Increasing Quality and Frequency of Goals-of-Care Documentation in the Highest-Risk Surgical Candidates: One-Year Results of the Surgical Pause Program : JBJS Open Access

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Increasing Quality and Frequency of Goals-of-Care Documentation in the Highest-Risk Surgical Candidates

One-Year Results of the Surgical Pause Program

Oyekan, Anthony A. MD1,2,a; Lee, Joon Y. MD1,2; Hodges, Jacob C. MS3; Chen, Stephen R. MD1,2; Wilson, Alan E. MD1; Fourman, Mitchell S. MD, MPhil2,4; Clayton, Elizabeth O. MS1; Njoku-Austin, Confidence BA1; Crasto, Jared A. MD5; Wisniewski, Mary Kay MA3; Bilderback, Andrew MS3; Gunn, Scott R. MD6,7; Levin, William I. MD8; Arnold, Robert M. MD8,9; Hinrichsen, Katie L. MSN3; Mensah, Christopher MBA3; Hogan, MaCalus V. MD, MBA1,3; Hall, Daniel E. MD3,10,11,12

Author Information

1Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania

2Pittsburgh Ortho Spine Research (POSR) Group, University of Pittsburgh, Pittsburgh, Pennsylvania

3Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania

4Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY

5Department of Orthopaedic Surgery, The Spine Institute of Arizona, Scottsdale, Arizona

6Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania

7Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania

8Department of Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania

9Section of Palliative Care and Medical Ethics, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania

10Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania

11Geriatric Research Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania

12Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania

aEmail for corresponding author: [email protected]

Investigation performed at the University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania

Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (https://links.lww.com/JBJSOA/A504).

JBJS Open Access 8(2):e22.00107, April-June 2023. | DOI: 10.2106/JBJS.OA.22.00107
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  • SDC
  • Disclosures

Abstract

Practice guidelines recommend minimizing the delay to surgery for orthopaedic trauma, when appropriate, to avoid deleterious outcomes1–5. However, surgery may not be consistent with patient values6–11. Some patients who are extremely frail or have a limited life expectancy may need additional counseling to weigh the risks and benefits of surgery. In such settings, careful communication aimed at shared decision-making with the patient or their surrogate decision-makers is required prior to any surgical treatment. Detailed risk assessment and the communication expertise required for shared decision-making in these complex patients are not always immediately available at initial presentation. This constellation of factors can lead to discordant care.

Multidisciplinary review before elective, complex, high-risk surgery is an effective approach to improve outcomes in both surgical oncology12–14 and high-frailty15–21 patients. Multidisciplinary advance care planning is a Medicare-reimbursable service that remains underutilized or poorly documented22. The applicability of multidisciplinary review for improving orthopaedic trauma outcomes through goals-of-care (GOC)23–26 documentation has not been evaluated, to our knowledge. An effective pathway would involve experts in preoperative assessment, anesthesia, and palliative care, and should require <24 hours to ensure that appropriate surgery is not delayed27–29. The goal of the quality improvement project in this study was to evaluate the impact of a complex, multidisciplinary behavioral intervention applied to high-risk patients. Specifically, we aimed to implement a multidisciplinary review and structured goal clarification to ensure goal-concordant treatment for patients who were ≥80 years of age, were nonambulatory (or had minimal ambulation) at baseline, and/or resided in a skilled nursing facility (SNF). We hypothesized that this “surgical pause” (SP) would increase the quality and frequency of GOC documentation, as a surrogate marker for goal-concordant treatment, without increasing the rate of adverse events.

Materials and Methods

Project Design and Participants

This quality improvement project was approved by the University of Pittsburgh Medical Center (UPMC) Quality Review Committee and is reported in accordance with the STROBE and SQUIRE guidelines30,31. It was designed as an analysis of longitudinal data in a prospective cohort. All adult patients who presented to a level-1 academic trauma center with traumatic orthopaedic injuries that were neither life- nor limb-threatening and warranted surgical intervention between January 1, 2020, and July 1, 2021, were screened for inclusion based on the presence of ≥1 of the following high-risk criteria: (1) age of ≥80 years, (2) minimal or absent ambulation at baseline, or (3) residence in an SNF. Patients could also be included by clinician request. The minimum patient follow-up for inclusion in this analysis was 90 days via a post-discharge phone call or outpatient clinical assessment. Exclusion criteria included hemodynamic instability or a threat to life or limb, which would necessitate immediate decision-making regarding surgery. Screening was performed by the orthopaedic surgery chief resident utilizing a checklist. Chief residents were instructed to discuss potentially eligible patients with their attending physician before deciding to initiate an SP.

The Surgical Pause Intervention

An SP facilitates rapid, multidisciplinary review of high-risk patients (Fig. 1). Patients selected for an SP were not scheduled for surgery until the team performed a risk assessment and clarified the GOC. The SP was designed to take <24 hours to complete. Members of the team included attending physicians from Orthopaedic Surgery, General and Trauma Surgery, Critical Care Medicine, Palliative Care, and a Hospitalist dedicated to the management of orthopaedic patients. Team members communicated with each other to reach consensus regarding the clinical outcomes expected with different management options, including operative and nonoperative management. One member with formal training in goal clarification32,33 then met with the patient to describe these options, elicit the patient’s goals and values, and identify the management pathway best aligned with those goals and values. When patients lacked decision-making capacity, the conversations were conducted with the identified surrogate (e.g., next of kin). Informed consent was solicited only from those patients whose goals aligned with surgical management.

F1
Fig. 1:
The typical management pathways for any orthopaedic trauma patient presenting to the center with an injury that is neither life- nor limb-threatening. The 4 phrases in squares indicate participant inclusion criteria. The yellow triangle represents the surgical pause procedure. The rounded rectangular and square boxes represent the initial and final dispositions, respectively. Patients with neither life- nor limb-threatening injuries proceed down the pause pathway rather than going straight to the operating room for emergency treatment. A surgical pause leads to meetings with the patient/family, risk stratification, and medical optimization. This process should take <24 hours, after which goal-concordant care continues with either operative or nonoperative management.

