Section of Geriatrics, Division of Primary Care and Population Health, Department of Medicine, Stanford School of Medicine, Palo Alto, California.
Department of Geriatric Medicine, Geriatric Research Education and Clinical Center (GRECC), Veterans Administration, Palo Alto Health Care System, Palo Alto, California.
JAMA Surg. 2022 Aug 1;157(8):676-683. doi: 10.1001/jamasurg.2022.1556.
Older adults (age ≥65 years) are at risk for high rates of delirium and poor outcomes; however, how to improve outcomes is still being explored.
To assess whether implementation of a geriatric trauma clinical pathway was associated with reduced rates of delirium in older adults with traumatic injury.
DESIGN, SETTING, AND PARTICIPANTS: A retrospective case-control study of electronic health records of patients aged 65 years or older with traumatic injury from 2018 to 2020 was conducted at a single level I trauma center. Eligible patients were age 65 years or older admitted to the trauma service and who did not undergo an operation.
The implementation of a clinical pathway based on geriatric best practices, which included order sets, guidelines, automated consultations, and escalation pathways executed by a multidisciplinary team.
The primary outcome was delirium. The secondary outcome was hospital length of stay. Process measures for pathway compliance were also assessed.
Of the 859 eligible patients, 712 patients were included in the analysis (442 [62.1%] in the baseline group; 270 [37.9%] in the postimplementation group; mean [SD] age: 81.4 [9.1] years; 394 [55.3%] were female). The mechanism of injury was not different between groups, with 247 in the baseline group (55.9%) and 162 in the postimplementation group (60.0%) (P = .43) experiencing a fall. Injuries were minor or moderate in both groups (261 in baseline group [59.0%] and 168 in postimplementation group [62.2%]; P = .87). The adjusted odds ratio for delirium in the postimplementation cohort was 0.54 (95% CI, 0.37-0.80; P < .001). Goals of care documentation improved significantly in the postimplementation cohort vs the baseline cohort with regard to documented goals of care notes (53.7% in the postimplementation cohort [145 of 270] vs 16.7% in the baseline cohort [74 of 442]; P < .001) and a shortened time to discussion from presenting to the emergency department (36 hours in the postimplementation cohort vs 50 hours in the baseline cohort; P = .03).
In this study, implementation of a multidisciplinary clinical pathway for injured older adults at a single level I trauma center was associated with improved care and clinical outcomes. Interventions such as these may have utility in this vulnerable population, and findings should be confirmed across multiple centers.
老年人（年龄≥65 岁）发生谵妄和不良结局的风险较高；然而，如何改善这些结果仍在探索之中。
评估老年创伤临床路径的实施是否与创伤后老年患者谵妄发生率的降低有关。
设计、地点和参与者：对 2018 年至 2020 年期间在一家一级创伤中心接受创伤的 65 岁或以上电子健康记录的患者进行了回顾性病例对照研究。合格的患者为年龄 65 岁或以上、入住创伤科且未接受手术的患者。
实施基于老年最佳实践的临床路径，包括医嘱集、指南、自动咨询和多学科团队执行的升级途径。
主要结局为谵妄。次要结局是住院时间。还评估了路径依从性的过程措施。
在 859 名符合条件的患者中，有 712 名患者纳入分析（基线组 442 名[62.1%]；实施后组 270 名[37.9%]；平均[标准差]年龄：81.4[9.1]岁；394 名[55.3%]为女性）。两组的损伤机制无差异，基线组 247 名（55.9%）和实施后组 162 名（60.0%）（P = .43）发生跌倒。两组的损伤均为轻微或中度（基线组 261 名[59.0%]和实施后组 168 名[62.2%]；P = .87）。实施后队列发生谵妄的调整优势比为 0.54（95%CI，0.37-0.80；P < .001）。与基线组相比，实施后组的目标治疗记录在记录目标治疗笔记方面有显著改善（实施后组 53.7%[270 名中的 145 名]与基线组 16.7%[442 名中的 74 名]；P < .001），从急诊科就诊到讨论的时间缩短（实施后组 36 小时，与基线组 50 小时；P = .03）。
在这项研究中，在一家一级创伤中心对老年受伤患者实施多学科临床路径与改善护理和临床结果有关。这些干预措施在这个脆弱的人群中可能具有实用性，应该在多个中心得到证实。
