Oyekan Anthony A, Lee Joon Y, Hodges Jacob C, Chen Stephen R, Wilson Alan E, Fourman Mitchell S, Clayton Elizabeth O, Njoku-Austin Confidence, Crasto Jared A, Wisniewski Mary Kay, Bilderback Andrew, Gunn Scott R, Levin William I, Arnold Robert M, Hinrichsen Katie L, Mensah Christopher, Hogan MaCalus V, Hall Daniel E
Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania.
Pittsburgh Ortho Spine Research (POSR) Group, University of Pittsburgh, Pittsburgh, Pennsylvania.
JB JS Open Access. 2023 Apr 24;8(2). doi: 10.2106/JBJS.OA.22.00107. eCollection 2023 Apr-Jun.
Patient values may be obscured when decisions are made under the circumstances of constrained time and limited counseling. The objective of this study was to determine if a multidisciplinary review aimed at ensuring goal-concordant treatment and perioperative risk assessment in high-risk orthopaedic trauma patients would increase the quality and frequency of goals-of-care documentation without increasing the rate of adverse events.
We prospectively analyzed a longitudinal cohort of adult patients treated for traumatic orthopaedic injuries that were neither life- nor limb-threatening between January 1, 2020, and July 1, 2021. A rapid multidisciplinary review termed a "surgical pause" (SP) was available to those who were ≥80 years old, were nonambulatory or had minimal ambulation at baseline, and/or resided in a skilled nursing facility, as well as upon clinician request. Metrics analyzed include the proportion and quality of goals-of-care documentation, rate of return to the hospital, complications, length of stay, and mortality. Statistical analysis utilized the Kruskal-Wallis rank and Wilcoxon rank-sum tests for continuous variables and the likelihood-ratio chi-square test for categorical variables.
A total of 133 patients were either eligible for the SP or referred by a clinician. Compared with SP-eligible patients who did not undergo an SP, patients who underwent an SP more frequently had goals-of-care notes identified (92.4% versus 75.0%, p = 0.014) and recorded in the appropriate location (71.2% versus 27.5%, p < 0.001), and the notes were more often of high quality (77.3% versus 45.0%, p < 0.001). Mortality rates were nominally higher among SP patients, but these differences were not significant (10.6% versus 5.0%, 5.1% versus 0.0%, and 14.3% versus 7.9% for in-hospital, 30-day, and 90-day mortality, respectively; p > 0.08 for all).
The pilot program indicated that an SP is a feasible and effective means of increasing the quality and frequency of goals-of-care documentation in high-risk operative candidates whose traumatic orthopaedic injuries are neither life- nor limb-threatening. This multidisciplinary program aims for goal-concordant treatment plans that minimize modifiable perioperative risks.
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
在时间紧迫和咨询有限的情况下做出决策时，患者的价值观可能会被忽视。本研究的目的是确定针对高风险骨科创伤患者进行多学科评估，以确保治疗方案与目标一致并进行围手术期风险评估，是否会提高医疗照护目标记录的质量和频率，同时不增加不良事件的发生率。
我们对2020年1月1日至2021年7月1日期间接受非危及生命或肢体的创伤性骨科损伤治疗的成年患者纵向队列进行了前瞻性分析。对于年龄≥80岁、基线时非步行或步行能力极小和/或居住在专业护理机构的患者，以及应临床医生要求的患者，可进行一种名为“手术暂停”（SP）的快速多学科评估。分析的指标包括医疗照护目标记录的比例和质量、再入院率、并发症、住院时间和死亡率。连续变量的统计分析采用Kruskal-Wallis秩和检验与Wilcoxon秩和检验，分类变量采用似然比卡方检验。
共有133例患者符合SP评估条件或由临床医生转诊。与未接受SP评估的符合SP条件的患者相比，接受SP评估的患者更频繁地有医疗照护目标记录被识别（92.4%对75.0%，p = 0.014）并记录在适当位置（71.2%对27.5%，p < 0.001），且记录的质量更高（77.3%对45.0%，p < 0.001）。SP患者的死亡率名义上较高，但这些差异无统计学意义（住院死亡率分别为10.6%对5.0%，30天死亡率为5.1%对0.0%，90天死亡率为14.3%对7.9%；p均> 0.08）。
该试点项目表明，对于创伤性骨科损伤既不危及生命也不危及肢体的高风险手术候选患者，SP是提高医疗照护目标记录质量和频率的一种可行且有效的方法。这个多学科项目旨在制定与目标一致的治疗计划，将可改变的围手术期风险降至最低。
治疗性三级。有关证据水平的完整描述，请参阅作者指南。
