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Effect of a Modified Hospital Elder Life Program on Delirium and Length of Hospital Stay in Patients Undergoing Abdominal Surgery: A Cluster Randomized Clinical Trial.
JAMA Surg 2017; 152(9):827-834JS

Abstract

Importance

Older patients undergoing abdominal surgery commonly experience preventable delirium, which extends their hospital length of stay (LOS).

Objective

To examine whether a modified Hospital Elder Life Program (mHELP) reduces incident delirium and LOS in older patients undergoing abdominal surgery.

Design, Setting, and Participants

This cluster randomized clinical trial of 577 eligible patients enrolled 377 older patients (≥65 years of age) undergoing gastrectomy, pancreaticoduodenectomy, and colectomy at a 2000-bed urban medical center in Taipei, Taiwan, from August 1, 2009, through October 31, 2012. Consecutive older patients scheduled for elective abdominal surgery with expected LOS longer than 6 days were enrolled, with a recruitment rate of 65.3%. Participants were cluster randomized by room to receive the mHELP or usual care.

Interventions

The intervention (implemented by an mHELP nurse) consisted of 3 protocols administered daily: orienting communication, oral and nutritional assistance, and early mobilization. Intervention group participants received all 3 mHELP protocols postoperatively, in addition to usual care, as soon as they arrived in the inpatient ward and until hospital discharge. Adherence to protocols was tracked daily.

Main Outcomes and Measures

Presence of delirium was assessed daily by 2 trained nurses who were masked to intervention status by using the Confusion Assessment Method. Data on LOS were abstracted from the medical record.

Results

Of 577 eligible patients, 377 (65.3%) were enrolled and randomly assigned to the mHELP (n = 197; mean [SD] age, 74.3 [5.8] years; 111 [56.4%] male) or control (n = 180; mean [SD] age, 74.8 [6.0] years; 103 [57.2%] male) group. Postoperative delirium occurred in 13 of 196 (6.6%) mHELP participants vs 27 of 179 (15.1%) control individuals, representing a relative risk of 0.44 in the mHELP group (95% CI, 0.23-0.83; P = .008). Intervention group participants received the mHELP for a median of 7 days (interquartile range, 6-10 days) and had a shorter median LOS (12.0 days) than control participants (14.0 days) (P = .04).

Conclusions and Relevance

For older patients undergoing abdominal surgery who received the mHELP, the odds of delirium were reduced by 56% and LOS was reduced by 2 days. Our findings support using the mHELP to advance postoperative care for older patients undergoing major abdominal surgery.

Trial Registration

clinicaltrials.gov Identifier: NCT01045330.

Authors+Show Affiliations

Department of Nursing, College of Medicine, National Taiwan University, Taipei, Taiwan. Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan.Department of Nursing, College of Medicine, National Taiwan University, Taipei, Taiwan. Department of Nursing, Sijhih Cathy General Hospital, New Taipei City, Taiwan.Department of Surgery, College of Medicine, National Taiwan University, Taipei, Taiwan. Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan.Department of Surgery, College of Medicine, National Taiwan University, Taipei, Taiwan. Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan.Institute of Statistics, National Chiao Tung University, Hsinchu, Taiwan.Taiwan Center for Disease Control, Taipei, Taiwan.Department of Surgery, College of Medicine, National Taiwan University, Taipei, Taiwan. Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan.Department of Surgery, College of Medicine, National Taiwan University, Taipei, Taiwan. Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan.Department of Surgery, College of Medicine, National Taiwan University, Taipei, Taiwan. Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan.Department of Surgery, College of Medicine, National Taiwan University, Taipei, Taiwan. Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan.Department of Surgery, College of Medicine, National Taiwan University, Taipei, Taiwan. Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan.Department of Surgery, College of Medicine, National Taiwan University, Taipei, Taiwan. Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan.Institute of Statistics, National Chiao Tung University, Hsinchu, Taiwan.Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts. Institute for Aging Research, Hebrew Senior-Life, Boston, Massachusetts.

