Association Between Implementation of a Geriatric Trauma Clinical Pathway and Changes in Rates of Delirium in Older Adults With Traumatic Injury

Abstract

IMPORTANCE Older adults (age Ն65 years) are at risk for high rates of delirium and poor outcomes; however, how to improve outcomes is still being explored.OBJECTIVE 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 PARTICIPANTSA 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.INTERVENTION 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. MAIN OUTCOMES AND MEASURESThe primary outcome was delirium. The secondary outcome was hospital length of stay. Process measures for pathway compliance were also assessed. RESULTSOf 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). CONCLUSIONS AND RELEVANCEIn 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.

A Comprehensive Multidisciplinary Approach—The Ideal Future State of Geriatric Trauma Care

“…Aziz HA, Lunde J, Barraco R, et al Evidence-based review of trauma center care and routine palliative care processes for geriatric trauma patients; A collaboration from the American Association for the Surgery of Trauma Patient Assessment Committee, the American Association for the Surgery of Trauma Geriatric Trauma Committee, and the Eastern Association for the Surgery of Trauma Guidelines Committee. Park and colleagues 1 present a timely and relevant study adding to the growing body of literature on the importance of interdisciplinary approaches to the care of older patients with trauma. As the older population increases, so will the number of geriatric patients with trauma.…”

More Explorations Needed to Assess Matrix Metalloproteinase 7 Expression When Predicting the Pathologic Response to Neoadjuvant Therapy for Pancreatic Ductal Adenocarcinoma

“…In Reply We appreciate the letter from Wang and Niu regarding our original JAMA Surgery research study, and we would like to share our perspective on the points raised in the letter. 1 The concerns raised regarding the effect size reported in our article and its relation to statistical power and clinical significance are due to the study's retrospective nature. Specimens for our discovery cohort (23 specimens) and validation cohort (80 specimens) were obtained from our robust institutional tissue biobank, which contains treatment-naive samples devoted to research after diagnosis.…”

“…To the Editor Identification and characterization of biomarkers predictive of pathologic response after neoadjuvant therapy has emerged as a hot topic in the oncology field. 1 Shoucair et al 2 shed some light on this topic, underscoring the practical importance of matrix metalloproteinase 7 as a promising biomarker teased out through RNA sequencing when predicting pathologic response to neoadjuvant therapy for pancreatic ductal adenocarcinoma (PDAC). This finding was derived from a discovery cohort involving 23 patients, a validation cohort involving 80 patients, and an exploratory cohort involving 60 patients, yet considerable methodological concerns have been raised regarding the robustness of this study by Shoucair et al The first concern relates to the large effect size estimate (odds ratio, 21.25) with wide 95% CI (6.19-72.95) when quantifying the association of skin matrix metalloproteinase 7 with pathologic response after neoadjuvant therapy, 2 which reflects lack of statistical power; albeit, this association was reproducible in both validation and exploratory sets.…”

“…To the Editor With great interest, we read the article by Park et al, 1 who performed a retrospective case-control study to assess whether implementation of a geriatric trauma clinical pathway was associated with reduced rates of delirium in older adults with traumatic injury. The study concluded that the implementation of a multidisciplinary clinical pathway for older adults with injuries was associated with improved care and clinical outcomes, which suggested the feasibility of the geriatric trauma clinical pathway.…”

Delirium in trauma ICUs: a review of incidence, risk factors, outcomes, and management

“…Park et al in 2022 [33 ▪▪ ] have gone further by showing how the implementation of a standardized geriatric trauma clinical pathway including integration of protocolized assessments and interventions specific to the elderly population as well as involvement of geriatric medicine specialists decreased delirium rates in elderly trauma patients by half within their institution.…”