Metrics

Age, body mass index (BMI), AO classification of fracture morphology34, injury location, admission source, admission priority, insurance status, and APR-DRG (All Patient Refined Diagnosis Related Group) and ICD-10 (International Classification of Diseases, 10th Revision) codes were extracted from the electronic medical record. Established methods were used to compute the severity of illness35, risk of mortality36, and Elixhauser Comorbidity Index (ECI) from the available diagnosis codes37. Clinical outcomes, also extracted from the electronic record, included vital status, hospital length of stay, intensive care unit (ICU) admission rate, hospital readmission rate, and emergency department (ED) return rate. Hospital discharge criteria were not altered for the purposes of this study and included hemodynamic stability, tolerance of nutrient intake, adequate pain control with enteral pharmacotherapy, and a plan for long-term care. Postoperative complications were abstracted from the electronic record by A.A.O., A.E.W., M.S.F., and S.R.C.

The primary outcome, specified a priori at the time of project charter, was the presence and quality of GOC documentation. Trained qualitative analysts used a previously validated codebook (see Appendix A) to review the electronic record of each patient to determine if GOC were documented and their quality. Reviews focused on the dedicated “Goals of Care” note template mandated by the health-care system (see Appendix B). However, comments about GOC located in progress notes or other locations were also coded. Each document was assessed for the presence of 4 indicators of a high-quality discussion: (1) statement and discussion of the prognosis, (2) articulation of the patient’s values and goals, (3) a clear and detailed description of the decision regarding clinical management (e.g., change in code status, time-limited trial), and (4) a narrative of the conversation that led to the clinical decision. These criteria were developed previously by the health-care system in the context of a separate quality initiative aimed at increasing the rate and quality of GOC documentation among patients admitted to ICUs and medical wards with serious chronic illnesses; consistency of ratings across coders was established as part of this separate initiative before its application to this project. Coders rated each note according to a global assessment of whether or not the clinicians made a “high overall effort” to engage in a goal clarification conversation. Finally, the prevalence and quality of GOC documentation were evaluated for patients treated within an ICU and those treated outside one. GOC documentation was anticipated to be better in ICUs, as Critical Care Medicine clinicians practicing in this environment are extensively trained and incentivized to establish and document patient GOC, and are supported by a dedicated team of nurses focused on facilitating GOC conversations38,39. ICU admission criteria previously established within the hospital system were not altered for the purposes of this study. Select ICU admission criteria include invasive mechanical ventilation or septic shock with a vasopressor requirement.

Bias and Sample Size

Bias was minimized using a rigorously structured coding scheme to quantify the quality of documentation. Qualitative coders were trained in the application of a codebook with clear examples of coding cases. Disagreements were resolved by consensus according to the codebook definitions. A sample of convenience was used, consisting of all orthopaedic trauma patients with neither life- nor limb-threatening injuries during the project.

Statistical Analysis

Analysis began by inspecting the completeness and distribution of the data and summarizing descriptive statistics using the frequency and proportion for demographic characteristics and stratification by eligibility criteria and admitting location for specified outcomes. Mortality rates were measured from admission, whereas all readmission and emergency department return rates were measured from discharge. Calculations excluded missing values. For all 30-day and 90-day mortality, readmission, and ED utilization outcomes, the 13 patients with in-hospital mortality were excluded when calculating the reported rates. For all readmission and ED utilization outcomes, all patients who died before the measurement timeframe were excluded from the calculation. There was no documented loss to follow-up. The Kruskal-Wallis rank test or Wilcoxon rank-sum test was used for comparisons of continuous variables, including length of stay. The likelihood-ratio chi-square test was used for comparisons of categorical variables, including the presence or absence of high-quality GOC documentation. Statistical analysis was performed using Stata MP 17.0 (StataCorp). Significance was set at p ≤ 0.05 for all tests.

Source of Funding

No external funding was received for this study.

Results

A total of 133 patients either met the inclusion criteria or were referred for an SP by clinician request (Table I). An SP was called for only 66 (62.3%) of the 106 who met at least 1 of the inclusion criteria for an SP, but for all 27 of the patients indicated by clinician request, yielding a total of 93 patients (69.9%) with an SP. Of the 133 eligible patients, 79 (59.4%) were female and 54 (40.6%) were male. The mean age (and standard deviation) was 79.9 ± 12.8 years, and 116 (87.2%) identified as White. The mean BMI was 27.0 ± 6.5 kg/m2 and the mean ECI was 2.2 ± 1.6, representing an overweight and expectantly medically comorbid patient population. Eighty-seven (65.4%) were ≥80 years old, 46 (35.1%) had minimal to no baseline mobility, and 27 (20.5%) resided in an SNF. Injuries were most commonly AO type-A fractures (111 [83.5%]) or type-B fractures (14 [10.5%]). Injuries of the hip (72 [54.1%]), spine (23 [17.3%]), and other locations (13 [9.8%]) (e.g., quadriceps tendon rupture or polyarticular septic arthritis) were the most common. Most presented to the trauma center (74 [55.6%]) or the ED (39 [29.3%]), and the cohort predominantly consisted of Medicare beneficiaries with an elevated severity of illness and mortality risk (Table I).

