Frailty Interdisciplinary Pathway: Compliance and Sustainability in a Level I Trauma Center.

BACKGROUND: Frailty is a state of physiological vulnerability that predisposes many older adult trauma patients to poor health outcomes. Specialized care pathways for frail trauma patients have been shown to improve outcomes, but the compliance and sustainability of these pathways have not been reported (Bryant et al., 2019; Engelhardt et al., 2018). METHODS: We retrospectively measured compliance and sustainability during the first 2 years of a frailty pathway for patients 65 years or older at an urban Level I trauma center. Compliance to 19 pathway elements was collected for 279 pathway patients between October 1, 2016, and September 30, 2018. Compliance was analyzed and reported as a percentage of the total possible times each element could have been completed per pathway guidelines. Benchmark compliance was 75% or more. RESULTS: Retrospective 2-year mean overall compliance to all pathway elements was 68.2% and improved from Year 1 (65.0%) to Year 2 (71.4%). Seven elements achieved a mean 75% or more compliance over the 2-year period: frailty screening on admission (92.8%), consultation requests for physical therapy (97.9%), geriatrics (96.2%), and nutrition (92.3%), consultant care within 72 hr of admission (78.0%), delirium screening 3 times daily (76.3%), and daily senna administration (76.0%). Compliance to 10 elements significantly improved from Year 1 to Year 2 and significantly worsened in 2 elements. CONCLUSION: Many standardized geriatric care processes for frail older adult trauma patients can be successfully integrated into routine daily inpatient practice and sustained over time. Multicenter studies are needed to demonstrate how to improve compliance and to understand better which pathway elements are most effective.

Identifying Population-Level and Within-Hospital Disparities in Surgical Care.

INTRODUCTION: The lack of consensus on equity measurement and its incorporation into quality-assessment programs at the hospital and system levels may be a barrier to addressing disparities in surgical care. This study aimed to identify population-level and within-hospital differences in the quality of surgical care provision. METHODS: The analysis included 657 National Surgical Quality Improvement Program participating hospitals with over 4 million patients (2014-2018). Multi-level random slope, random intercept modeling was used to examine for population-level and in-hospital disparities. Disparities in surgical care by Area Deprivation Index (ADI), race, and ethnicity were analyzed for five measures: all-case inpatient mortality, all-case urgent readmission, all-case postoperative surgical site infection, colectomy mortality, and spine surgery complications. RESULTS: Population-level disparities were identified across all measures by ADI, two measures for Black race (all-case readmissions and spine surgery complications), and none for Hispanic ethnicity. Disparities remained significant in the adjusted models. Prior to risk-adjustment, in all measures examined, within-hospital disparities were detected in: 25.8-99.8% of hospitals for ADI, 0-6.1% of hospitals for Black race, and 0-0.8% of hospitals for Hispanic ethnicity. Following risk-adjustment, in all measures examined, fewer than 1.1% of hospitals demonstrated disparities by ADI, race, or ethnicity. CONCLUSIONS: Following risk adjustment, very few hospitals demonstrated significant disparities in care. Disparities were more frequently detected by ADI than by race and ethnicity. The lack of substantial in-hospital disparities may be due to the use of postoperative metrics, small sample sizes, the risk adjustment methodology, and healthcare segregation. Further work should examine surgical access and healthcare segregation.

Geospatial Analysis of Access to Emergency Cesarean Delivery for Military and Civilian Populations in the US.

