Abstract
As the population ages, more older adults will undergo surgical procedures, and common
physiologic changes can raise the risk for surgical complications while increasing
morbidity and mortality. In conjunction with the National Surgical Quality Improvement
Program, we piloted a comprehensive and interdisciplinary assessment and intervention
protocol for perioperative care for patients aged ≥75 years undergoing elective general,
gynecology-oncologic, and orthopedic surgery. The intervention included screening
tools for cognitive, functional, and nutritional deficits, a Geriatric Nurse Champion
on each inpatient surgical unit, and an interdisciplinary Geriatric Surgery Quality
Committee. Our intervention group was compared to surgical patients during the same
time period 1 year prior to the intervention, and the groups were well matched in
demographics and comorbidities. The intervention group had significantly higher rates
of advance care plan documentation in analysis of all patients (P < .001) and in subgroup analysis of those 85 and older (P = .006). The preintervention group had less postoperative delirium compared to the
postintervention group but it was not significant and there was no difference in length
of stay between groups. Various explanations for the minimal impact of the protocol
exist: small sample size, presence of other hospital initiatives to reduce pressure
ulcer and delirium, and clinician’s awareness of project planning that led to incorporating
ideas prior to official implementation. Future research implementing this protocol
in naïve and/or underperforming institutions may demonstrate a greater effect. Larger
sample size as well as implementation in other surgical fields may reveal a significant
impact. However, if additional study does not reveal a meaningful impact of a comprehensive
geriatric assessment for surgical patients, then consideration must be made regarding
unrecognized factors in surgical care for older adults or perhaps that factors cannot
be mitigated in older adults because they are intrinsically a higher surgical risk.
Keywords
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References
- Proactive care of older people undergoing surgery (‘POPS’): designing, embedding, evaluating and funding a comprehensive geriatric assessment service for older elective surgical patients.Age Ageing. 2007; 36: 190-196
- The outcomes of the elderly in acute care general surgery.Eur J Trauma Emerg Surg. 2016; 42: 107-113
- The impact of pre-operative comprehensive geriatric assessment on postoperative outcomes in older patients undergoing scheduled surgery: a systematic review.Anaesthesia. 2014; 69: 8-16
- Unique aspects of the elderly surgical population: an anesthesiologist's perspective.Geriatr Orthop Surg Rehabil. 2011; 2: 56-64
- The effects of pre-existing dementia on surgical outcomes in emergent and nonemergent general surgical procedures: assessing differences in surgical risk with dementia.BMC Geriatr. 2018; 18: 153
- Impact of early mobilization protocol on the medical-surgical inpatient population: an integrated review of literature.Clin Nurse Spec. 2012; 26: 87-94
- Self-reported mobility in older patients predicts early postoperative outcomes after elective noncardiac surgery.Anesthesiology. 2016; 124: 815-825
- Comprehensive geriatric assessment for older people admitted to a surgical service..Cochrane Database Syst Rev. 2018; 31
- Randomized clinical trial of comprehensive geriatric assessment and optimization in vascular surgery.Br J Surg. 2017; 104: 679-687
- Association of pre-operative medication use with post-operative delirium in surgical oncology patients receiving comprehensive geriatric assessment.BMC Geriatr. 2016; 16: 134
- Preliminary data demonstrate the Geriatric Surgery Verification program reduces postoperative length of stay.J Am Geriatr Soc. 2021; 69: 1993-1999
- Optimal preoperative assessment of the geriatric surgical patient: a best practices guideline from the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society.Perioper Care Oper Room Manag. 2017; 9: 33-38
- Optimal perioperative management of the geriatric patient. Best practices guideline from ACS NSQIP®.https://www.facs.org/-/media/files/quality-programs/geriatric/acs-nsqip-geriatric-2016-guidelines.ashxDate accessed: October 7, 2021
- Performance of the Vulnerable Elders Survey 13 screening tool in identifying cancer treatment modification after geriatric assessment in pre-treatment patients: a retrospective analysis.J Geriatr Oncol. 2019; 10: 229-234
- American Geriatrics Society 2019 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults.J Am Geriatr Soc. 2019; 67: 674-694
- Banner Mobility Assessment Tool for Nurses: instrument validation.Am J SPHM. 2014; 4: 86-92
- The confusion assessment method for the intensive care unit (CAM-ICU) and intensive care delirium screening checklist (ICDSC) for the diagnosis of delirium: a systematic review and meta-analysis of clinical studies.Crit Care. 2012; 16: R115
- Perioperative care of geriatric patients..Hosp Pract. 2020; 48: 26-36
- Preoperative assessment in older adults: a comprehensive approach.Am Fam Physician. 2018; 98: 214-220
- Preoperative assessment of geriatric patients.Anesthesiol Clin. 2016; 34: 171-183
- The looming geriatrician shortage: ramifications and solutions.J Aging Health. 2020; 32: 1052-1062
- The use and interpretation of quasi-experimental studies in medical informatics.J Am Med Inform Assoc. 2006; 13: 16-23
- Changing to basal-bolus insulin therapy for the inpatient management of hyperglycemia—a natural experiment.Endocr Pract. 2019; 25: 836-845
Article info
Publication history
Published online: February 25, 2022
Footnotes
The authors declare no conflicts of interest.
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© 2022 AMDA - The Society for Post-Acute and Long-Term Care Medicine.