TABLE I - Baseline Characteristics Stratified by Inclusion Criteria, Whether a Surgical Pause Was Called, and ICU Admission Status*†
Characteristic All Study Participants ≥1 Inclusion Criterion Met ≥1 Inclusion Criterion Met but Pause not Called ≥1 Inclusion Criterion Met and Pause Called No Inclusion Criteria but Referred by Clinician and Pause Called
All Admitted to ICU† Admitted Elsewhere than ICU† All Admitted to ICU† Admitted Elsewhere than ICU†
No. 133 106 40 3 37 66 20 46 27
Age (yr) 79.9 ± 12.8 83.5 ± 10.5‡ 82.9 ± 11.2 82.2 ± 1.7 83.0 ± 11.6 83.9 ± 10.2§ 83.4 ± 6.5 84.1 ± 11.5 65.8 ± 11.3#
Female sex 79 (59.4%) 64 (60.4%) 24 (60.0%) 0 (0.0%)** 24 (64.9%) 40 (60.6%) 7 (35.0%)†† 33 (71.7%) 15 (55.6%)
White race 116 (87.2%) 91 (85.8%) 33 (82.5%) 2 (66.7%) 31 (83.8%) 58 (87.9%) 17 (85.0%) 41 (89.1%) 25 (92.6%)
BMI (kg/m 2 ) 27.0 ± 6.5 26.8 ± 6.5 26.9 ± 5.8 24.3 ± 3.3 27.2 ± 5.9 26.7 ± 7.0 26.3 ± 6.6 26.8 ± 7.2 27.7 ± 6.3
ECI 2.2 ± 1.6 2.1 ± 1.5 2.3 ± 1.6 3.0 ± 1.0 2.3 ± 1.6 2.0 ± 1.5 1.8 ± 1.5 2.1 ± 1.5 2.5 ± 1.7
Inclusion criteria
 Age ≥80 yr 87 (65.4%) 87 (82.1%)‡ 36 (90.0%) 3 (100.0%) 33 (89.2%) 51 (77.3%)§ 15 (75.0%) 36 (78.3%) 0 (0.0%)#
 Minimal mobility 46 (35.1%) 46 (44.2%)‡ 10 (25.0)%‡‡ 0 (0.0%) 10 (27.0%) 36 (56.3%)§ 10 (55.6%) 26 (56.5%) 0 (0.0%)#
 SNF resident 27 (20.5%) 27 (25.7%)‡ 7 (17.5%) 0 (0.0%) 7 (18.9%) 20 (30.8%)§ 5 (26.3%) 15 (32.6)% 0 (0.0%)#
AO fracture classification
 A 111 (83.5%) 90 (84.9%) 35 (87.5%) 2 (66.7%) 33 (89.2%) 55 (83.3%) 11 (55.0%)†† 44 (95.7%) 21 (77.8%)
 B 14 (10.5%) 11 (10.4%) 4 (10.0%) 1 (33.3%) 3 (8.1%) 7 (10.6%) 5 (25.0%)†† 2 (4.3%) 3 (11.1%)
 C 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%)
 Other 8 (6.0%) 5 (4.7%) 1 (2.5%) 0 (0.0%) 1 (2.7%) 4 (6.1%) 4 (20.0%)†† 0 (0.0%) 3 (11.1%)
Injury location
 Hip 72 (54.1%) 59 (55.7%) 21 (52.5%) 1 (33.3%) 20 (54.1%) 38 (57.6%) 8 (40.0%) 30 (65.2%) 13 (48.1%)
 Femoral shaft 6 (4.5%) 6 (5.7%) 2 (5.0%) 0 (0.0%) 2 (5.4%) 4 (6.1%) 1 (5.0%) 3 (6.5%) 0 (0.0%)
 Distal femur 10 (7.5%) 7 (6.6%) 2 (5.0%) 0 (0.0%) 2 (5.4%) 5 (7.6%) 2 (10.0%) 3 (6.5%) 3 (11.1%)
 Tibia 7 (5.3%) 6 (5.7%) 3 (7.5%) 0 (0.0%) 3 (8.1%) 3 (4.5%) 0 (0.0%) 3 (6.5%) 1 (3.7%)
 Upper extremity 5 (3.8%) 3 (2.8%) 1 (2.5%) 0 (0.0%) 1 (2.7%) 2 (3.0%) 1 (5.0%) 1 (2.2%) 2 (7.4%)
 Spine 23 (17.3%) 15 (14.2%) 2 (5.0%)‡‡ 1 (33.3%) 1 (2.7%) 13 (19.7%) 8 (40.0%)†† 5 (10.9%) 8 (29.6%)#
 Other 13 (9.8%) 13 (12.3%) 9 (22.5%)‡‡ 1 (33.3%) 8 (21.6%) 4 (6.1%) 1 (5.0%) 3 (6.5%) 0 (0.0%)#
Admit source
 Hospital transfer 56 (42.1%) 43 (40.6%)‡ 16 (40.0%) 1 (33.3%) 15 (40.5%) 27 (40.9)§ 13 (65.0) 14 (30.4) 13 (48.1)#
 Medical referral 60 (45.1%) 51 (48.1%) 22 (55.0%) 1 (33.3%) 21 (56.8%) 29 (43.9%) 5 (25.0%) 24 (52.2%) 9 (33.3%)
 Non-staff referral 8 (6.0%) 3 (2.8%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 3 (4.5%) 1 (5.0%) 2 (4.3%) 5 (18.5%)
 Transfer from SNF 9 (6.8%) 9 (8.5%) 2 (5.0%) 1 (33.3%) 1 (2.7%) 7 (10.6%) 1 (5.0%) 6 (13.0%) 0 (0.0%)
Patient priority
 Elective 5 (3.8%) 4 (3.7%) 4 (10.0%) 1 (33.3%)** 3 (8.1%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 1 (3.7%)
