NSQIP Geriatric Pilot Project. Sandhya Lagoo-Deenadayalan

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1 NSQIP Geriatric Pilot Project Sandhya Lagoo-Deenadayalan

2 Older Adults Ever-increasing proportion of the population Higher rates of surgical procedures Increased post-operative complications Delayed recovery Extended hospitalizations Loss of independence

3 NSQIP GERIATRIC VARIABLES PILOT PROJECT ADMISSION CRITERIA ORIGIN STATUS USE OF MOBILITY AID (Cane, walker, wheelchair) PREVIOUS FALL WITHIN ONE YEAR (3, 6, 12 months) COGNITIVE STATUS ON ADMISSION (cognitive decline, dementia, Alzheimer ) COMPETENCY STATUS ON ADMISSION PALLIATIVE CARE UPON ADMISSION (Hospice, palliative care) NSQIP GERIATRIC VARIABLES PILOT PROJECT - POSTOPERATIVE OCCURENCES PRESSURE ULCER POSTOPERATIVE DELIRIUM NEW DNR ORDER DURING HOSPITALIZATION PALLIATIVE CARE CONSULT (Hospice, palliative care) FUNCTIONAL HEALTH STATUS ON DISCHARGE FALL RISK ON DISCHARGE POSTOPERATIVE USE OF MOBILITY AID NSQIP GERIATRIC VARIABLES PILOT PROJECT DISCHARGE OCCURENCES DISCHARGE WITH /WITHOUT SERVICES (SNF, Home)

4 Geriatric Pilot Project: Jan Sept 2014 Hospital Status 27 hospitals 10,478 cases Demographics Median age: 79 Female gender: 30% Race: 80% White, 10% Black, 10% other Emergent cases: 873 (8.33%) ASA Classification: ASA I -II: 37%; ASA III: 53%; ASA IV: 10% Ronnie Rosenthal, MD and Thomas Robinson, MD

5 Thank you to the SCRs!

6 Geriatric Specific Variables Variable N % Origin from home Home Alone Home with Support Not home Unknown Cognitive decline or dementia on admission Yes No Unknown Palliative / Hospiceupon admission No

7 Geriatric Outcomes Variable N % Postop Delirium Yes No Missing New DNR Yes Palliative Care Consult Yes Functional status on DC Independent Partially dependent Totally dependent Unknown Newmobility aid on DC Yes

8 Geriatric Pilot -Complications Event N % All SSI (Deep + Superficial) DVT/PE Renal Failure 74 1 Respiratory Failure Cardiac event Delirium Any Morbidity

9 POSH Perioperative Optimization of Senior Health 1) Pre-operative, multidisciplinary care planning 2) Intra-operative protocols 3) Post-operative continuity of care 4) Transitions planning Michael Lidsky, MD, Zhifei Sun, MD, Mohammed Adam, MD, Paul Speicher, MD

10 Christopher Mantyh, MD

11 Duke Enhanced Recovery Focus Elements Pre-Operative Intra-Operative Post-Operative Counseling and Patient Education Medical Optimization Strong for Surgery Epidural/regional blocks Monitored, Goal-Directed Fluid Administration Immediate Diet Immediate Mobilization No maintenance IVF Food until 6 hours preop Clears until 2 hours preop No long-acting sedatives or anxiolytics Minimally invasive surgery Avoidance of tubes, drains, and lines Multimodal pain regimen Multimodal prevention of PONV Defined discharge criteria and teaching Julie Thacker, MD, John Migaly, MD, Christopher Mantyh, MD

12 NEWS Scoring System Cara O Brien, MD 12

13 Treatment Goals for SIRS or Sepsis Assess level of care with refractory hypotension and increasing lactate levels 1. Early fluid resuscitation 2. Blood cultures + Antibiotics within 1 hr. of recognition 3. Primary vasopressors as needed for hemodynamic support: Norepinephrine 4. Assess and reassess hypo-perfusion via lactate levels 5. Consider secondary vasopressor/inotrope if lactate level continues to rise and unable to maintain MAP>65 despite adequate fluids: Vasopressin ( units/min) Dobutamine(in the presence of myocardial dysfunction) Cara O Brien, MD 13

14 Studies on Pancreaticoduodenectomyin the Elderly Pancreaticoduodenectomy in the Elderly, de la Fuente, SG, et al, HBP, 2011, (12) Comparison of outcomes and use of multimodality therapy, Barbas, AS et al, JAGS, 2012, 60 (2): Care Maps in HBP surgery Length of stay, readmission and wound infection rates Kevin Shah, MD, Dan Blazer, MD, Becke White, MD, Sabino Zani, MD, Alexander Perez, MD, Theodore Pappas, MD

15 Geriatric Pilot: Effect of Delirium on Outcomes 60% 50% 40% % Patients 30% 20% 10% 0% Post-acute care discharge Serious morbidity* 30-day mortality No Delirium (N=4,704) Delirium (N=614)

