ACS-NSQIP Geriatric Collaborative. Thomas Robinson MD MS FACS Associate Professor, Surgery University of Colorado
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1 ACS-NSQIP Geriatric Collaborative Thomas Robinson MD MS FACS Associate Professor, Surgery University of Colorado
2 Disclosures The following planner, speaker and panelist of this CME activity has no relevant financial relationships with commercial interests to disclose: Tom Robinson, MD
3 THANK YOU TO ALL THE PARTICIPATING HOSPITALS!!! Brigham and Women's Hospital University of Virginia Health Systems Exempla Saint Joseph Hospital Duke University Hospital William Beaumont Hospital - Royal Oak William Beaumont Hospital Troy Mercy Hospital and Medical Center Yale New Haven Hospital Sinai Hospital of Baltimore John Muir Medical Center - Concord John Muir Medical Center - Walnut Creek Beaumont Hospital Grosse Pointe Exempla Good Samaritan Medical Center Sentara RMH Medical Center Advocate Illinois Masonic Medical Center UNC Hospitals Munroe Regional Medical Center (FSCI) Penticton Regional Hospital (Canada) Bridgeport Hospital Wyckoff Heights Medical Center Lawrence Memorial Hospital University of Connecticut Health Center
4 MULTI-DIMENSIONAL VULNERABILITY OF OLDER ADULTS FRAILTY DISABILITY CO-MORBIDITY Fried LP. J GerontMed Sci(2004) 59: 255.
5 TAILORING NSQIP VARIABLES TO THE OLDER ADULT Function Mobility Cognition Healthcare Goals
6 TAILORING NSQIP VARIABLES TO THE OLDER ADULT Function Mobility Cognition Healthcare Goals Origin from home with support lives alone at home lives with support in home origin status not from home Discharge functional health status independent partially dependent dependent Discharge with / without services home alone with self care home alone with skilled care home with support & self care home with support & skilled care
7 TAILORING NSQIP VARIABLES TO THE OLDER ADULT Function Mobility Cognition Healthcare Goals Pre-op use of mobility aid yes / no Pre-op history of prior falls yes (within 3, 6 or 12 months) / No Postoperative pressure ulcer new ulcer / stable ulcer / no Fall risk on discharge low fall risk / greater than low fall risk New mobility aid on discharge yes / no
8 TAILORING NSQIP VARIABLES TO THE OLDER ADULT Function Mobility Cognition History of dementia yes / no Competency status on admission consent signed by patient consent signed by surrogate Postoperative delirium yes / no Healthcare Goals
9 TAILORING NSQIP VARIABLES TO THE OLDER ADULT Function Mobility Cognition Palliative care on admission yes / no DNR order during hospitalization No / Yes (with date) Postop palliative care consult No / Yes (with date) Healthcare Goals
10 NAVIGATING UNCHARTED SURGICAL WATERS ADJUSTED ODDS OF DEVELOPING POSTOPERATIVE DELIRIUM Impaired Cognition Odds Ratio 95% Confidence Interval Lower Upper Surgical Patients Medical Patients Hospitalized Patients NSQIP Geriatric Collaborative Robinson TN et al. Ann Surg(2009) 249: 173. Bo M et al. Am J Ger Psych (2009) 17: 760. Inouye SK et al. Ann Intern Med (1993) 119: 474.
11 NAVIGATING UNCHARTED SURGICAL WATERS ADJUSTED ODDS OF DEVELOPING POSTOPERATIVE DELIRIUM Impaired Cognition Odds Ratio 95% Confidence Interval Lower Upper Surgical Patients Medical Patients Hospitalized Patients NSQIP Geriatric Collaborative Robinson TN et al. Ann Surg(2009) 249: 173. Bo M et al. Am J Ger Psych (2009) 17: 760. Inouye SK et al. Ann Intern Med (1993) 119: 474.
12 NAVIGATING UNCHARTED SURGICAL WATERS ADJUSTED ODDS OF DEVELOPING POSTOPERATIVE DELIRIUM Impaired Cognition Odds Ratio 95% Confidence Interval Lower Upper Surgical Patients Medical Patients Hospitalized Patients NSQIP Geriatric Collaborative Robinson TN et al. Ann Surg(2009) 249: 173. Bo M et al. Am J Ger Psych (2009) 17: 760. Inouye SK et al. Ann Intern Med (1993) 119: 474.
13 NAVIGATING UNCHARTED SURGICAL WATERS ADJUSTED ODDS OF DEVELOPING POSTOPERATIVE DELIRIUM Impaired Cognition Odds Ratio 95% Confidence Interval Lower Upper Surgical Patients Medical Patients Hospitalized Patients NSQIP Geriatric Collaborative Robinson TN et al. Ann Surg(2009) 249: 173. Bo M et al. Am J Ger Psych (2009) 17: 760. Inouye SK et al. Ann Intern Med (1993) 119: 474.
14 NAVIGATING UNCHARTED SURGICAL WATERS ADJUSTED ODDS OF DEVELOPING POSTOPERATIVE DELIRIUM Impaired Cognition Odds Ratio 95% Confidence Interval Lower Upper Surgical Patients Medical Patients Hospitalized Patients NSQIP Geriatric Collaborative Robinson TN et al. Ann Surg(2009) 249: 173. Bo M et al. Am J Ger Psych (2009) 17: 760. Inouye SK et al. Ann Intern Med (1993) 119: 474.