 ED 39 (29.3%) 34 (32.1%) 13 (32.5%) 0 (0.0%) 13 (35.1%) 21 (31.8%) 3 (15.0%) 18 (39.1%) 5 (18.5%)
 Trauma center 74 (55.6%) 58 (54.7%) 18 (45.0%) 0 (0.0%) 18 (48.6%) 40 (60.6%) 15 (75.0%) 25 (54.3%) 16 (59.3%)
 Unknown 5 (3.8%) 4 (3.8%) 2 (5.0%) 0 (0.0%) 2 (5.4%) 2 (3.0%) 1 (5.0%) 1 (2.2%) 1 (3.7%)
 Urgent 10 (7.5%) 6 (5.7%) 3 (7.5%) 2 (66.7%) 1 (2.7%) 3 (4.5%) 1 (5.0%) 2 (4.3%) 4 (14.8%)
Primary payer
 Commercial 5 (3.8%) 3 (2.8%) 1 (2.5%) 0 (0.0%) 1 (2.7%) 2 (3.0%) 0 (0.0%) 2 (4.3%) 2 (7.4%)#
 Medicaid 8 (6.0%) 4 (3.8%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 4 (6.1%) 0 (0.0%) 4 (8.7%) 4 (14.8%)
 Medicare 110 (82.7%) 90 (84.9%) 36 (90.0%) 3 (100.0%) 33 (89.2%) 54 (81.8%) 16 (80.0%) 38 (82.6%) 20 (74.1%)
 Self-pay or other 10 (7.5%) 9 (8.5%) 3 (7.5%) 0 (0.0%) 3 (8.1%) 6 (9.1%) 4 (20.0%) 2 (4.3%) 1 (3.7%)
Severity of illness 35 ‡ †† #
 1 7 (5.5%) 7 (6.9%) 4 (10.5%) 0 (0.0%) 4 (11.4%) 3 (4.8%) 1 (5.0%) 2 (4.7%) 0 (0.0%)
 2 32 (25.0%) 30 (29.7%) 15 (39.5%) 1 (33.3%) 14 (40.0%) 15 (23.8%) 0 (0.0%) 15 (34.9%) 2 (7.4%)
 3 51 (39.8%) 38 (37.6%) 13 (34.2%) 0 (0.0%) 13 (37.1%) 25 (39.7%) 8 (40.0%) 17 (39.5%) 13 (48.1%)
 4 38 (29.7%) 26 (25.7%) 6 (15.8%) 2 (66.7%) 4 (11.4%) 20 (31.7%) 11 (55.0%) 9 (20.9%) 12 (44.4%)
Risk of mortality 36 ‡‡ †† #
 1 16 (12.5%) 15 (14.9%) 9 (23.7%) 1 (33.3%) 8 (22.9%) 6 (9.5%) 1 (5.0%) 5 (11.6%) 1 (3.7%)
 2 32 (25.0%) 26 (25.7%) 13 (34.2%) 0 (0.0%) 13 (37.1%) 13 (20.6%) 2 (10.0%) 11 (25.6%) 6 (22.2%)
 3 45 (35.2%) 36 (35.6%) 11 (28.9%) 1 (33.3%) 10 (28.6%) 25 (39.7%) 6 (30.0%) 19 (44.2%) 9 (33.3%)
 4 35 (27.3%) 24 (23.8%) 5 (13.2%) 1 (33.3%) 4 (11.4%) 19 (30.2%) 11 (55.0%) 8 (18.6%) 11 (40.7%)
*Categorical values are given as the count (percentage). Continuous variables are given as the mean ± standard deviation. Some patients had >1 injury location. Continuous variables were compared between groups using the Kruskal-Wallis rank test or Wilcoxon rank-sum test, and categorical variables were compared between groups using the likelihood-ratio chi-square test. Comparisons of admit source, patient priority, primary payer, severity of illness, and risk of mortality are made across the range of values in the group, and significant findings are only noted for the first value within the group. ICU = intensive care unit, BMI = body mass index, ECI = Elixhauser Comorbidity Index, SNF = skilled nursing facility, ED = emergency department.
†Reported counts are accurate; proportions exclude missing data from the denominator.
‡P < 0.01 versus the 27 patients with no inclusion criteria but referral by a clinician and a pause called.
§P < 0.01 versus the 27 patients with no inclusion criteria but referral by a clinician and a pause called.
#P < 0.01 versus the 40 patients with ≥1 inclusion criteria but no pause called.
**P < 0.01 versus the 37 patients with ≥1 inclusion criterion but no pause called and admission elsewhere than the ICU.
††P < 0.01 versus the 46 patients with ≥1 inclusion criterion, a pause called, and admission elsewhere than the ICU.
‡‡P < 0.01 versus the 66 patients with ≥1 inclusion criterion and a pause called.

