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The American College of Surgeons (ACS) has developed a Geriatric Surgery Verification Program, aimed at improving surgical care and outcomes for the aging adult population.
The GSV Program provides hospitals with a validated list of 30 evidence-based and patient-centered standards for geriatric surgery that hospitals can implement to continuously optimize surgical care for this vulnerable population (ACS 2019). The standards were developed by the ACS in conjunction with over 50 stakeholder organizations, with support from the John A. Hartford Foundation.
Hospitals can formally enroll in the GSV program this October at the 2019 ACS Clinical Congress in San Francisco.
Hospitals must submit a letter of commitment from their CEO and demonstrate they have a Geriatric Surgery Director, Geriatric Surgery Coordinator, and Geriatric Surgery Quality Committee (roles of each are explained in the ACS document).
There is a requirement for geriatric-friendly patient rooms, which must include space for family and caregiver visitation and include directed elements for patient reorientation (for example, large clock or other display of date, day, and time; daily planned activity goals; any anticipated medical tests or procedures; names of care team; and so on). If space for visitation cannot be provided within the patient room, there must be an alternative communal visiting area.
Each surgical floor must have at least one Geriatric Surgery Nurse Champion (GSNC), whose responsibilities include not only leadership but also responsibility for nursing education, quality improvement, and continuing education.
Shared decision making is a key component of the standards. Deliberation over surgical decision making must allow older adults the opportunity to discuss the following with the surgeon:
- Overall health goals (not limited to the current condition or treatment options)
- Treatment goals (specific to the current condition)
- Anticipated impact of both surgical and non-surgical treatments on symptoms, function, burden of care, living situation, and survival
After discussion, the surgeon needs to document the treatment plan and how it has been informed by shared discussion of the patient’s goals. Patient health goals relative to the surgical condition can be categorized broadly into (1) prolonging life, (2) preserving function or independence, (3) relieving symptoms, (4) curing a condition, or (5) establishing a diagnosis. Older adults should have the opportunity to identify an overall health goal that is personal and specific, such as “I want to be able to walk at my grandson’s wedding this summer.” This standard aims to distinguish between overall health goals and treatment goals specific to the current condition. Though overall health goals and health care treatment preferences are often aligned, this is not always the case; this standard aims to improve that alignment
Another standard is that code status and any existing advance directive must be reviewed preoperatively by the surgeon. Patients without a defined code status or an advance care plan must be offered the opportunity to establish an advance directive in addition to being provided with educational resources on advance care planning. All patients must have a health care representative, surrogate, or proxy identified with name and contact information clearly documented. For those without, there must be documentation of an effort to identify one. Educational materials must be provided to facilitate discussion between the patient and his or her surrogate about the patient’s overall health and treatment goals.
For patients with anticipated admission to the intensive care unit (ICU), there must be a discussion regarding the indications for, limitations of, and patient’s desire for life-sustaining treatments, including issues such as cardiopulmonary resuscitation, mechanical ventilation, feeding tubes, hemodialysis, and blood transfusion. These might be discussed as part of a standard anesthesia visit or preoperative admission process.
The patient and family/caregiver(s) must be offered the opportunity to reaffirm the initial surgical decision making, by an in-person visit, a telephone call, or a telehealth visit with surgical staff or a designated representative.
The standards put an important focus on the preoperative evaluation. Patients must be screened for the following high-risk characteristics to identify potential areas of vulnerability:
- Age ≥ 85 years
- Impaired cognition
- Delirium risk
- Impaired functional status
- Impaired mobility
- Difficulty swallowing
- Need for palliative care assessment
We are very pleased to see the focus on identifying delirium risk and the several factors that contribute to frailty. Moreover, the standards call for a documented management plan directed at positive findings from the screens.
