Original Investigation 

June 8, 2022

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

Caroline Park, Ankur Bharija, Matthew Mesias, et al

JAMA Surg. 2022;157(8):676-683. doi:10.1001/jamasurg.2022.1556

Key Points

Question  Is the establishment of a geriatric-centered clinical pathway associated with improved outcomes in older adults with traumatic injury?

Findings  In this case-control study of 712 older adults with traumatic injury in a single level I trauma center, outcomes before and after implementation of a novel clinical pathway were compared. Reductions in delirium in unadjusted analyses and adjusted analyses were noted.

Meaning  In this case-control study, implementation of a multidisciplinary care pathway was associated with improved rates of delirium.

Abstract

Importance  Older adults (age ≥65 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 Participants  A 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 Measures  The primary outcome was delirium. The secondary outcome was hospital length of stay. Process measures for pathway compliance were also assessed.

Results  Of 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 Relevance  In 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.