Ron Donna, Briggs Alexandra, Landsman H Samuel, Amarante Catherine M, Charette Kristin E, Deiner Stacie G
From the Department of Community and Family Medicine, Dartmouth Health and Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire.
Department of Surgery, Dartmouth Health and Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire.
Anesth Analg. 2024 Jun 12. doi: 10.1213/ANE.0000000000006949.
For the first time in history, people age older than 65 years make up >20% of the non-metro population, compared with 16% of the metro population. From 2010 to 2020 the nonmetro population age older than 65 years grew by 22%, while the working-age population declined by 4.9%, and the population aged under 18 years declined by 5.7%.1,2 Multidisciplinary geriatric surgical programs are an increasingly recognized approach to the care of older surgical patients and preliminary data suggest they can reduce length of stay. Although rural areas have the greatest proportion of patients age older than 65 years, implementation of such programs faces special challenges in rural settings with limited resources. Dartmouth-Hitchcock Medical Center is one of the most rural academic centers in the United States. Challenges include a shortage of geriatric-trained providers, long distances to access primary care and subspecialists, and extremely limited postacute care options and skilled nursing facility beds. To address the unique needs of our provider and patient population we began with a development period where we conducted stakeholder interviews. Using these data, we mapped out a workflow and developed pilot projects to address different portions of the workflow, such as preoperative screening for frailty and cognitive impairment, interdisciplinary weekly case conferences, proactive case management, delirium and geriatric surgery postoperative pathway order sets, and a variety of tools for reorientation and delirium management. Herein we describe the process of development and pragmatic clinical implementation of geriatric-focused care for older surgical patients in our rural tertiary center, including some of the main challenges we faced and the strategies we undertook to overcome them, and some of our early patient centered and clinical outcomes. This information may assist other institutions as they design geriatric-focused surgical programs to address the growing population of older adults and the need for compliance with state legislation. The clinical program described is not a research study, and the outcome data we report is for the purpose of description, and should not be interpreted as a rigorous research investigation of the effect of our intervention.
历史上首次出现，65岁以上人群在非都市人口中所占比例超过20%，而在都市人口中这一比例为16%。从2010年到2020年，非都市地区65岁以上人口增长了22%，而劳动年龄人口下降了4.9%，18岁以下人口下降了5.7%。多学科老年外科项目是一种越来越被认可的老年外科患者护理方法，初步数据表明它们可以缩短住院时间。尽管农村地区65岁以上患者的比例最高，但在资源有限的农村地区实施此类项目面临特殊挑战。达特茅斯-希区柯克医疗中心是美国最具乡村特色的学术中心之一。挑战包括缺乏经过老年医学培训的医疗人员、获得初级保健和专科医生的路途遥远，以及急性后期护理选择和专业护理机构床位极其有限。为了满足我们的医疗人员和患者群体的独特需求，我们首先进入了一个开发阶段，在此期间我们进行了利益相关者访谈。利用这些数据，我们规划了一个工作流程，并开展了试点项目来处理工作流程的不同部分，如术前衰弱和认知障碍筛查、跨学科每周病例讨论会、主动病例管理、谵妄和老年外科术后路径医嘱集，以及各种用于重新定向和谵妄管理的工具。在此，我们描述了在我们农村三级中心为老年外科患者开展以老年医学为重点的护理的开发过程和实际临床实施情况，包括我们面临的一些主要挑战以及我们为克服这些挑战所采取的策略，以及我们一些以患者为中心的早期情况和临床结果。这些信息可能会帮助其他机构设计以老年医学为重点的外科项目，以应对不断增长的老年人口以及遵守州立法的需求。所描述的临床项目不是一项研究，我们报告的结果数据仅用于描述目的，不应被解释为对我们干预效果的严格研究调查。
