Foothills Medical Center, 1403-29th Street NW, Calgary, University of Calgary, Calgary, Alberta, Canada.
Implement Sci. 2010 Oct 22;5:81. doi: 10.1186/1748-5908-5-81.
Delirium occurs in up to 65% of older hip fracture patients. Developing delirium in hospital has been associated with a variety of adverse outcomes. Trials have shown that multi-component preventive interventions can lower delirium rates. The objective of this study was to implement and evaluate the effectiveness of an evidence-based electronic care pathway, which incorporates multi-component delirium strategies, among older hip fracture patients. We conducted a pragmatic study using an interrupted time series design in order to evaluate the use and impact of the intervention. The target population was all consenting patients aged 65 years or older admitted with an acute hip fracture to the orthopedic units at two Calgary, Alberta hospitals. The primary outcome was delirium rates. Secondary outcomes included length of hospital stay, in-hospital falls, in-hospital mortality, new discharges to long-term care, and readmissions. A Durbin Watson test was conducted to test for serial correlation and, because no correlation was found, Chi-square statistics, Wilcoxon test and logistic regression analyses were conducted as appropriate. At study completion, focus groups were conducted at each hospital to explore issues around the use of the order set. During the 40-week study period, 134 patients were enrolled. The intervention had no effect on the overall delirium rate (33% pre versus 31% post; p = 0.84). However, there was a significant interaction between study phase and hospital (p = 0.03). Although one hospital did not experience a decline in delirium rate, the delirium rate at the other hospital declined from 42% to 19% (p = 0.08). This difference by hospital was mirrored in focus group feedback. The hospital that experienced a decline in delirium rates was more supportive of the intervention. Overall, post-intervention there were no significant differences in mean length of stay (12 days post versus 14 days pre; p = 0.74), falls (6% post versus 10% pre; p = 0.43) or discharges to long-term care (6% post versus 13% pre; p = 0.20). Translation of evidence-based multi-component delirium prevention strategies into everyday clinical care, using the electronic medical record, was not found to be effective at decreasing delirium rates among hip facture patients.
谵妄在多达 65%的老年髋部骨折患者中发生。在医院发生谵妄与多种不良结局有关。试验表明，多组分预防干预措施可以降低谵妄发生率。本研究的目的是实施和评估纳入老年髋部骨折患者的基于证据的电子护理路径的有效性，该路径结合了多组分谵妄策略。我们采用中断时间序列设计进行了一项实用研究，以评估干预措施的使用和影响。目标人群为在艾伯塔省卡尔加里的两家医院骨科病房因急性髋部骨折入院且年龄在 65 岁或以上的所有同意参与的患者。主要结局是谵妄发生率。次要结局包括住院时间、院内跌倒、院内死亡率、新出院至长期护理、再入院。进行 Durbin Watson 检验以检验序列相关性，由于未发现相关性，因此适当进行了卡方检验、Wilcoxon 检验和逻辑回归分析。在研究完成时，在每个医院进行了焦点小组讨论，以探讨使用医嘱集的问题。在 40 周的研究期间，共纳入 134 名患者。该干预措施对总体谵妄发生率没有影响（干预前为 33%，干预后为 31%；p = 0.84）。然而，研究阶段和医院之间存在显著交互作用（p = 0.03）。尽管一家医院的谵妄发生率没有下降，但另一家医院的谵妄发生率从 42%下降到 19%（p = 0.08）。这种医院之间的差异反映在焦点小组的反馈中。谵妄发生率下降的医院对干预措施更为支持。总体而言，干预后，住院时间（干预后为 12 天，干预前为 14 天；p = 0.74）、跌倒（干预后为 6%，干预前为 10%；p = 0.43）或出院至长期护理（干预后为 6%，干预前为 13%；p = 0.20）均无显著差异。在电子病历中，将基于证据的多组分谵妄预防策略转化为日常临床护理，并未发现可有效降低髋部骨折患者的谵妄发生率。
