虚弱筛查和虚弱途径可缩短虚弱老年创伤和急诊普通外科患者的住院时间、丧失独立性和 30 天再入院率。
Frailty screening and a frailty pathway decrease length of stay, loss of independence, and 30-day readmission rates in frail geriatric trauma and emergency general surgery patients.
机构信息
From the Surgical Outcomes and Quality Improvement Center (K.E.E.), Northwestern University, Chicago, Illinois; Department of Surgery (K.E.E.), Medical University of South Carolina, Charleston, South Carolina; Department of Emergency Medicine (Q.R.), Northwestern University, Chicago, Illinois; Department of Surgery (J.L.), Emory University, Atlanta, Georgia; Department of Surgery (J.F.B., J.B., M.B.S., A.A., A.D., M.M., C.S., J.P.), and Department of Hospital Medicine (T.R.), Northwestern University, Chicago, Illinois.
出版信息
J Trauma Acute Care Surg. 2018 Jul;85(1):167-173. doi: 10.1097/TA.0000000000001931.
BACKGROUND
Frail geriatric trauma and emergency general surgery (TEGS) patients have longer lengths of stay (LOS), more readmissions, and higher rates of postdischarge institutionalization than their nonfrail counterparts. Despite calls to action by national trauma coalitions, there are few published reports of prospective interventions. The objective of this quality improvement project was to first develop a frailty screening program, and, then, if frail, implement a novel frailty pathway to reduce LOS, 30-day readmissions, and loss of independence.
METHODS
This was a before-after study of a prospective cohort of all geriatric (≥65-years-old) patients admitted to the TEGS service from October 2016 to October 2017. All patients were screened for frailty for 3 months (preintervention) to obtain baseline outcomes. Subsequently, frail patients were entered into our frailty pathway (postintervention). Nonparametric statistical tests were used to assess significant differences in continuous variables; χ and Fisher exact tests were used for categorical variables, where appropriate. Both process and outcome measures were evaluated.
RESULTS
Of 239 geriatric TEGS patients screened, 70 (29.3%) were frail. All TEGS geriatric patients were screened within 24 hours of admission. Following frailty pathway implementation, median LOS for frail patients decreased from 9 to 6 days (p = 0.4), readmissions decreased from 36.4% to 10.2% (p = 0.04), and loss of independence decreased by 40%, (100% vs 60%; p = 0.01). Outcomes for nonfrail geriatric patients did not differ between cohorts.
CONCLUSIONS
Screening for frailty followed by implementing a frailty pathway decreased LOS, loss of independence, and 30-day readmission rates for frail geriatric TEGS patients at a single urban academic institution. The pathway required no additional resources; rather, we shifted focus toward frail patients without negatively affecting outcomes in nonfrail geriatric TEGS patients. Implementation of this pathway with larger patient cohorts and in varied settings is needed to confirm a causal relationship between our intervention and improved outcomes.
LEVEL OF EVIDENCE
Therapeutic study, level IV.
背景
虚弱的老年创伤和急诊普通外科（TEGS）患者的住院时间（LOS）更长，再入院率更高，出院后机构化率也更高，与非虚弱患者相比。尽管国家创伤联盟呼吁采取行动，但很少有关于前瞻性干预的报道。本质量改进项目的目的是首先制定一个虚弱筛查计划，如果患者虚弱，则实施一种新的虚弱途径，以减少 LOS、30 天再入院率和丧失独立性。
方法
这是一项前瞻性队列研究，对 2016 年 10 月至 2017 年 10 月期间接受 TEGS 服务的所有老年（≥65 岁）患者进行了前后比较。所有患者在 3 个月内接受虚弱筛查（干预前）以获得基线结果。随后，虚弱患者被纳入我们的虚弱途径（干预后）。使用非参数统计检验评估连续变量的显著差异；适当情况下，使用 χ 和 Fisher 确切检验评估分类变量。评估了过程和结果指标。
结果
在筛查的 239 名老年 TEGS 患者中，有 70 名（29.3%）虚弱。所有 TEGS 老年患者在入院后 24 小时内都接受了筛查。实施虚弱途径后，虚弱患者的中位 LOS 从 9 天降至 6 天（p=0.4），再入院率从 36.4%降至 10.2%（p=0.04），丧失独立性的比例下降了 40%（100%比 60%；p=0.01）。两组非虚弱老年患者的结局无差异。
结论
在单一城市学术机构，对虚弱老年 TEGS 患者进行虚弱筛查，然后实施虚弱途径，可降低 LOS、丧失独立性和 30 天再入院率。该途径不需要额外的资源；相反，我们将注意力转向虚弱患者，而不会对非虚弱老年 TEGS 患者的结局产生负面影响。需要在更大的患者群体和不同的环境中实施这一途径，以确认我们的干预措施与改善结局之间的因果关系。
证据水平
治疗研究，IV 级。
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