Development of a clinical pathway for acute pain management as an element of the prevention of delirium in older adult trauma surgery patients

For hospitalized patients, delirium is prevalent and associated with poor outcomes including increased mortality, morbidity, hospital length of stay, and healthcare costs. Although past studies have identified effective interventions to both prevent and manage delirium in critically ill patients, the most widely used evidence is not easily generalized to non-critically ill patients, specifically trauma patients who experience acute pain, serial surgical procedures, and other notable precipitating and predisposing factors. Clinical pathways are structured plans that are useful for encouraging consistent, evidence-based interventions for various medical conditions and situations. At this time, there is no clinical pathway for the prevention of delirium in non-critically ill trauma patients at the student’s current practice setting. The theoretical framework used to guide this process was the Knowledge to Action Framework. Therefore, the purpose of this scholarly project was to develop an initial draft of a clinical pathway on one element of the complex delirium prevention processes, to provide Trauma Surgery acute care providers – nurse practitioners (NPs), physician assistants (PAs), doctors of medicine (MDs), doctors of osteopathic medicine (DOs), and registered nurses (RNs) - with evidence-based strategies for patients aged 65 years and older for use in the inpatient acute care setting at the practice site. This was completed via a comprehensive literature review and feedback from a panel of experts on the overall pathway, with subsequent rounds on a selected element of the pathway identified as the most critical in the development of delirium in this population, as an initial step in the quality improvement plan at this practice setting. Results of this scholarly project identified untreated pain as the most noted delirium risk factor, which led to its selection for an in-depth draft pathway focused on improving pain management. Noted limitations were small sample size, single project site, and limited time. Future recommendations include continued pathway drafts for other identified risk factors and ongoing education to assist in the implementation of the comprehensive pathway in clinical practice.