Kathryn E Engelhardt1, Quentin Reuter, Jessica Liu, Jonathan F Bean, Joliette Barnum, Michael B Shapiro, Allison Ambre, Amanda Dunbar, Mara Markzon, Tara N Reddy, Christine Schilling, Joseph A Posluszny. 1. From the Surgical Outcomes and Quality Improvement Center (K.E.E.), Northwestern University, Chicago, Illinois; Department of Surgery (K.E.E.), Medical University of South Carolina, Charleston, South Carolina; Department of Emergency Medicine (Q.R.), Northwestern University, Chicago, Illinois; Department of Surgery (J.L.), Emory University, Atlanta, Georgia; Department of Surgery (J.F.B., J.B., M.B.S., A.A., A.D., M.M., C.S., J.P.), and Department of Hospital Medicine (T.R.), Northwestern University, Chicago, Illinois.
Abstract
BACKGROUND: Frail geriatric trauma and emergency general surgery (TEGS) patients have longer lengths of stay (LOS), more readmissions, and higher rates of postdischarge institutionalization than their nonfrail counterparts. Despite calls to action by national trauma coalitions, there are few published reports of prospective interventions. The objective of this quality improvement project was to first develop a frailty screening program, and, then, if frail, implement a novel frailty pathway to reduce LOS, 30-day readmissions, and loss of independence. METHODS: This was a before-after study of a prospective cohort of all geriatric (≥65-years-old) patients admitted to the TEGS service from October 2016 to October 2017. All patients were screened for frailty for 3 months (preintervention) to obtain baseline outcomes. Subsequently, frail patients were entered into our frailty pathway (postintervention). Nonparametric statistical tests were used to assess significant differences in continuous variables; χ and Fisher exact tests were used for categorical variables, where appropriate. Both process and outcome measures were evaluated. RESULTS: Of 239 geriatric TEGS patients screened, 70 (29.3%) were frail. All TEGS geriatric patients were screened within 24 hours of admission. Following frailty pathway implementation, median LOS for frail patients decreased from 9 to 6 days (p = 0.4), readmissions decreased from 36.4% to 10.2% (p = 0.04), and loss of independence decreased by 40%, (100% vs 60%; p = 0.01). Outcomes for nonfrail geriatric patients did not differ between cohorts. CONCLUSIONS: Screening for frailty followed by implementing a frailty pathway decreased LOS, loss of independence, and 30-day readmission rates for frail geriatric TEGS patients at a single urban academic institution. The pathway required no additional resources; rather, we shifted focus toward frail patients without negatively affecting outcomes in nonfrail geriatric TEGS patients. Implementation of this pathway with larger patient cohorts and in varied settings is needed to confirm a causal relationship between our intervention and improved outcomes. LEVEL OF EVIDENCE: Therapeutic study, level IV.
BACKGROUND: Frail geriatric trauma and emergency general surgery (TEGS) patients have longer lengths of stay (LOS), more readmissions, and higher rates of postdischarge institutionalization than their nonfrail counterparts. Despite calls to action by national trauma coalitions, there are few published reports of prospective interventions. The objective of this quality improvement project was to first develop a frailty screening program, and, then, if frail, implement a novel frailty pathway to reduce LOS, 30-day readmissions, and loss of independence. METHODS: This was a before-after study of a prospective cohort of all geriatric (≥65-years-old) patients admitted to the TEGS service from October 2016 to October 2017. All patients were screened for frailty for 3 months (preintervention) to obtain baseline outcomes. Subsequently, frail patients were entered into our frailty pathway (postintervention). Nonparametric statistical tests were used to assess significant differences in continuous variables; χ and Fisher exact tests were used for categorical variables, where appropriate. Both process and outcome measures were evaluated. RESULTS: Of 239 geriatric TEGS patients screened, 70 (29.3%) were frail. All TEGS geriatric patients were screened within 24 hours of admission. Following frailty pathway implementation, median LOS for frail patients decreased from 9 to 6 days (p = 0.4), readmissions decreased from 36.4% to 10.2% (p = 0.04), and loss of independence decreased by 40%, (100% vs 60%; p = 0.01). Outcomes for nonfrail geriatric patients did not differ between cohorts. CONCLUSIONS: Screening for frailty followed by implementing a frailty pathway decreased LOS, loss of independence, and 30-day readmission rates for frail geriatric TEGS patients at a single urban academic institution. The pathway required no additional resources; rather, we shifted focus toward frail patients without negatively affecting outcomes in nonfrail geriatric TEGS patients. Implementation of this pathway with larger patient cohorts and in varied settings is needed to confirm a causal relationship between our intervention and improved outcomes. LEVEL OF EVIDENCE: Therapeutic study, level IV.
Authors: Rachel G Khadaroo; Lindsey M Warkentin; Adrian S Wagg; Raj S Padwal; Fiona Clement; Xiaoming Wang; William D Buie; Jayna Holroyd-Leduc Journal: JAMA Surg Date: 2020-04-15 Impact factor: 14.766
Authors: Carol J Peden; Geeta Aggarwal; Robert J Aitken; Iain D Anderson; Nicolai Bang Foss; Zara Cooper; Jugdeep K Dhesi; W Brenton French; Michael C Grant; Folke Hammarqvist; Sarah P Hare; Joaquim M Havens; Daniel N Holena; Martin Hübner; Jeniffer S Kim; Nicholas P Lees; Olle Ljungqvist; Dileep N Lobo; Shahin Mohseni; Carlos A Ordoñez; Nial Quiney; Richard D Urman; Elizabeth Wick; Christopher L Wu; Tonia Young-Fadok; Michael Scott Journal: World J Surg Date: 2021-03-06 Impact factor: 3.352