Importance: Many women in the US, particularly those living in rural areas, have limited access to obstetric care. Military-civilian partnership could improve access to obstetric care and benefit military personnel, their civilian dependents, and the civilian population as a whole. Objective: To identify medical facilities within military and civilian geographic areas that present opportunities for military-civilian partnership in obstetric care and to assess whether civilian use of military medical treatment facilities (MTFs) could improve access to emergency cesarean delivery care in the US. Design, Setting, and Participants: This geospatial epidemiological population-based cross-sectional study was conducted from November 2020 to March 2021. ArcGIS Pro software, version 2.7 (Esri), was used to assess population coverage for TRICARE (military insurance) beneficiaries and civilian populations and to estimate 30-minute travel time to 2392 total military and civilian medical facilities that were capable of providing emergency cesarean delivery care in the continental US. Data on health insurance coverage for TRICARE beneficiaries and their civilian dependents per county were obtained from the American Community Survey tables available through ArcGIS Pro software. Demographic characteristics of the general population were obtained from the 2020 key demographic indicators published by Esri. Race and ethnicity were not examined because the data used for this study were aggregated and did not include further categorization by race or ethnicity. Main Outcomes and Measures: Population coverage rates (measured in percentages) within 30-minute catchment areas, defined as areas that were within a 30-minute travel time to a medical facility capable of providing emergency cesarean delivery care. Results: A total of 29 MTFs and 2363 civilian hospitals capable of providing emergency cesarean delivery were identified across the contiguous US. Overall, an estimated 167 759 762 women (3 640 000 TRICARE beneficiaries and 164 119 762 civilians) were included in these service areas. The analysis identified 17 of 29 MTFs (58.6%) capable of providing emergency cesarean delivery care that were located within 30-minute catchment areas. Of those, 3 MTFs were the only facilities capable of providing emergency cesarean delivery care within a 30-minute travel time in those regions, and 14 additional MTFs had catchment areas partially overlapping with civilian hospitals that also covered areas without alternative access to emergency cesarean delivery. Expanded use of these 14 MTFs could enhance access to emergency cesarean delivery care not otherwise covered by current civilian hospitals. Conclusions and Relevance: In this study, 58.6% of MTFs capable of providing emergency cesarean delivery care were located in areas with the potential to improve access to obstetric care within a 30-minute travel time. Maintenance of MTFs in these important access regions could be prioritized in the context of restructuring MTFs. This prioritization has the potential to improve access to emergency cesarean delivery care for underserved civilian populations in the US, particularly among those living in rural areas.

Frailty Identification and Care Pathway: An Interdisciplinary Approach to Care for Older Trauma Patients.

BACKGROUND: Frailty is a well-established marker of poor outcomes in geriatric trauma patients. There are few interventions to improve outcomes in this growing population. Our goal was to determine if an interdisciplinary care pathway for frail trauma patients improved in-hospital mortality, complications, and 30-day readmissions. STUDY DESIGN: This was a retrospective cohort study of frail patients ≥65 years old, admitted to the trauma service at an academic, urban level I trauma center between 2015 and 2017. Patients transferred to other services and those who died within the first 24 hours were excluded. An interdisciplinary protocol for frail trauma patients, including early ambulation, bowel/pain regimens, nonpharmacologic delirium prevention, nutrition/physical therapy consults, and geriatrics assessments, was implemented in 2016. Our main outcomes were delirium, complications, in-hospital mortality, and 30-day readmission, which were compared with these outcomes in patients treated the year before the pathway was implemented. Multivariate logistic regression was used to determine the association of being on the pathway with outcomes. RESULTS: There were 125 and 144 frail patients in the pre- and post-intervention cohorts, respectively. There were no significant demographic differences between the 2 groups. Among both groups, the mean age was 83.51 years (SD 7.11 years), 60.59% were female, and median Injury Severity Score was 10 (interquartile range 9 to 14). In univariate analysis, there were no significant differences in complications (28.0% vs 28.5%, respectively, p = 0.93); however, there was a significant decrease in delirium (21.6% to 12.5%, respectively, p = 0.04) and 30-day readmission (9.6% to 2.7%, respectively, p = 0.01). After adjusting for patient characteristics, patients on the pathway had lower delirium (odds ratio [OR] 0.44, 95% CI 0.22 to 0.88, p = 0.02) and 30-day readmission rates (OR 0.25, 95% CI 0.07 to 0.84, p = 0.02), than pre-pathway patients. CONCLUSIONS: An interdisciplinary care protocol for frail geriatric trauma patients significantly decreases their delirium and 30-day readmission risk. Implementing pathways standardizing care for these vulnerable patients could improve their outcomes after trauma.