Of the 106 patients who met ≥1 inclusion criterion, patients with an SP were less mobile (56.3% versus 25.0%, p = 0.001) and had a higher predicted risk of mortality (30.2% versus 13.2% in the highest risk category, p = 0.034). Inclusion criteria-eligible patients with SP were also more likely to be admitted to the ICU (30.3% versus 7.5%, p = 0.003). Compared with patients who met ≥1 inclusion criterion but for whom an SP was not called (n = 40), patients referred by clinician request (n = 27) were younger (65.8 ± 11.3 versus 82.9 ± 11.2 years, p < 0.001), more mobile (100% versus 75%, p < 0.001), and less likely to reside in an SNF (0.0% versus 17.5%), and had a higher severity of illness and risk of mortality (44.4% versus 15.8% and 40.7% versus 13.2%, respectively, in the highest category; p < 0.001 for both).

GOC Documentation

GOC notes were identified for 111 (83.5%) of the 133 patients, and were recorded in the appropriate location using the mandated note template for 70 (52.6%). Of all notes regardless of location, 85 (63.9%) achieved a global quality rating indicating a high overall effort to clarify goals, even though only 29 (21.8%) included all 4 quality indicators (Table II). Of the 106 patients who met ≥1 SP criterion, GOC notes were more frequently identified (92.4% versus 75.0%, p = 0.014) and recorded in the appropriate location (71.2% versus 27.5%, p < 0.001) in patients with an SP compared with patients without an SP. The notes for these 66 SP patients were also of higher quality, with 77.3% versus 45.0% representing a high overall effort at goal clarification (p < 0.001), and more likely to document prognosis (47.0% versus 20.0%, p = 0.004), values/goals (51.5% versus 25.0%, p = 0.004), and decision-making (65.2% versus 37.5%, p = 0.005). However, there was no significant difference in the proportion of notes documenting all of the quality indicators, which was low among those with and without an SP (25.8% versus 15%, p = 0.184) (Table II).

TABLE II - Goals-of-Care Documentation Stratified by Inclusion Criteria, Whether a Surgical Pause Was Called, and ICU Admission Status*
All Study Participants ≥1 Inclusion Criterion Met ≥1 Inclusion Criterion Met but Pause not Called ≥1 Inclusion Criterion Met and Pause Called No Inclusion Criteria but Referred by Clinician and Pause Called
All Admitted to ICU Admitted Elsewhere than ICU All Admitted to ICU Admitted Elsewhere than ICU
No. 133 106 40 3† 37† 66 20† 46† 27
Note identified 111 (83.5%) 91 (85.8%) 30 (75.0%)† 0 (0.0%)‡ 30 (81.1%) 61 (92.4%)§ 17 (85.0%) 44 (95.7%) 20 (74.1%)
Note in appropriate location 70 (52.6%) 58 (54.7%) 11 (27.5%)† 0 (0.0%) 11 (29.7%) 47 (71.2%)§ 14 (70.0%) 33 (71.7%) 12 (44.4%)
Global quality rating 85 (63.9%) 69 (65.1%) 18 (45.0%)† 0 (0.0%) 18 (48.6%) 51 (77.3%) 15 (75.0%) 36 (78.3%) 16 (59.3%)
Individual quality indicators
 Prognosis 49 (36.8%) 39 (36.8%) 8 (20.0%)† 0 (0.0%) 8 (21.6%) 31 (47.0%) 12 (60.0%) 19 (41.3%) 10 (37.0%)
 Patient values/goals 53 (39.8%) 44 (41.5%) 10 (25.0%)† 0 (0.0%) 10 (27.0%) 34 (51.5%) 9 (45.0%) 25 (54.3%) 9 (33.3%)
 What to do next 99 (74.4%) 82 (77.4%) 27 (67.5%) 0 (0.0%)‡ 27 (73.0%) 55 (83.3%)§ 17 (85.0%) 38 (82.6%) 17 (63.0%)
 Decision-making 69 (51.9%) 58 (54.7%) 15 (37.5%)† 0 (0.0%) 15 (40.5%) 43 (65.2%)§ 16 (80.0%) 27 (58.7%) 11 (40.7%)
Any quality indicator 105 (78.9%) 88 (83.0%)# 29 (72.5%)† 0 (0.0%)‡ 29 (78.4%) 59 (89.4%)§ 17 (85.0%) 42 (91.3%) 17 (63.0%)
All 4 quality indicators 29 (21.8%) 23 (21.7%) 6 (15.0%) 0 (0.0%) 6 (16.2%) 17 (25.8%) 7 (35.0%) 10 (21.7%) 6 (22.2%)
*The values are given as the number (percentage). ICU = intensive care unit. †Calculations exclude missing values. P values are from the likelihood-ratio chi-square test. There were no significant differences between the 40 patients with ≥1 inclusion criterion but no pause called and the 27 patients with no inclusion criteria but referral by a clinician and a pause called. There were also no significant differences between the 20 patients with ≥1 inclusion criterion met, a pause called, and admission to the ICU and the 46 patients with ≥1 inclusion criterion met, a pause called, and admission elsewhere than the ICU.
†P < 0.03 versus the 66 patients with ≥1 inclusion criterion and a pause called.
‡P < 0.03 versus the 46 patients with ≥1 inclusion criterion met, a pause called, and admission elsewhere than the ICU.
§P < 0.03 versus the 27 patients with no inclusion criteria but referral by a clinician and a pause called.
#P < 0.03 versus the 37 patients with ≥1 inclusion criterion but no pause called and admission elsewhere than the ICU.

The 66 eligible patients with an SP had significantly higher rates of appropriately located documentation (71.2% versus 44.4%, p = 0.016) and documentation of any of the 4 quality indicators (89.4% versus 63.0%, p = 0.004) compared with the 27 patients included by clinician referral (Table II). However, there were no significant differences in the rates or quality of documentation between the 40 eligible patients without an SP and the 27 patients included by clinician referral (Table II). There was no documentation of GOC discussion for the 3 eligible patients admitted to the ICU who did not have an SP called.

The most frequently documented quality indicator involved what to do next (74.4%), and this indicator was found in 93.3% (28) of the 30 notes that documented only 1 quality indicator. The next most frequently documented indicator was a description of the decision-making, which was found in 51.9% of the notes overall and 25% (11) of the 44 notes that documented only 2 quality indicators. Prognosis and values/goals were less frequently documented, appearing in only 36.8% and 39.8% of notes, respectively; among the notes documenting only 3 quality indicators, these factors appeared in only 26.3% (20) and 31.6% (24) of 76, respectively.

Clinical Outcomes

Among all patients, the median length of stay (and interquartile range width) was 9.0 (6.0) days; 19 (16.4%) were readmitted and 4 (3.3%) died within 30 days (Table III). Among the 106 SP-eligible patients, there were no significant differences in mortality rates between those with (n = 66) and without (n = 40) an SP, although the rates were nominally higher in the group with an SP (10.6% versus 5.0%, 5.1% versus 0.0%, and 14.3% versus 7.9% for in-hospital, 30-day, and 90-day mortality, respectively; p > 0.08 for all). No significant differences in length of stay, readmission, or adverse events were seen between eligible patients with and without an SP (Table III). Compared with patients meeting the inclusion criteria who had an SP (n = 66), those referred for an SP by clinician request (n = 27) had a longer hospital length of stay (median, 12.0 versus 7.0 days; p < 0.001) and higher rates of pneumonia (29.6% versus 10.6%, p = 0.030).