In the elective setting, all patients identified as high risk based on the geriatric vulnerability screens must be evaluated with interdisciplinary input after the implementation of focused management plans and before surgery to reassess the indications, risks, and benefits of the proposed operation. This may be conducted in the form of an interdisciplinary conference or by obtaining input from at least the following health professionals:
- Case management, care transitions, or social work
- Health care provider with geriatric expertise
- Health professionals from the following areas are recommended but not mandatory: relevant medical specialties (for example, oncology, pulmonology, cardiology, and so on), Geriatric Surgery Nurse Champions, nutrition, palliative care, Pharmacy, physical medicine and rehabilitation, physical/occupational therapy
Interdisciplinary conferences should arrive at documentation of a consensus treatment recommendation and ensure communication of recommendations to patients and their families/caregivers and other clinicians responsible for the care of the patients.
A very important point is that, for patients at high risk, the surgeon or surgeon’s representative must communicate the goals of care and decision-making discussion to the patient’s preferred primary care provider (PCP) or the provider designated by the patient as his or her “main doctor.”
Multiple standards apply to post-operative care. There is an emphasis on ensuring that patients’ personal sensory equipment (glasses, hearing aids, dentures, etc.) are collected and returned to the patient immediately postoperatively. We’ve discussed the importance of this in our many columns on preventing and managing delirium.
There must be processes, protocols, or policies in place to assess for and alert providers to the use of potentially inappropriate medications, using tools such as Beers Criteria®. The ACS suggests use of standardized order sets/bundles/pathways to protocolize medication management for geriatric patients or use of templated order sets with Beers medications removed and alternatives provided. Hospitals should also have ways for flagging and reviewing inappropriate medications when they are ordered (eg. daily pharmacy reviews, embedded decision support tools within the electronic health record that provide alerts when a potentially inappropriate medication is prescribed). They also stress provider education identifying surgically relevant Beers medications along with alternatives available within institutional formulary
They stress opioid-sparing, multimodality pain management for all postoperative patients. That includes opioid-sparing techniques like use of regional analgesia and use of pre-, intra-, or postoperative non-opioid analgesics. But it also stresses avoidance of other potentially inappropriate analgesics as defined by the AGS Beers Criteria, appropriate titration of medications for the increased sensitivity and altered physiology of the older adult, prophylactic pharmacologic bowel regimen, and use of non-medication-based strategies for pain control.
Standards really focus on prevention, identification, and management of postoperative delirium. There should be daily screening with a validated tool such as the CAM (confusion assessment method). Identifying and treating or discontinuing precipitating factors through non-pharmacologic and pharmacologic interventions (eg. correcting electrolyte derangements, treating infections, minimizing tethering devices, etc.) is important. There also needs to be attention to mobility, with a goal of ambulation or non-ambulatory mobilization by postoperative day one, fall prevention, daily evaluation of need for tethering devices, and daily assessment of pressure ulcer risk and skin integrity. Other factors needing special post-operative attention are nutrition and hydration (preferably via the enteral route), a bowel regimen (especially for those requiring opioid pain medications), and aspiration precautions (eg. elevated head-of-bed, upright post-prandial positioning). The above issues may be addressed through pathways, bundles, order sets, protocols, or a combination thereof.
The standards call for interdisciplinary care for all patients identified as high risk based on the geriatric vulnerability screens. Initial postoperative care must be provided by interdisciplinary health care professionals, including but are not limited to:
- Care transitions/social work/case management
- Physical therapy/occupational therapy
- Health care provider with geriatric expertise
- Health professionals from the following areas as clinical situations demand: relevant medical specialties (for example, oncology, cardiology, nephrology, etc.), nutrition, palliative care, Pharmacy, inpatient pain management service
Recommendations by participating members of the interdisciplinary team must be documented daily.
Goals of care must be revisited when an older adult experiences an unexpected escalation of care to the ICU and must be readdressed at least every three days for all ICU patients.