16 Delirium Prevention Measures Education: recognizing delirium Avoiding deliriogenic medications Quiet times, no unnecessary disturbances at night Keep visual and hearing aids Encourage family to stay with patient

17 Geriatric Pilot: Disposition and Functional Status 50% 45% 45% 40% 35% 32% 30% 25% 20% 15% 10% 5% 0% Home with Skilled Care Worse Function

18 Duke Vascular Surgery 509 vascular procedures were performed on patients older than 65 years between 1/21/2014 and 12/12/2014. Other 12% HD Access 19% Amputation 22% LE Open 9% EVAR Open Aortic 9% Carotid Surgery 9% 20% HD Access LE Open Open Aortic Surgery Carotid EVAR Amputation Other

19 RT11 Open Lower Extremity Revascularization Discharge All Age < 55 Age Destination Age Age Age > 85 Home(%) Skilled Care or Rehab (%) Discharge Destination Home Skilled Care or Rehab Age < >85 Ryan Turley, MD, Leila Mureebee, Dan Geersen, Cynthia Shortell, MD

20 Slide 19 RT11 Ryan Turley, 3/22/2015

21 Interventions Preoperative Medical Optimization Assess need for Statin, Beta-blocker, and Anti-platelet therapy Nutritional Assessment and Blood sugar optimization Smoking cessation counseling Cardiac clearance Discharge destination planning OR Planning Postoperative Optimization Delirium precautions Wound care counseling Ryan Turley, MD, Leila Mureebee, Dan Geersen, Cynthia Shortell, MD

22 HOPE Mission: Ensure vulnerable seniors with complex care needs receive innovative and integrated geriatric care services across the continuum of care. Inpatient Team Inter-organizational Collaboration Discharge planners facilitate identification Obtain a Geriatrics Consultation Nurse/Physician handoff HOPE workgroup Collecting data Reviewing data Testing process changes Heidi White, MD

23 NSQIP Geriatric Pilot Project Survey Results 15 hospitals participated 33% hospitals had routine pre-op screening for older adults Evals: Anesthesiologist 80%, Geriatrician 12%, SW 29% Geriatric Department 46% Hospitalists involvement in geriatric surgical patients: 26% Palliative services present in 86% of hospitals In patient geriatric ward: 13% Care maps in 10 hospitals: medicine reconciliation, delirium, pain, functional decline, nutritional support Zara Cooper, MD and Sanjay Mohanty, MD

24 Duke Geriatric Workforce Enhancement Program (GWEP) Communities Caring for Seniors Strengthen capacity to provide patient-centered coordinated healthcare for seniors locally, regionally, and nationally. The GWEP will bring together geriatrics training programs, primary care practices, community agencies and healthcare organizations to implement a new model of workforce development that strives to improve outcomes for older adults. Mitch Heflin, MD

25 Educational Leadership Immersion Training in ELDERcare ELITE Heidi White, MD, MHS, MEd, CMD Division of Geriatrics, Dept. of Medicine Sandhya Lagoo-Deenadayalan, MD, PhD Div. of General Surgery, Dept. of Surgery

26 NSQIP Geriatric Pilot Project Team All 27 participating hospitals and the SCRs Clifford Ko, MD Ronnie Rosenthal, MD Thomas Robinson, MD Sanjay Mohanty, MD Julia Berian, MD Matt Fordham Christopher Mantyh, MD Patricia Tucker, SCR

27 POSH Clinic: Shelley R. McDonald, DO, PhD Lisa Legath, RN Joyce Anderson, MLPN Cornelia Poer, MSW, LCSW Gwendolyn Mumford Mitchell T. Heflin, MD Kenneth Schmader, MD Cathleen Colon-Emeric, MD Heidi White, MD Melissa Aselage-Batchelor, NP General Surgery: Michael Lidsky, MD Zhifei Sun, MD Mohammed Adam, MD Christopher Mantyh, MD Paul Speicher, MD John Migaly, MD Julie Thacker, MD Alex Perez, MD Theodore Pappas, MD Jacquelyn Sullivan, NP Hema Bhandura, RN The POSH Team POSH Planning Team: Mitch Heflin, MD Dan Geersen, PA Rick Sloane, MPH Phillip Liu, MD, MBA Miriam Morey, PhD Shelley McDonald, DO, PhD Heather Whitson, MD Caitlin Dailey Neurosurgery: Carlos Bagley, MD Jessica Moreno, RN Delissa Ordronneau, PA Owoicho Adogwa, MD Urology: Andrew Peterson, MD Brant Inman, MD Edward Rampersaud, MD Chuck Scales, MD Anesthesia Preop: Ron Olson, MD Julie Little, NP Mary Hixon, NP Pam Pennigar, NP Karen Pagnotta, RN Holly Muir, MD Geriatrics Consult Team: Bobaker Elalem, MD Adedayo Fashoyin, MD Rachel Suter, MD Sarah Wingfield, MD Liza Genao, MD Juliessa Pavon, MD Mamata Yanamadala, MD Loren Wilkerson, MD Mitchell T. Heflin, MD Heidi White, MD Heather Whitson, MD