TABLE III - Clinical Outcomes Stratified by Inclusion Criteria, Whether a Surgical Pause Was Called, and Whether Surgery Was Performed*
Characteristic All Study Participants ≥1 Inclusion Criterion Met ≥1 Inclusion Criterion Met but Pause not Called Pause Called
All Surgery No Surgery ≥1 Inclusion Criterion Met No Inclusion Criteria but Referred by Clinician All Surgery No Surgery
No. 133 106 40 33† 7† 66 27 93† 58† 35†
Mortality‡
 In hospital 13 (9.8%) 9 (8.5%) 2 (5.0%) 1 (3.0%) 1 (14.3%) 7 (10.6%) 4 (14.8%) 11 (12.0%) 5 (8.6%) 6 (17.1%)
 30 days† 4 (3.3%) 3 (3.1%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 3 (5.1%) 1 (4.3%) 4 (4.9%) 2 (3.8%) 2 (6.9%)
 90 days† 13 (11.2%) 11 (11.7%) 3 (7.9%) 2 (6.3%) 1 (16.7%) 8 (14.3%) 2 (9.1%) 10 (12.8%) 3 (6.0%)‡ 7 (25.0%)
Readmission§
 3 days† 3 (2.5%) 2 (2.1%) 2 (5.3%) 2 (6.3%) 0 (0.0%) 0 (0.0%) 1 (4.3%) 1 (1.2%) 1 (1.9%) 0 (0.0%)
 7 days† 8 (6.7%) 4 (4.2%) 3 (7.9%) 2 (6.3%) 1 (16.7%) 1 (1.7%)§ 4 (17.4%) 5 (6.2%) 4 (7.5%) 1 (3.6%)
 30 days† 19 (16.4%) 12 (12.8%) 5 (13.2%) 3 (9.4%) 2 (33.3%) 7 (12.5%) 7 (31.8%) 14 (17.9%) 10 (19.6%) 4 (14.8%)
ED visit§
 7 days† 4 (3.4%) 4 (4.2%) 2 (5.3%) 2 (6.3%) 0 (0.0%) 2 (3.4%) 0 (0.0%) 2 (2.5%) 2 (3.8%) 0 (0.0%)
 30 days† 11 (9.5%) 9 (9.6%) 5 (13.2%) 5 (15.6%) 0 (0.0%) 4 (7.1%) 2 (9.1%) 6 (7.7%) 6 (11.8%)‡ 0 (0.0%)
Length of stay (d)
 Hospital 9.0 (6.0) 8.0 (6.0)# 8.5 (4.5) 9.0 (5.0)** 4.0 (7.0) 7.0 (7.0)§ 12.0 (8.0)†† 9.0 (7.0) 10.0 (8.0)‡ 7.0 (7.0%)
ICU 2.6 (3.6) 2.1 (2.8)# 1.5 (1.7) 1.5 (1.7) NA 2.5 (2.9) 3.9 (4.2) †† 2.8 (3.9) 2.8 (4.3) 1.3 (3.3%)
Surgical delay (hr) NA NA NA 19.7 (13.9) NA NA NA NA 47.2 (48.8) NA
AE, not surgery-specific
 Prolonged wound drainage 14 (10.5%) 10 (9.4%) 1 (2.5%)‡‡ 1 (3.0%) 0 (0.0%) 9 (13.6%) 4 (14.8%) 13 (14.0%)‡‡ 11 (19.0%)‡ 2 (5.7%)
 DVT 3 (2.3%) 1 (0.9%) 1 (2.5%) 1 (3.0%) 0 (0.0%) 0 (0.0%)§ 2 (7.4%) 2 (2.2%) 1 (1.7%) 1 (2.9%)
 PE 2 (1.5%) 0 (0.0%)# 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%)§ 2 (7.4%) 2 (2.2%) 2 (3.4%) 0 (0.0%)
 MI 1 (0.8%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 1 (3.7%) 1 (1.1%) 0 (0.0%) 1 (2.9%)
 CVA 1 (0.8%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 1 (3.7%) 1 (1.1%) 0 (0.0%) 1 (2.9%)
 Respiratory distress 26 (19.5%) 20 (18.9%) 7 (17.5%) 5 (15.2%) 2 (28.6%) 13 (19.7%) 6 (22.2%) 19 (20.4%) 13 (22.4%) 6 (17.1%)
 Renal failure/dialysis 2 (1.5%) 1 (0.9%) 1 (2.5%) 1 (3.0%) 0 (0.0%) 0 (0.0%) 1 (3.7%) 1 (1.1%) 1 (1.7%) 0 (0.0%)
 Aspiration 9 (6.8%) 8 (7.5%) 4 (10.0%) 2 (6.1%) 2 (28.6%) 4 (6.1%) 1 (3.7%) 5 (5.4%) 3 (5.2%) 2 (5.7%)
 Pneumonia 18 (13.5%) 10 (9.4%)# 3 (7.5%) 2 (6.1%) 1 (14.3%) 7 (10.6%) 8 (29.6%)†† 15 (16.1%) 10 (17.2%) 5 (14.3%)
 Reintubation 4 (3.0%) 3 (2.8%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 3 (4.5%) 1 (3.7%) 4 (4.3%) 4 (6.9%)‡ 0 (0.0%)
 Hardware failure 2 (1.5%) 0 (0.0%)# 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%)§ 2 (7.4%) 2 (2.2%) 2 (3.4%) 0 (0.0%)
 ≥1 non-specific AE 50 (37.6%) 34 (32.1%)# 12 (30.0%) 9 (27.3%) 3 (42.9%) 22 (33.3%)§ 16 (59.3%)†† 38 (40.9%) 27 (46.6%) 11 (31.4%)
AE, surgery-specific†
 Surgical site infection 6/91 (6.6%) 5/70 (7.1%) 2/33 (6.1%) 2/33 (6.1%) NA 3/37 (8.1%) 1/21 (4.8%) 4/58 (6.9%) 4/58 (6.9%) NA
 Return to OR 9/91 (9.9%) 5/70 (7.1%) 1/33 (3.0%) 1/33 (3.0%) NA 4/37 (10.8%) 4/21 (19.0%) 8/58 (13.8%) 8/58 (13.8%) NA
