My 77-year old father underwent surgery two years ago and I recall how frightening it was for him, my mother, and our entire family. Unfortunately, our fear was realized when he had a terrible post-operative infection that sent him to the emergency room and on to a follow-up surgery.
Sadly, he and my mom were not given good hospital discharge instructions and they ignored signs of problems far too long. No follow-up appointment with his primary care provider had been set, either, which could have averted the complication (and to this day, I kick myself for not catching that).
It could have been much worse. For patients older than my father with more chronic conditions, even surgery that is technically perfect can be fraught with danger and poor outcomes without the application of geriatric best practices that address the whole-person needs of the patient.
Fortunately, we have a new tool that can help surgical teams and hospitals ensure they are thinking about the distinct needs of older adults undergoing surgery. A new collaborative best practices guideline was released earlier this month for optimal care of older adults immediately before, during, and after surgical operations (a timeframe known as the “perioperative” period).
If the guideline had been referenced by my father’s surgical team, they would have noted the importance of good transitional care and reviewed the important warning signs and symptoms. They would have seen this statement on p. 36:
“The importance of consistent communication between the inpatient health care team, the patient, any family or caregivers, and primary care doctors regarding the inpatient course and expectations for recovery postoperative cannot be emphasized enough.”
Amen.
The new consensus-based guideline was developed by the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®) and the American Geriatrics Society’s (AGS) Geriatrics-for- Specialists Initiative (GSI) , with support from The John A. Hartford Foundation. This work built on a successful collaboration in 2012 to develop joint guidelines addressing the preoperative care of older patients before admittance to a hospital or surgery center . (I previously mentioned the preoperative guideline in a post titled Tools You Can Use: Residency Training Toolkits and Best Practices Guidelines for Surgeons and Related Specialists.)
The new perioperative guideline provides a framework for thinking about the complex issues faced by the growing population of older patients, who are more prone to experience postoperative complications and prolonged recovery. The ACS Geriatric Surgery Task Force developed the guideline with an expert multidisciplinary panel, which evaluated current evidence and best practices in the medical literature to arrive at a set of expert recommendations targeting surgeons, anesthesiologists, and allied health care professionals who work with older adults.
The perioperative guideline is organized into three distinct sections and addresses multiple issues that need to be considered when caring for older adults facing surgery:
- Immediate Preoperative Management: This section addresses patient goals, preferences, and advance directives; preoperative fasting; antibiotic prophylaxis; venous thromboembolism prevention; and medication management.
- Intraoperative Management: This section provides a management checklist for the “intraoperative” period during surgery itself, addressing the use of anesthesia in older adults; perioperative analgesia in older adults; perioperative nausea and vomiting; patient safety; strategies to prevent postoperative complications and hypothermia; fluid management; and targeting physiologic parameters.
- Postoperative Management: This section provides a postoperative rounding checklist, covering postoperative delirium; methods for preventing pulmonary complications; fall risk assessment and prevention; postoperative nutrition; ways to prevent urinary tract infections; functional decline; and pressure ulcer prevention and treatment.
The guideline, along with its preoperative companion, lays the foundation for a new ACS-John A. Hartford Foundation initiative, The Coalition for Quality in Geriatric Surgery (CQGS) Project, which includes the AGS as a stakeholder organization. The CQGS Project aims to set geriatric surgical standards for hospitals and launch a broad-reaching quality program designed to systematically improve care and outcomes for the older adult surgical patient in 2019.
I look forward to the day three years from now when we have the CQGS standards and a national verification and quality improvement program for hospitals delivering surgical care to older adults. If my dad ever needs an operation in the future, it will be at a hospital that has adopted these standards.
Should my dad need surgery before that process is complete, I will hand-deliver this guideline of best practices myself to his surgical team if necessary to ensure he gets the age-appropriate care he needs and deserves.
Read the full press release and raise awareness of the new guideline with your hospitals and surgical centers.
This is the 16th in an occasional series. See other Health AGEnda posts on Tools You Can Use:
State-by-State Palliative Care Report Card
What You Need to Know About Evidence-Based Programs
An Online Educational Series Focusing on Dementia in Older Adults
The Quality Care Through a Quality Workforce Toolkit
Webinar Series Covers Geriatrics-Competent Care for Medicare-Medicaid Population
The Essentials of Cardiovascular Care in Older Adults
Residency Training Toolkits and Best Practices Guidelines for Surgeons and Related Specialists
Geriatric Transitions Objective Structured Video Examination
A Non-pharmacologic Toolkit for Addressing Behavioral and Psychological Symptoms of Dementia
A New APProach to Treating Older Patients
Detecting Cognitive Impairment During the Medicare Annual Wellness Visit
Preparing a Personal Advance Care Plan
Guidelines for Assessing Patients Facing Surgery
Principles for Treating Patients with Multiple Chronic Conditions