Chen Cheryl Chia-Hui, Li Hsiu-Ching, Liang Jin-Tung, Lai I-Rue, Purnomo Jerry Dwi Trijoyo, Yang Yi-Ting, Lin Been-Ren, Huang John, Yang Ching-Yao, Tien Yu-Wen, Chen Chiung-Nien, Lin Ming-Tsan, Huang Guan-Hua, Inouye Sharon K
Department of Nursing, College of Medicine, National Taiwan University, Taipei, Taiwan.
Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan.
JAMA Surg. 2017 Sep 1;152(9):827-834. doi: 10.1001/jamasurg.2017.1083.
Older patients undergoing abdominal surgery commonly experience preventable delirium, which extends their hospital length of stay (LOS).
To examine whether a modified Hospital Elder Life Program (mHELP) reduces incident delirium and LOS in older patients undergoing abdominal surgery.
DESIGN, SETTING, AND PARTICIPANTS: This cluster randomized clinical trial of 577 eligible patients enrolled 377 older patients (≥65 years of age) undergoing gastrectomy, pancreaticoduodenectomy, and colectomy at a 2000-bed urban medical center in Taipei, Taiwan, from August 1, 2009, through October 31, 2012. Consecutive older patients scheduled for elective abdominal surgery with expected LOS longer than 6 days were enrolled, with a recruitment rate of 65.3%. Participants were cluster randomized by room to receive the mHELP or usual care.
The intervention (implemented by an mHELP nurse) consisted of 3 protocols administered daily: orienting communication, oral and nutritional assistance, and early mobilization. Intervention group participants received all 3 mHELP protocols postoperatively, in addition to usual care, as soon as they arrived in the inpatient ward and until hospital discharge. Adherence to protocols was tracked daily.
Presence of delirium was assessed daily by 2 trained nurses who were masked to intervention status by using the Confusion Assessment Method. Data on LOS were abstracted from the medical record.
Of 577 eligible patients, 377 (65.3%) were enrolled and randomly assigned to the mHELP (n = 197; mean [SD] age, 74.3 [5.8] years; 111 [56.4%] male) or control (n = 180; mean [SD] age, 74.8 [6.0] years; 103 [57.2%] male) group. Postoperative delirium occurred in 13 of 196 (6.6%) mHELP participants vs 27 of 179 (15.1%) control individuals, representing a relative risk of 0.44 in the mHELP group (95% CI, 0.23-0.83; P = .008). Intervention group participants received the mHELP for a median of 7 days (interquartile range, 6-10 days) and had a shorter median LOS (12.0 days) than control participants (14.0 days) (P = .04).
For older patients undergoing abdominal surgery who received the mHELP, the odds of delirium were reduced by 56% and LOS was reduced by 2 days. Our findings support using the mHELP to advance postoperative care for older patients undergoing major abdominal surgery.
clinicaltrials.gov Identifier: NCT01045330.
接受腹部手术的老年患者常发生可预防的谵妄，这会延长他们的住院时间（LOS）。
研究改良版医院老年生活计划（mHELP）是否能降低接受腹部手术的老年患者的谵妄发生率和住院时间。
设计、地点和参与者：这项整群随机临床试验纳入了577名符合条件的患者，其中377名老年患者（≥65岁）于2009年8月1日至2012年10月31日在台湾台北一家拥有2000张床位的城市医疗中心接受胃切除术、胰十二指肠切除术和结肠切除术。连续入选预计住院时间超过6天的择期腹部手术老年患者，招募率为65.3%。参与者按病房整群随机分组，接受mHELP或常规护理。
干预措施（由一名mHELP护士实施）包括每天执行的3项方案：定向沟通、口腔和营养协助以及早期活动。干预组参与者术后除接受常规护理外，一旦进入住院病房直至出院，还需接受所有3项mHELP方案。每天跟踪方案的执行情况。
由2名经过培训的护士每天使用谵妄评估方法评估谵妄的存在情况，这些护士对干预状态不知情。住院时间数据从病历中提取。
在577名符合条件的患者中，377名（65.3%）被纳入并随机分配到mHELP组（n = 197；平均[标准差]年龄，74.3[5.8]岁；111名[56.4%]男性）或对照组（n = 180；平均[标准差]年龄，74.8[6.0]岁；103名[57.2%]男性）。196名mHELP参与者中有13名（6.6%）发生术后谵妄，而179名对照组个体中有27名（15.1%）发生术后谵妄，mHELP组的相对风险为0.44（95%CI，0.23 - 0.83；P = 0.008）。干预组参与者接受mHELP的中位时间为7天（四分位间距，6 - 10天），中位住院时间（12.0天）比对照组参与者（14.0天）短（P = 0.04）。
对于接受腹部手术的老年患者，接受mHELP可使谵妄几率降低56%，住院时间缩短2天。我们的研究结果支持使用mHELP改善接受大型腹部手术的老年患者的术后护理。
clinicaltrials.gov标识符：NCT01045330。