15 HOW WILL THE GERIATRIC COLLABORATIVE IMPROVE THE SURGICAL CARE OF OLDER ADULTS? I. Quality programs initiated at the local hospital level can aim to improve the functional outcomes vital to older adults. II. Reporting outcomes relevant to older adults can improve shared, patient-centered decision making. III.New, pioneering areas of surgical outcomes research will be possible. Optimizing preoperative risk stratification Creating of a quality database frail score Defining physical and mental outcomes of older adults Understanding care goals of older adults
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17 Case Study #1 Mr. M a 75 year old male is brought to the ER after a fall at home. Pt. complains of pain in right hip. He is unable to bear weight. Pt. is a poor historian awaiting son who is the POA. PMH: Hypertension, CHF, prostate CA (2001), former smoker, chronic renal insufficiency, and mild dementia. X-ray reveals Rt hip fracture. Pt. is consented and brought to the OR in the AM after being cleared by medicine.
18 Case #1 (cont.) Mr. M is admitted to the orthopedic floor. Nancy nurse admits Mr. M. Upon arrival to the floor he is alert and oriented x2 Soon after he arrives to the floor he becomes more confused and combative. Fall risk assessment is complete and Mr. M is placed on high fall risk. Nancy nurse attempts reorients Mr. M. She was unsuccessful and has to medicate Mr. m. with Ativan.
19 Case #1 (cont.) The next morning during rounds Mr. M is oriented x2 and noncombative. His son is present during rounds and states that his dad is at baseline. PT comes in for the initial consult. Mr M is married and lives with his wife in a one story ranch. He uses a straight cane for ambulation and has had a history of falling over the last 3 months. Pt is still a high fall risk (reference hospital fall risk assessment). PT suggest that he go to short term rehabilitation
20 Case #1 (cont.) On POD #2 Mr. M is incontinent and oriented x1. Nancy nurse tends to Mr. M and notices that he has a small blister on his coccyx. Nancy nurse applies the proper barrier and documents her findings in the W10. On POD #3 Mr. M. is transferred to a rehab facility. PT goals for Mr. M. are to increase his mobility to baseline, and help Pt. become independent with ADL s
21 Finding Variables 1. Origin Status From Home With Support 2. Use of Mobility Aid: 3. Fall History: 4. Fall History Date Unknown: 5. Cognitive Status on Admission: 6. Not Competent on Admission: 7. Palliative Care Upon Admission:
22 Finding Variables (cont.) 8. Postoperative Pressure Ulcer(s): 9. Postoperative Delirium 10. New Do-Not-Resuscitate (DNR) Order During Hospitalization 11. Palliative Care Consult 12. Functional Health Status on Day of Discharge Following Surgery 13.Fall Risk on Discharge
23 Finding Variables (cont.) 14. Postoperative Use of Mobility Aid: 15.Hospital Discharge With or Without Services:
24 Questions?
25 Case #1 (cont.) The next morning during rounds Mr. M is oriented x2 and noncombative. His son is present during rounds and states that his dad is at baseline. Pt. comes in for the initial consult. He uses a straight cane for ambulation and has had a history of falling over the last 3 months. Pt. suggest that he goes to a short term skilled facility
26 Case #1 (cont.) The next morning during rounds Mr. M is oriented x2 and noncombative. His son is present during rounds and states that his dad is at baseline. Pt. comes in for the initial consult. Mr. M is married and lives with his wife in a one story ranch. and has had a history of falling over the last 3 months. Pt. suggest that he goes to a short term skilled facility
27 Case #1 (cont.) The next morning during rounds Mr. M is oriented x2 and noncombative. His son is present during rounds and states that his dad is at baseline. Pt. comes in for the initial consult. Mr. M is married and lives with his wife in a one story ranch. He uses a straight cane for ambulation Pt. suggest that he goes to a short term skilled facility
28 Case Study #1 Mr. M a 75 year old male is brought to the ER after a fall at home. Pt. complains of pain in right hip. He is unable to bear weight. Pt is a poor historian awaiting son who is the POA. PMH: Hypertension, CHF, prostate CA (2001), former smoker, chronic renal insufficiency, and X-ray reveals Rt hip fracture. Pt. is consented and brought to the OR in the AM after being cleared by medicine.
29 Case Study #1 Mr. M a 75 year old male is brought to the ER after a fall at home. Pt. complains of pain in right hip. He is unable to bear weight. Pt. is a poor historian awaiting PMH: Hypertension, CHF, prostate CA (2001), former smoker, chronic renal insufficiency, and mild dementia. X-ray reveals Rt hip fracture. Pt. is consented and brought to the OR in the AM after being cleared by medicine.
30 Case #1 (cont.) On POD #2 Mr. M is incontinent and oriented x1. Nancy nurse applies the proper barrier and documents her findings in the W10. On POD #3 Mr. M. is transferred to a rehab facility.
31 Case #1 (cont.) Mr. M is admitted to the orthopedic floor. Nancy nurse admits Mr. M. Upon arrival to the floor he is alert and oriented x2 Fall risk assessment is complete and Mr. M is placed on high fall risk. Nancy nurse attempts reorients Mr. M. She was unsuccessful and has to medicate Mr. M. with Ativan.
32 Case #1 (cont.) On POD #2 Mr. M is incontinent and oriented x1. Nancy nurse tends to Mr. M and notices that he has a small blister on his coccyx. Nancy nurse applies the proper barrier and documents her findings in the W10. On POD #3 Mr. M. is transferred to a rehab facility.
33 Case #1 (cont.) The next morning during rounds Mr. M is oriented x2 and noncombative. His son is present during rounds and states that his dad is at baseline. PT comes in for the initial consult. Mr. M is married and lives with his wife in a one story ranch. He uses a straight cane for ambulation and has had a history of falling over the last 3 months. PT suggest that he go to short term rehabilitation
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