 ≥1 surgery-specific AE 15/91 (16.5%) 10/70 (14.3%) 3/33 (9.1%) 3/33 (9.1%) NA 7/37 (18.9%) 5/21 (23.8%) 12/58 (20.7%) 12/58 (20.7%) NA
Discharge disposition
 SNF 77 (57.9%) 66 (62.3%) 25 (62.5%) 23 (69.7%)** 2 (28.6%) 41 (62.1%) 11 (40.7%) 52 (55.9%) 37 (63.8%)‡ 15 (42.9%)
 Home health agency 15 (11.3%) 10 (9.4%) 4 (10.0%) 1 (3.0%)** 3 (42.9%) 6 (9.1%) 5 (18.5%) 11 (11.8%) 8 (13.8%)‡ 3 (8.6%)
 Death in hospital 13 (9.8%) 9 (8.5%) 2 (5.0%) 1 (3.0%)** 1 (14.3%) 7 (10.6%) 4 (14.8%) 11 (11.8%) 5 (8.6%)‡ 6 (17.1%)
 Rehabilitation facility 12 (9.0%) 9 (8.5%) 6 (15.0%) 6 (18.2%)** 0 (0.0%) 3 (4.6%) 3 (11.1%) 6 (6.5%) 5 (8.6%)‡ 1 (2.9%)
 Hospice at home 6 (4.5%) 3 (2.8%) 1 (2.5%) 1 (3.0%)** 0 (0.0%) 2 (3.0%) 3 (11.1%) 5 (5.4%) 0 (0.0%)‡ 5 (14.3%)
 Home/self-care 3 (2.3%) 3 (2.8%) 1 (2.5%) 0 (0.0%)** 1 (14.3%) 2 (3.0%) 0 (0.0%) 2 (2.2%) 1 (1.7%)‡ 1 (2.9%)
 Hospice at medical facility 2 (1.5%) 1 (0.9%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 1 (1.5%) 1 (3.7%) 2 (2.2%) 0 (0.0%)‡ 2 (5.7%)
 Long-term hospital 2 (1.5%) 2 (1.9%) 1 (2.5%) 1 (3.0%)** 0 (0.0%) 1 (1.5%) 0 (0.0%) 1 (1.1%) 1 (1.7%)‡ 0 (0.0%)
 Short-term hospital 2 (1.5%) 2 (1.9%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 2 (3.0%) 0 (0.0%) 2 (2.2%) 0 (0.0%)‡ 2 (5.7%)
 Psychiatric hospital/unit 1 (0.8%) 1 (0.9%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 1 (1.5%) 0 (0.0%) 1 (1.1%) 1 (1.7%)‡ 0 (0.0%)
*Categorical values are given as the count (percentage). Continuous variables are given as the mean ± standard deviation or median (interquartile range width). Mortality is measured from admission, whereas all readmission and ED times are measured from discharge. Length of stay in the ICU is based on only those patients who stayed in the ICU at any time. Surgical delay is defined as the time between initial presentation and the start of surgery for those patients having surgery. Continuous variables were compared between groups using the Kruskal-Wallis rank test or Wilcoxon rank-sum test, and categorical variables were compared between groups using the likelihood-ratio chi-square test. ED = emergency department, ICU = intensive care unit, NA = not applicable (due to either no surgery or no admission), AE = adverse event, DVT = deep vein thrombosis, PE = pulmonary embolus, MI = myocardial infarction, CVA = cerebrovascular accident, OR = operating room, SNF = skilled nursing facility.
†Calculations exclude missing values. For 30-day mortality, 90-day mortality, all readmissions, and all ED utilization outcomes, the 13 patients with in-hospital mortality were excluded. For all readmission and ED utilization outcomes, any patient who died before the measurement timeframe was excluded from the calculation.
‡P < 0.05 versus the 35 patients with a pause called but no surgery.
§P < 0.05 versus the 27 patients with no inclusion criteria but referral by a clinician and a pause called.
#P < 0.05 versus the 27 patients with no inclusion criteria but referral by a clinician and a pause called.
**P < 0.05 versus the 7 patients with ≥1 inclusion criterion but no pause called and no surgery.
††P < 0.05 versus the 40 patients with ≥1 inclusion criterion but no pause called.
‡‡P < 0.05 versus the 66 patients with ≥1 inclusion criterion and a pause called.
§§P < 0.05 versus the patients with ≥1 inclusion criterion but no pause called.