Pub Type(s)

Journal Article
Randomized Controlled Trial

Language

eng

PubMed ID

28538964

Citation

Chen, Cheryl Chia-Hui, et al. "Effect of a Modified Hospital Elder Life Program On Delirium and Length of Hospital Stay in Patients Undergoing Abdominal Surgery: a Cluster Randomized Clinical Trial." JAMA Surgery, vol. 152, no. 9, 2017, pp. 827-834.
Chen CC, Li HC, Liang JT, et al. Effect of a Modified Hospital Elder Life Program on Delirium and Length of Hospital Stay in Patients Undergoing Abdominal Surgery: A Cluster Randomized Clinical Trial. JAMA Surg. 2017;152(9):827-834.
Chen, C. C., Li, H. C., Liang, J. T., Lai, I. R., Purnomo, J. D. T., Yang, Y. T., ... Inouye, S. K. (2017). Effect of a Modified Hospital Elder Life Program on Delirium and Length of Hospital Stay in Patients Undergoing Abdominal Surgery: A Cluster Randomized Clinical Trial. JAMA Surgery, 152(9), pp. 827-834. doi:10.1001/jamasurg.2017.1083.
Chen CC, et al. Effect of a Modified Hospital Elder Life Program On Delirium and Length of Hospital Stay in Patients Undergoing Abdominal Surgery: a Cluster Randomized Clinical Trial. JAMA Surg. 2017 Sep 1;152(9):827-834. PubMed PMID: 28538964.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Effect of a Modified Hospital Elder Life Program on Delirium and Length of Hospital Stay in Patients Undergoing Abdominal Surgery: A Cluster Randomized Clinical Trial. AU - Chen,Cheryl Chia-Hui, AU - Li,Hsiu-Ching, AU - Liang,Jin-Tung, AU - Lai,I-Rue, AU - Purnomo,Jerry Dwi Trijoyo, AU - Yang,Yi-Ting, AU - Lin,Been-Ren, AU - Huang,John, AU - Yang,Ching-Yao, AU - Tien,Yu-Wen, AU - Chen,Chiung-Nien, AU - Lin,Ming-Tsan, AU - Huang,Guan-Hua, AU - Inouye,Sharon K, PY - 2017/5/26/pubmed PY - 2017/10/3/medline PY - 2017/5/25/entrez SP - 827 EP - 834 JF - JAMA surgery JO - JAMA Surg VL - 152 IS - 9 N2 - Importance: Older patients undergoing abdominal surgery commonly experience preventable delirium, which extends their hospital length of stay (LOS). Objective: To examine whether a modified Hospital Elder Life Program (mHELP) reduces incident delirium and LOS in older patients undergoing abdominal surgery. Design, Setting, and Participants: This cluster randomized clinical trial of 577 eligible patients enrolled 377 older patients (≥65 years of age) undergoing gastrectomy, pancreaticoduodenectomy, and colectomy at a 2000-bed urban medical center in Taipei, Taiwan, from August 1, 2009, through October 31, 2012. Consecutive older patients scheduled for elective abdominal surgery with expected LOS longer than 6 days were enrolled, with a recruitment rate of 65.3%. Participants were cluster randomized by room to receive the mHELP or usual care. Interventions: The intervention (implemented by an mHELP nurse) consisted of 3 protocols administered daily: orienting communication, oral and nutritional assistance, and early mobilization. Intervention group participants received all 3 mHELP protocols postoperatively, in addition to usual care, as soon as they arrived in the inpatient ward and until hospital discharge. Adherence to protocols was tracked daily. Main Outcomes and Measures: Presence of delirium was assessed daily by 2 trained nurses who were masked to intervention status by using the Confusion Assessment Method. Data on LOS were abstracted from the medical record. Results: Of 577 eligible patients, 377 (65.3%) were enrolled and randomly assigned to the mHELP (n = 197; mean [SD] age, 74.3 [5.8] years; 111 [56.4%] male) or control (n = 180; mean [SD] age, 74.8 [6.0] years; 103 [57.2%] male) group. Postoperative delirium occurred in 13 of 196 (6.6%) mHELP participants vs 27 of 179 (15.1%) control individuals, representing a relative risk of 0.44 in the mHELP group (95% CI, 0.23-0.83; P = .008). Intervention group participants received the mHELP for a median of 7 days (interquartile range, 6-10 days) and had a shorter median LOS (12.0 days) than control participants (14.0 days) (P = .04). Conclusions and Relevance: For older patients undergoing abdominal surgery who received the mHELP, the odds of delirium were reduced by 56% and LOS was reduced by 2 days. Our findings support using the mHELP to advance postoperative care for older patients undergoing major abdominal surgery. Trial Registration: clinicaltrials.gov Identifier: NCT01045330. SN - 2168-6262 UR - https://www.unboundmedicine.com/medline/citation/28538964/Effect_of_a_Modified_Hospital_Elder_Life_Program_on_Delirium_and_Length_of_Hospital_Stay_in_Patients_Undergoing_Abdominal_Surgery:_A_Cluster_Randomized_Clinical_Trial_ L2 - https://jamanetwork.com/journals/jamasurgery/fullarticle/10.1001/jamasurg.2017.1083 DB - PRIME DP - Unbound Medicine ER -