Pre-operative Identification of the “At Risk” Elderly Surgical Patient

Presented by: Jennifer Lindsay and Sarah Paul

Penticton Regional Hospital

MR. T

○ 87 years old – lives independently

○ Scheduled for elective inpatient surgery – expected LOS 1 day

○ Seen in Pre-surgical screening clinic by RN & anesthetist

○ Pre-operative documentation from pre-screening clinic

Dementia

HTN

COPD

Bypass grafting x4

Frail Elderly

Coping poorly at home

ASA 4

WHAT WAS MR. T’S OUTCOME?

○ Discharged POD 1 and readmitted POD 6 post fall / hip

fracture

○ Returned to Operating Room on POD 7

○ Developed UTI

○ 2nd admission 43 days

○ 92 years, assisted living

○ Scheduled for elective inpatient surgery – expected LOS 1 day

○ Seen in Pre-surgical screening clinic by RN and anesthetist

○ Pre-operative documentation from Pre-screening:

Frail elderly

Compromised mobility requiring assist with ADL’s

HTN

A-Fib

Albumin 32

Anemia requiring transfusions

MR. R

○ Returned to operating room on POD 0 to control bleeding

○ Discharged POD 2

○ Readmitted POD 7 for Acute Coronary Syndrome

○ 2nd admission 28 days

○ Discharged to hospice for end of life care

WHAT WAS MR. R’S OUTCOME?

○ 82 years, nursing home resident

○ Scheduled for elective day surgery

○ Seen in pre-surgical screening clinic by RN & anesthetist

○ Pre-operative documentation from pre-screening

Walker and wheelchair dependent

Parkinson’s

HTN

Pitting edema to lower legs (lower legs bandaged for cellulitis)

CVA with residual RT sided deficit

IDDM

Hx Multiple Falls

On Warfarin

MR. W

○ Admitted for day surgery and transferred back to LTC

○ Readmitted on POD 14 with urosepsis, bacteremia and acute

renal failure

○ Discharged to LTC for end of life care

WHAT WAS MR. W’S OUTCOME?

○ These cases highlight the complexities that accompany the frail

elderly into the operating room

○ Of note, these cases were not reviewed by internal medicine

pre-operatively

○ The indicators of frailty, immobility, functional status and

cognitive status are strong predictors of outcome requiring

preoperative consideration

○ Re-evaluation of the “simple” procedure – a seemingly benign

procedure can be the catalyst for catastrophic outcomes

WHY THESE CASES?

○ NSQIP defines “elderly” as >65 years of age

○ DSM is Death and Serious Morbidity

○ Serious morbidity encompasses a wide range of post operative complications including wound infections, urinary tract infections, renal failure/ progressive renal insufficiency, major cardiac events (MI & cardiac arrest), a return to the OR, pneumonia, and sepsis.

WHAT IS ELDERLY DSM?

○ NSQIP data identified PRH as a high outlier for the measure of DSM

○ A peak of 20% occurrence was noted in January of 2013

○ NSQIP expected rate of DSM occurrence is 8%

○ Pre-surgical Screening /Internal Medicine initiative launched in July 2013

○ A working group was established consisting of PSSC nurses, Internal

Medicine physicians, Family practice GP, PT and RT practice leaders, OR

Manager, NSQIP SCR and SC and site Quality consultant

WHERE WE STARTED

Elderly Patient

PSSC RN

Internal Medicine

Family Practice

NSQIP SCR

OR Manager

NSQIP Surgeon

Champion

PT and RT

Quality Consultant

○ Internal Medicine specialist contribution is a key element

○ IM physicians were engaged and supportive

○ Participated in the development of an assessment tool

○ IM physicians were available for all consults generated through

PSSC

○ As the initiative evolved, a partnership between the surgical

specialties and internal medicine developed

ROLE OF INTERNAL MEDICINE

UCL

LCL0%

5%

10%

15%

20%

25%1

/1/1

3

2/1

/13

3/1

/13

4/1

/13

5/1

/13

6/1

/13

7/1

/13

8/1

/13

9/1

/13

10/1

/13

11/1

/13

12/1

/13

Death and Serious Morbidity Elderly 2013 PRH

UCL

LCL0%

5%

10%

15%

20%

25%

1/1

/14

2/1

/14

3/1

/14

4/1

/14

5/1

/14

6/1

/14

7/1

/14

8/1

/14

9/1

/14

10/1

/14

11/1

/14

12/1

/14

Death and Serious Morbidity Elderly 2014 PRH

WHERE ARE WE NOW?

=+

○ This initiative has been pivotal in the management of our at risk elderly patient

○ Multidisciplinary team caring for this specialized population

○ Creating a framework to encourage communication and ethical decision-making throughout the perioperative journey

○ Breaking down the hierarchy to bridge the communication gap between Internal Medicine and Nursing

○ Promoting earlier connection between Internal Medicine and Surgical services

○ Decrease of DSM rates from 13.2% in 2013 to 7.7% at the end of 2014

○ This initiative has shown an improvement in patient outcomes and supports long term sustainability

TO SUMMARIZE….

“We have definitely made some gains and

I really want to capitalize and improve

further”

Dr. David Kincade

Internal Medicine

Penticton Regional Hospital