Operative Versus Nonoperative Management

Of the 93 patients for whom an SP was called, 58 (62.4%) elected operative management and 35 (37.6%) opted nonoperative management. The median delay from presentation to surgery was 47.2 hours for the 58 patients electing surgery compared with 19.7 hours for the 33 patients who had surgery without an SP. Patients with an SP who elected surgery experienced more 30-day returns to the ED (11.8% versus 0%, p = 0.023) compared with those who elected nonoperative management (Table III). In contrast, patients electing nonoperative management had a shorter median length of stay (7.0 versus 10.0 days, p = 0.004) despite more frequent admissions to the ICU (50% versus 20.7%, p = 0.015; data not shown). Patients managed nonoperatively were more likely to die within 90 days (25.0% versus 6.0%), which is consistent with their greater pre-injury lack of mobility (65.6% versus 40.0%, p < 0.001; data not shown) and greater likelihood of residence in an SNF (42.4% versus 22.0%, p < 0.001; data not shown). Operatively managed patients were more likely to be discharged to a skilled nursing facility (p < 0.01) compared with nonoperatively managed patients (Table III).

Discussion

This project sought to evaluate the impact of a complex, preoperative, multidisciplinary behavioral intervention aimed at ensuring goal-concordant treatment and risk assessment for high-risk orthopaedic trauma patients. Our primary finding was that an SP increased the frequency and quality of GOC documentation by a clinically important and statistically significant amount. We also observed an increased rate of nonoperative management after an SP compared with similar patients without an SP. These data further suggest that, for eligible patients, an SP may avoid unwanted surgery and increase goal-concordant care without clinically important increases in adverse events or estimated mortality rates.

Our findings provide new data on the feasibility and utility of a standardized program for rapid multidisciplinary review of high-risk patients with acute orthopaedic trauma. Our pilot study found that the first 24 to 48 hours after injury in such patients without life- or limb-threatening conditions may be used for risk assessment, goal clarification, and shared decision-making. The SP procedures did extend the time between presentation and the start of surgery, but not beyond the 48-hour window associated with optimal outcomes and recommended by the American Academy of Orthopaedic Surgeons40. The required time for such a program has not been previously quantified, to our knowledge. The current study and prior investigations on risk stratification and shared decision-making have indicated that multidisciplinary review before high-risk surgery is safe and may potentially improve outcomes, including goal-concordant care. For example, Grigoryan et al. performed a meta-analysis of outcomes associated with orthopaedic surgery and geriatric co-management services that demonstrated a significant reduction in in-hospital mortality (relative risk [RR], 0.60 [95% confidence interval, 0.43 to 0.84]) and long-term mortality (RR, 0.83 [95% confidence interval, 0.74 to 0.94])41.

Clinical Implications

There are latent system-level pressures that contribute to the provision of risky and undesired invasive medical care42. Patients with an SP had a higher rate of nonoperative management compared with similar patients without an SP, suggesting that as many as one-third of eligible patients are at risk for undergoing goal-discordant surgery in the absence of an SP. We also observed improved GOC documentation, which may in turn provide objective evidence of advance care planning services for Medicaid billing. The opportunity for goal clarification and nonoperative management of select patients is reinforced by a recent multicenter study from the Netherlands examining a standardized shared decision-making process for frail patients with proximal femoral fractures43. More than half (88) of the 172 enrolled patients elected nonoperative management, and these patients were compared with the 84 patients managed with surgery in a noninferiority analysis; their quality of life was not significantly different and they had a lower rate of adverse events. Thirty-day mortality was higher in the nonoperative group (83% versus 25%), but treatment satisfaction was high and the surviving family members of the deceased rated the quality of dying as good to almost perfect.

Geriatric multidisciplinary intervention programs have been safely implemented for patients with hip fractures in nations with national health-care networks, including Austria, Japan, the United Kingdom, and Denmark44–48. The Own the Bone intervention program provides evidence of the translatability of such programs to the uniquely organized and financed health-care system in the United States49,50, and in a similar program by Gregersen et al., the implementation of a multidisciplinary geriatric intervention was not associated with increased rates of perioperative adverse events44,51. The SP program’s focus on goal clarification before deciding whether to have surgery is distinct from any of the interventions facilitated by Own the Bone, and it may thus serve as an important adjunct that could augment the suite of services delivered through Own the Bone.

Strengths and Limitations

Strengths of our study include the use of a prospective, longitudinal design with at least 90 days of patient follow-up. Limitations include missing data in patients with in-hospital mortality and inconsistent initiation of the intervention. A sample of convenience was used, and the resulting relatively small sample size precluded multivariable modeling. The sample size might also explain why some of the nominally different outcome rates did not reach significance. These nominal differences may warrant exploration in a larger sample that could support multivariable adjustment. Furthermore, some of the event rates were low or zero, limiting the reliability of the resulting estimates; a larger sample would better establish low but detectable event rates. The sample was also heterogeneous with regard to injury types, and further research in a larger sample is needed for a meaningful analysis of injury subgroups. Heterogeneity and limited sample size also precluded reliable estimates of the financial implications of the intervention, and this could be the focus of future research. It was also beyond the scope of this project to analyze qualitative details regarding the interaction between patient and clinician that culminated in the treatment decision; collection and analysis of such qualitative information would permit future studies to examine patient (and provider) satisfaction as well as provide a more detailed understanding of the decision-making process. Finally, biases may have been introduced by including patients on the basis of clinician referral and by the subjective rating of GOC documentation, although the codebook definitions were designed to minimize bias resulting from the latter.

Conclusion

The SP pilot program was shown to be a feasible and effective means of increasing the quality and frequency of GOC documentation in high-risk operative candidates with traumatic orthopaedic injuries that are neither life- nor limb-threatening. The aim of the multidisciplinary program is goal-concordant treatment plans that minimize modifiable perioperative risks.

Appendix

Supporting material provided by the authors is posted with the online version of this article as a data supplement at jbjs.org (https://links.lww.com/JBJSOA/A505).

Note: The authors thank Megan E. Metcalf, BS, Jared S. Weiner, MBA, Adam Brideweser, BS, Peter A. Siska, MD, Ivan S. Tarkin, MD, Raquel M. Forsythe, MD, Christina Tedesco, BSN, RN, and Tamra Minnier, MSN, for their efforts in advancing the surgical pause program.

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