Interdisciplinary Protocol for Surgery in Older Persons: Development and Implementation |
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| Institution: | 1. NYU Long Island School of Medicine, Mineola, NY, USA;2. NYU Langone-Long Island Hospital, Mineola, NY, USA;1. Health Services and Systems Research, Duke-NUS Graduate Medical School, Singapore;2. Department of General Surgery, Singapore General Hospital, Singapore;3. Department of Emergency Medicine, Singapore General Hospital, Singapore;4. Centre for Quantitative Medicine, Duke-NUS Graduate Medical School, Singapore;5. Trauma Service, Tan Tock Seng Hospital, Singapore;6. Department of General Surgery, National University Hospital, Singapore;7. Accident & Emergency, Changi General Hospital, Singapore;8. Department of General Surgery, Khoo Teck Puat Hospital, Singapore;9. Emergency Medicine Department, Ng Teng Fong General Hospital, Singapore;10. Department of Geriatric Medicine, Singapore General Hospital, Singapore;11. School of Pharmacy, Memorial University of Newfoundland, Canada, St. John''s, Newfoundland, Canada;12. Department of Rehabilitation Medicine, Singapore General Hospital, Singapore;13. Centre for Ageing Research and Education, Duke-NUS Graduate Medical School, Singapore;14. Department of Vascular Surgery, Singapore General Hospital, Singapore;1. Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA;2. University of Rochester School of Medicine and Dentistry, Rochester, NY, USA;3. James P Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY, USA;1. College of Pharmacy, University of Houston, TX, USA;2. Center for Economic and Social Research, University of Southern California, Los Angeles, CA, USA;3. Healogics Inc, Jacksonville, FL, USA;4. Wound Healing and Tissue Repair Program, University of Illinois at Chicago, Chicago, IL, USA |
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| 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. |
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| Keywords: | Perioperative assessment geriatric protocols comprehensive geriatric assessment |
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