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J Am Coll Surg. 2019 Jun;228(6):852-859.e1. doi: 10.1016/j.jamcollsurg.2019.02.052. Epub 2019 Apr 5.

Frailty Identification and Care Pathway: An Interdisciplinary Approach to Care for Older Trauma Patients.

Author information

1
Division of Trauma, Burn, and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Boston, MA.
2
Division of Aging, Department of Medicine, Brigham and Women's Hospital, Boston, MA.
3
Division of Trauma, Burn, and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Boston, MA. Electronic address: zcooper@bwh.harvard.edu.

Abstract

BACKGROUND:

Frailty is a well-established marker of poor outcomes in geriatric trauma patients. There are few interventions to improve outcomes in this growing population. Our goal was to determine if an interdisciplinary care pathway for frail trauma patients improved in-hospital mortality, complications, and 30-day readmissions.

STUDY DESIGN:

This was a retrospective cohort study of frail patients ≥65 years old, admitted to the trauma service at an academic, urban level I trauma center between 2015 and 2017. Patients transferred to other services and those who died within the first 24 hours were excluded. An interdisciplinary protocol for frail trauma patients, including early ambulation, bowel/pain regimens, nonpharmacologic delirium prevention, nutrition/physical therapy consults, and geriatrics assessments, was implemented in 2016. Our main outcomes were delirium, complications, in-hospital mortality, and 30-day readmission, which were compared with these outcomes in patients treated the year before the pathway was implemented. Multivariate logistic regression was used to determine the association of being on the pathway with outcomes.

RESULTS:

There were 125 and 144 frail patients in the pre- and post-intervention cohorts, respectively. There were no significant demographic differences between the 2 groups. Among both groups, the mean age was 83.51 years (SD 7.11 years), 60.59% were female, and median Injury Severity Score was 10 (interquartile range 9 to 14). In univariate analysis, there were no significant differences in complications (28.0% vs 28.5%, respectively, p = 0.93); however, there was a significant decrease in delirium (21.6% to 12.5%, respectively, p = 0.04) and 30-day readmission (9.6% to 2.7%, respectively, p = 0.01). After adjusting for patient characteristics, patients on the pathway had lower delirium (odds ratio [OR] 0.44, 95% CI 0.22 to 0.88, p = 0.02) and 30-day readmission rates (OR 0.25, 95% CI 0.07 to 0.84, p = 0.02), than pre-pathway patients.

CONCLUSIONS:

An interdisciplinary care protocol for frail geriatric trauma patients significantly decreases their delirium and 30-day readmission risk. Implementing pathways standardizing care for these vulnerable patients could improve their outcomes after trauma.

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