Planning for discharge or other transitions of care is critical. All patients must undergo geriatric vulnerability screens at discharge to assess for changes in vulnerability during their hospital stay. An appropriate plan of action to address identified deficits must be documented in the medical record as part of the discharge documentation. Geriatric vulnerabilities to especially be assessed at discharge include impaired cognition. delirium risk, impaired functional status, impaired mobility, and malnutrition. Discharge documentation should also specifically identify any deficits discovered on pre-discharge screens along with the plan of action to address each vulnerability. Information regarding common geriatric syndromes, including risk factors for functional decline, falls, delirium, and how to respond to each if it occurs after discharge should be included. The contents of the discharge summary must be discussed with the patient and/or his or her caregiver, and a copy must be provided to:
- Patient or caregiver(s)
- PCP or the patient’s main doctor
- Health professional assuming care if the patient is discharged to a non-home facility
There must be a process, protocol, or policy in place addressing the communication structure between the institution and post-acute care facilities.
The standards also include collection and review of data for all patients included within the scope of the GSV Program. Data must be reviewed at least quarterly by the GSQC to identify, trend, and address issues specific to geriatric surgical care. The GSV document discusses the metrics to review and the need for a process, protocol, or policy in place for feedback of the data collected and reviewed. The SV program mandates at least one quality improvement (QI)/performance improvement (PI) project annually pertinent to geriatric surgical care informed by the data collected and reviewed by the GSQC.
The standards go on to discuss other potential quality improvement collaborative opportunities and to discuss the ongoing educational requirements and recommendations for physicians, nurses, and other healthcare professionals. Also required is a community outreach project focused on issues pertinent to geriatric surgical care, and it must be conducted at least annually. This project may take the form of awareness, prevention, or education. The GSV also strongly urges participation in research or work toward advancement of geriatric surgical knowledge and care.
Many of the standards are also in keeping with a findings of a recent study on factors that lead to successful care of older patients on medical wards Baxter 2019). Those researchers hypothesized there were 14 care team factors that contributed to patient safety on the wards:
- Knowing each other
- Multidisciplinary approach
- Integrating allied health professionals throughout ward activities
- Openness to questions from staff members
- Setting expectations
- Pleasure in coming to work
- Learning from incidents
- Acquiring additional staff
- Stable and static teams
- Focus on discharge
- Support from healthcare organization leadership
- Keeping patients and families informed
They focused on five characteristics that healthcare professionals considered to be most salient in successful care of older patients. These included the relational aspects of teamworking, specifically regarding staff knowing one another and working together in truly integrated multidisciplinary teams. The cultural and social context of successful wards was perceived to influence the way in which practical tools (eg, safety briefings and bedside boards) were implemented.
The findings of the Baxter study mesh well with the GSV focus on teamwork and interdisciplinary collaboration in caring for the older surgical patient.
One other program we’ve previously mentioned is the American College of Surgeons’ Strong for Surgery program. That program is intended for all surgical patients, but its components are equally applicable to the older surgical patient. This program is intended to optimize patients’ overall status prior to surgery and provides a toolkit with checklists. “Strong for Surgery” empowers hospitals and clinics to integrate checklists into the preoperative phase of clinical practice for elective operations. The checklists are used to screen patients for potential risk factors that can lead to surgical complications, and to provide appropriate interventions to ensure better surgical outcomes.” The checklists in the Strong for Surgery Toolkit target eight areas known to be influential determinants of surgical outcomes:
- Glycemic Control
- Medication Management
- Smoking Cessation
- Safe and Effective Pain Management after Surgery
- Patient Directives
There’s no reason the concepts from the ACS Strong for Surgery program cannot be used in conjunction with the new ACS Geriatric Surgery Verification Program,
ACS (American College of Surgeon). Geriatric Surgery Verification Quality Improvement Program. Optimal Resources for Geriatric Surgery2019 Standards. ACS 2019
Baxter R, Taylor N, Kellar I, et al. A qualitative positive deviance study to explore exceptionally safe care on medical wards for older people BMJ Quality & Safety 2019; 28: 618-626
ACS (American College of Surgeons). Strong for Surgery. Updated November 2018
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