老年患者在一级创伤中心就诊并填写《维持生命治疗医师指令表》：一项倾向评分匹配分析。
Elderly patients presenting to a Level I trauma center with Physician Orders for a Life-Sustaining Treatment form: A propensity-matched analysis.
机构信息
From the Division of Trauma, Surgical Critical Care, and Acute Care Surgery, Department of Surgery (J.H.B., D.H.Z.), and Department of Surgery (E.D.), Oregon Health and Science University, Portland, Oregon.
出版信息
J Trauma Acute Care Surg. 2019 Jul;87(1):153-160. doi: 10.1097/TA.0000000000002321.
BACKGROUND
Physician Orders for Life-Sustaining Treatment (POLST) forms are portable medical orders documenting patient treatment preferences in an acute health decline. It is unclear how these forms are used in the management of elderly trauma patients.
METHODS
Patients 65 years and older presenting to a Level I trauma center were identified between 2012 and 2017. Hospital trauma registry and medical records were used to identify a preinjury POLST and its acknowledgment by providers within 24 hours of arrival. A 1:1 propensity score matched sample was used to evaluate clinical outcomes based on the presence of a POLST limiting interventions with p less than 0.05 deemed significant.
RESULTS
There were 3,342 elderly trauma patients identified. One hundred ninety-two (6%) had a POLST identified by the institutional trauma registry dated before the injury. Do not attempt resuscitation (DNR) was listed in 154 patients (80%), and 79% desired to avoid the intensive care unit (ICU) with limited (54%) or comfort measures only (CMO, 25%). One hundred seven (76%) of admitted POLST DNR patients had a DNR code status for the majority of their admission. 59 (58%) of the limited and 29 (60%) of the comfort measures only patients were admitted to the ICU. Acknowledgment of a preinjury POLST or code status was explicitly documented in 110 cases (57%). Propensity score analysis yielded a comparison sample of 288 patients. In the matched comparison, an acknowledged POLST with limitations was associated with a shorter ICU stay (1.7 vs. 2.8 days, p = 0.008) but there was no difference in ICU admission (58% vs. 61%, p = 0.69), total length of stay (3.8 days vs. 4.8 days, p = 0.08), or in-hospital mortality (13% vs. 8%, p = 0.2).
CONCLUSION
Limited provider acknowledgment of preinjury medical directives necessitates protocol development for the management of frail elderly trauma patients. When acknowledged, patients with a POLST limiting interventions had fewer ICU days without increased in-hospital mortality compared with similarly injured elderly patients.
LEVEL OF EVIDENCE
Care Management, level IV.
背景
医生签署的维持生命治疗医嘱（POLST）表格是一种便携的医疗医嘱，记录了患者在急性健康恶化时的治疗偏好。目前尚不清楚这些表格在老年创伤患者的管理中是如何使用的。
方法
2012 年至 2017 年期间，确定了在一级创伤中心就诊的 65 岁及以上的患者。利用医院创伤登记处和病历，确定了受伤前的 POLST，并在患者入院后 24 小时内确认了其是否得到了提供者的认可。采用 1:1 倾向评分匹配样本，根据是否存在限制干预的 POLST 来评估临床结局，p 值小于 0.05 被认为具有统计学意义。
结果
共确定了 3342 名老年创伤患者。192 名（6%）患者的 POLST 在受伤前通过机构创伤登记处识别出来。154 名患者（80%）被列为“不进行心肺复苏”（DNR），79%的患者希望避免入住重症监护病房（ICU），其中 54%希望仅接受限制治疗，25%希望仅接受舒适治疗。107 名（76%）入院的 DNR 患者中，有 59 名（58%）患者在大多数住院期间的 DNR 编码状态为 DNR，59 名（58%）接受限制治疗的患者和 29 名（60%）接受舒适治疗的患者入住了 ICU。110 例（57%）明确记录了受伤前 POLST 或编码状态的承认。倾向性评分分析得出了 288 例患者的匹配比较样本。在匹配比较中，有明确限制的承认 POLST 与较短的 ICU 住院时间相关（1.7 天 vs. 2.8 天，p = 0.008），但 ICU 入院率无差异（58% vs. 61%，p = 0.69），总住院时间无差异（3.8 天 vs. 4.8 天，p = 0.08），院内死亡率也无差异（13% vs. 8%，p = 0.2）。
结论
由于提供者对受伤前医疗指令的承认程度有限，因此需要制定协议来管理脆弱的老年创伤患者。当得到承认时，与同样受伤的老年患者相比，接受 POLST 限制干预的患者 ICU 天数减少，而院内死亡率没有增加。
证据水平
护理管理，IV 级。
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