, 0.54; 95% CI 0.37-0.80; P < .001) (Table 3). Those individuals who were non–English speakers did not experience significant reductions in delirium (for English speakers, baseline 21.9% vs postimplementation 15.2%; P = .02; for non–English speakers, baseline 6.3% vs postimplementation 3.3%; P = .11). There was no significant difference in the mean (SD) length of stay between the baseline and postimplementation cohorts (mean [SD], 4.3 [3.8] days for the baseline group and mean [SD], 4.3 [2.9] days for the postimplementation group; P = .20).

Table 2. Unadjusted Clinical Outcomes.

Clinical outcome	No. (%)		P value for difference
	Baseline	Postimplementation
No. (%)	442 (62.1)	270 (37.9)	NA
Delirium
All patients	125 (28.3)	50 (18.5)	.002
By ISS
ISS <15	69 (15.6)	23 (8.5)	.001
ISS >15	56 (12.7)	27 (10.0)	.26
LOS, mean (SD), d
All patients	4.3 (3.8)	4.3 (2.9)	.20
By ISSa
ISS <15	3.9 (2.9)	3.9 (2.3)	.95
ISS >15	5.0 (4.8)	4.9 (3.7)	.28

Abbreviations: ISS, Injury Severity Score; LOS, length of stay; NA, not applicable.

^a For statistical analysis, injury severity was dichotomized into minor or moderate (ISS <15) and severe injury (ISS >15) (ISS range, 0-75; ≥16 indicates serious overall injury).

Figure. Percent Reduction in Delirium for Postimplementation and Baseline Cohorts.

Percent reduction in delirium in the cohorts based on age, sex, mechanism of fall, and injury severity scores (ISS).

^aP < .05.

Table 3. Summary of Regression Results Postimplementation vs Baseline.

Outcome	Odds ratio or coefficient (95% CI)	P value
Delirium	0.54 (0.37 to 0.80)	<.001
LOS, d	−0.12 (−0.65 to 0.41)	.65

Abbreviation: LOS, length of stay.

Process measures used to track pathway goals included time to first mobilization, time to goals of care discussion, and having a goals of care discussion documented (Table 4). Notably, pain scores were higher in the postimplementation group for the first 24 hours compared with baseline (mean [SD] score, 2.2 [1.9] vs 1.5 [1.7]; P < .001). The time to first mobilization was not statistically significant between cohorts (mean [SD] time, 27.6 [20.8] hours in the implementation group vs 32.4 [24.2] hours in the baseline group; P = .11). Goals of care metrics improved significantly, with an increase in the postimplementation period vs the baseline periods with regard to documented goals of care notes (53.7% [145 of 270] vs 16.7% 74 of 442]; P < .001) and a shortened time to discussion from presenting to the emergency department (mean [SD] time, 35.7 [25.3] hours vs 49.6 [105.5] hours; P = .03).

Table 4. Process Metric Outcomes.

Process metric outcome	Mean (SD)		P value for difference
	Baseline	Postimplementation
No. (%)	442 (62.1)	270 (37.9)	NA
Pain control (first 24 h)
Pain scorea	1.5 (1.7)	2.2 (1.9)	<.001
Pain score of 4 or higher	50 (11.3)	54 (20.0)	.001
Timing of first mobilization (if LOS >2 d)
Hours to first ambulation	32.4 (24.2)	27.6 (20.8)	.11
Goals of care (if LOS >2 d)
Had a goals of care discussion	74 (16.7)	145 (53.7)	<.001
Hours to first goals of care discussion	49.6 (105.5)	35.7 (25.3)	.03

Abbreviations: LOS, length of stay; NA, not applicable.

^a Verbal pain score, where 0 indicates no pain and 10 indicates maximal pain.

Discussion

In this case-control study, we found that the implementation of a multidisciplinary Geriatric Trauma Care Pathway was associated with reductions in the adjusted odds ratio for delirium. Reductions were associated with those individuals with minor injuries, suggesting that minor injuries can have outcomes associated with mortality or debilitation in older adults. We found subgroups of patients who did (and did not) experience a reduction in delirium. For example, when stratified by language, we found that non–English speakers did not experience a significant reduction in delirium, highlighting language-induced isolation as a potential factor in rates of delirium and social determinants of health in patient outcomes.

