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Frailty screening and a frailty pathway decrease length of stay, loss of independence, and 30-day readmission rates in frail geriatric trauma and emergency general surgery patients

Engelhardt, Kathryn E., MD; Reuter, Quentin, MD; Liu, Jessica, MD; Bean, Jonathan F., MD; Barnum, Joliette, MD; Shapiro, Michael B., MD; Ambre, Allison, DPT; Dunbar, Amanda; Markzon, Mara; Reddy, Tara N., MD; Schilling, Christine, MFS; Posluszny, Joseph A. Jr., MD

Journal of Trauma and Acute Care Surgery: July 2018 - Volume 85 - Issue 1 - p 167–173
doi: 10.1097/TA.0000000000001931
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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; χ2 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.

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.

Submitted: December 1, 2017, Revised: March 20, 2018, Accepted: March 21, 2018, Published online: April 16, 2018.

Presented at the 31st Eastern Association for the Surgery of Trauma Annual Meeting, January 9–13, 2018 in Lake Buena Vista, Florida.

Address for reprints: Joseph Posluszny, MD, Assistant Professor of Surgery, Northwestern University, 676 N Saint Clair, Ste 650, Chicago, IL 60611; email: Joseph.Posluszny@nm.org.

© 2018 Lippincott Williams & Wilkins, Inc.