SAN DIEGO – A project to assess geriatric-specific variables for inclusion in the American College of Surgeons/National Surgical Quality Improvement Program National Conference is underway, according to Thomas N. Robinson, MD.
Dr. Robinson discussed results from the ACS-NSQIP Geriatric Surgery Pilot Collaborative, an effort launched in January 2014 with the ultimate goal of evaluating specific geriatric variables for incorporation into the ACS NSQIP set of essential variables collected by all participating hospitals.
Dr. Thomas N. Robinson
Dr. Robinson, professor of surgery at the University of Colorado, Denver, said that 23 clinical sites in the United States are currently studying the following geriatric-specific variables in surgery patients aged 65 and older:
• Origin from home with support (to determine baseline functional status: lives alone at home, lives with support in home, origin status not from home).
• Discharge functional health status (ability to perform activities of daily living).
• Discharge with/without services (to capture care needs upon discharge).
• Preoperative use of a mobility aid.
• Preoperative history of prior falls.
• Postoperative history of pressure ulcer.
• Fall risk on discharge.
• New mobility aid on discharge.
• History of dementia.
• Competency status on admission.
• Postoperative delirium (yes or no).
• Hospice care on admission (yes or no).
• Do Not Resuscitate (DNR) order in place on admission (yes or no).
• DNR order during hospitalization (yes or no).
• Setting where DNR order was placed.
• Postoperative palliative care consult (yes or no).
• 30-day postoperative outcomes: functional health status (ability to perform activities of daily living), physical function compared with baseline, and living location.
The number of surgery cases in the collaborative grew from 7,235 in the first 6 months of 2014 to 24,835 cases in the last 6 months of 2015. The top 10 operations were total joint arthroplasty (29%), colectomy (12%), spine (8%), hip fracture (7%), carotid endarterectomy (4%), hysterectomy (4%), lung resection (2%), open lower extremity bypass (2%), laparoscopic cholecystectomy (2%), and pancreatectomy (2%).
Dr. Robinson reported that the rate of preoperative dementia among cases studied in the collaborative was 10%. “The incorporation of dementia into a surgical dataset represents an important step forward in providing quality surgical care for the elderly,” he said. “Dementia is a global public health concern.” He went on to note that patients with dementia have a 2.5-fold increased risk of developing postoperative delirium, making it “the perfect place to start a quality project. One in three cases of delirium is preventable. In our data set, delirium is associated with a hospital stay that’s 4 days longer, an increased chance of requiring discharge to an institutional care facility, an increased chance of a serious complication, and a higher 30-day mortality.”
Simple, low-tech bedside interventions such as ambulating in the hall three times a day, orienting the person, having the person sleep at night rather than sleep during the day, and avoiding medications with high risk for adverse events in older adults can prevent postoperative delirium, Dr. Robinson said.
One way that the Geriatric Surgery Pilot Collaborative can improve the surgical care of older adults is by fostering quality programs initiated at the participating local hospitals. “Preserving function after hospital stays is a first major goal,” he said. Another strategy involves creating a multidisciplinary frailty assessment to aid with decision making and risk assessment. “This takes into consideration NSQIP variables such as function, nutrition, comorbidity burden, cognition, social vulnerability, and mobility,” he said. The final and ultimate goal of the geriatric surgery collaborative is to establish a foundation of quality measurement for the Coalition for Quality in Geriatric Surgery, a project initiated by the American College of Surgeons to systematically improve the surgical care of older adults.
Dr. Robinson reported having no relevant financial disclosures.