Our findings are consistent with previous reports, which have shown that geriatric-focused interdisciplinary trauma care pathways are associated with improved outcomes in hospitalized older adults, whether in the setting of a dedicated unit^22,23 or a consultation-based service.^14,24,25 Data from outside the US, for example in Germany, also have shown that a certified center for geriatric trauma surgery operated by an interdisciplinary team of trauma surgeons, geriatricians, therapists, and pharmacists was associated with improved patient outcomes.²⁶ Our study is unique in several respects. We included all adults older than 65 years who have sustained traumatic injury, in contrast to preselecting those at high risk for adverse outcomes. The rationale is that although high-risk patients may benefit more, a comprehensive approach would be more likely to help induce culture change across the multidisciplinary groups. We also sought to identify which groups empirically were high risk, rather than focus the program on those we assumed to be high risk. In this way, we were able to recognize subgroups of patients who were at risk, such as non–English speakers. This focus was feasible in our hospital, which might not be the case elsewhere. In that respect, knowledge of at-risk groups from our study may help inform targeted interventions for these populations.

Our study originally sought to study mortality. We did not include numbers because postimplementation mortality was too low for statistical reporting. Most studies have shown reductions that range from 3% to 48% for mortality^23,24,25 and 9% for delirium.¹³ We hope that once numbers have sufficiently accrued over the next 2 to 3 years, we will be able to report on the mortality outcomes associated with this pathway.

We observed improvements in 2 of 4 process measures tracked as part of the program: having a documented goals of care discussion and time to first goals of care discussion. Our pathway not only promoted goals of care discussions during the hospital stay but also prioritized early identification of health care surrogate, documenting patient and family goals for the hospital stay via a 4M framework question and engaging them in care within the first 48 hours of hospital stay. Our study is, to our knowledge, unique in implementing and evaluating this process measure. Notably, one of the process measures, pain control within the first 24 hours, worsened from baseline to postimplementation. Although the reason is not clear, this finding reveals the challenges and importance of obtaining accurate pain scores in older adults. Through our education processes, nurses became more adept at measuring pain. Awareness of pain scoring through the education process may have resulted in higher scores even if pain control had substantially improved. Future comparisons with teams educated around pain management may more fully explore the complexities and solutions in the geriatric population.

We observed that reductions mostly occurred in those with minor injuries. While the specific reason for this is not clear, we hypothesize that the difference may be associated with the fact that our interventions focused on outcomes with baseline frailty and function as factors. In contrast, outcomes in those with severe injuries may have been based on he intersection of the injury severity (eg, severe traumatic brain injury) and baseline health. These patients were also less likely to directly benefit from interventions because it was more likely that the teams were interacting with family more than the patient. In addition, patients with severe injuries were more likely to be transferred to another facility, which meant they left before some of these interventions were fully implemented.

Limitations

This study has several limitations. One limitation is that the Stanford population with trauma may not reflect the demographic characteristics of other trauma centers owing to racial and ethnic homogeneity. Approximately 60% to 70% of the population was White and more than 80% spoke English. Cultural barriers in trauma centers serving racial and ethnic minority populations might pose challenges in establishing guidelines. Another limitation is the challenge in comparing some of the baseline metrics with postimplementation metrics. For example, pain scores changed because of the interventions. Furthermore, recognition and diagnosis of delirium also could have changed. For delirium, we relied on nursing documentation of CAM scores because these have been consistently obtained before and after implementation. However, CAM scores reflect screening rather than confirmed diagnoses of delirium. We are now also capturing delirium diagnoses made by geriatric clinicians as part of the pathway, so that future analyses may more accurately capture this variable. Although the present study was based on a relatively small cohort size, we anticipate that we will accrue more patients as time progresses, which will allow for higher degrees of stratification and more detailed findings. In addition, there were statistically significant differences in the proportions of White patients between the baseline and postimplementation cohorts. Race and ethnicity were included in all regression models as a variable and were nonsignificant; however, that finding does not exclude the possibility that factors associated with race (such as implicit bias or other structural factors) may have affected our findings.

Conclusions

In this case-control study, we report findings of a substantial improvement in clinical outcomes from a single center experience with geriatric patients with traumatic injury who did not undergo an operation through the creation of an age-friendly multidisciplinary care pathway. A crucial learning point from the creation of this pathway is that caring for injured older adults does take communal effort. Care must be coordinated to obtain optimal results, which does not happen without deliberate effort. Given the reproducibility of proven benefits of such care for hospitalized injured adults, trauma systems should consider formalizing requirements for these types of efforts within trauma centers.

Supplement.

eTable. Essential Elements of Geriatric Trauma Care Pathway