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As the proportion of the population age 60+ continues to increase, there is a rising need for specialized programs to address their needs. The Medical-Orthopedic Trauma Service (MOTS) at NewYork-Presbyterian/ÈÕ±¾avÉ«ÇéƬ Medical Center was created as an integrated approach to assessing the multiple complex needs that older trauma patients often have and to bring in the specialists required to provide the most effective care.

While initially established for senior patients presenting in the Emergency Department with hip fractures, the MOTS team cares for any medically complex older trauma patient. "We recognized that there is a lot of complexity and fragility associated with other fractures as well," asserted Eva Flores, MD, the hospitalist who leads the MOTS initiative. In addition to those with hip fractures, patients with ankle, humerus, elbow, and wrist fractures, finger infections, and nonoperative pelvic fractures are among those seen by the MOTS team.

The Care Team at Medical-Orthopedic Trauma Service (MOTS) 

MOTS physicians are deeply embedded as part of these patients' care teams. When an elderly or medically complex patient is admitted through the Emergency Department at NewYork-Presbyterian/ÈÕ±¾avÉ«ÇéƬ Medical Center for a fracture, he or she is treated by an Emergency Department physician, surgeons from the Orthopaedic Trauma service, and an internal medicine hospitalist and physician assistant from the MOTS team. The aim is to get the patient as ready as possible for surgery.

Many patients with fractures have a variety of medical issues that must be addressed preoperatively. Cardiac and pulmonary co-morbidities are the most common, as well as neurologic disorders. The MOTS team conducts an in-depth medical evaluation and cardiopulmonary risk assessment that often includes speaking with and obtaining records from the patient’s physicians, particularly when those doctors are not affiliated with ÈÕ±¾avÉ«ÇéƬ.

Armed with this knowledge, they may alter the patient's medications that may interfere with surgery (such as stopping blood thinners) and work with the perioperative team to select the most appropriate anesthesia. Thirteen anesthesiologists who specialize in the care of complex older orthopedic patients are on the MOTS team. Regional anesthesia is used whenever possible to reduce the risk of postoperative delirium.

Treatment Options Available Through MOTS

After the patient comes out of surgery, MOTS team members provide daily comprehensive care throughout the entire hospital stay, including bedside rounding and multiple visits to a patient each day. Physical and/or occupational therapists begin working with patients to increase mobility when feasible, and social workers collaborate with the patient and caregivers to address hospital discharge and coordinate acute or subacute rehabilitation. If the patient needs the expertise of other physicians during the hospital stay, such as a cardiologist or pulmonologist, MOTS arranges those consultations as well. "It takes a lot of effort to unite all of the different services needed for each patient, but the outcomes are worth it," explained Tiffany Tedore, MD, Director of Orthopedic Anesthesiology and a member of the MOTS team.

Other MOTS services include:

• Evaluation and treatment for osteoporosis and other bone problems. If a patient is already being treated for osteoporosis, his or her treatment plan will be re-assessed.
• Pain management geared toward geriatric and medically complex patients.
• Nutritional guidance to optimize patients' diets.
• Specialized surgical nursing care, featuring nurses trained to recognize problems in older patients who have had surgery.

Since the COVID-19 pandemic began, the MOTS team has observed an increase in physical deconditioning (due to patients staying in more instead of running their usual errands) as well as cognitive deconditioning associated with increased isolation. Both are increasing the risk of fractures in a population of patients that already has a greater risk of traumatic injury.

The MOTS approach ensures consistent communication among care team members to promote stability and recovery for medically complex orthopedic patients. "We are a small group of dedicated hospitalists with more than 20 years of experience understanding and managing these patients," concluded Dr. Flores. "We take care of many issues that elsewhere might be consulted to other specialists. We know the rhythm of the perioperative process so well and are very attuned to the changes that can happen around surgery, which greatly benefits our patients."

To learn more about MOTS, or to receive a referral, please consult with your care team at WCM.