Operative risk stratification in the older adult.

As the population ages, the health care system must to adapt to the needs of the older population. Hospitalization risks are particularly significant in the frail geriatric patients, with costly and morbid consequences. Appropriate preoperative assessment can identify sources of increased risk and enable the surgical team to manage this risk, through "prehabilitation," intraoperative modification, and postoperative care. Geriatric preoperative assessment expands usual risk stratification and careful medication review to include screening for functional disability, cognitive impairment, nutritional deficiency, and frailty. The information gathered can also equip the surgeon to develop a patient-centered and realistic treatment plan.

Intervention thresholds: a conceptual frame for advance care planning choices.

BACKGROUND: Advance care planning (ACP) provides for decisions in the event of decisional incapacity. Determining ahead of time what a person may want is challenging and limits the utility of ACP. We present empirical evidence for a new approach to ACP: the individual's "intervention threshold." The intervention threshold is intuitively understood by clinicians and lay people, but has not been thoroughly described, measured, or analyzed. METHODS: Using a mixed-methods approach to address the concept of the intervention thresholds, we recruited 52 subjects from a population of chronically ill outpatients for structured telephone interviews assessing knowledge, attitudes, and prior ACP activities. Respondents were presented with 11 interventions for each of four medical scenarios. For each scenario, they were asked whether they would accept each intervention. Data was evaluated by descriptive statistics and chi-squared statistics. RESULTS: Complete data were obtained from 52 patients, mean age of 64.5, 34.6% of whom were male. Only 17.3% reported prior ACP discussion with a physician. Rates of accepting and refusing interventions varied by scenario (p < 0.0001) and intervention intensity (p < 0.0001). CONCLUSIONS: These data provide evidence that people display transitions between wanting or not wanting interventions based on scenarios. Further research is needed to determine effective ways to identify, measure, and represent the components of an individual's intervention threshold in order to facilitate informed decision making during future incapacity.

Patient safety in the nursing home: how nursing staff assess and communicate about change in condition.

Nursing homes must improve quality of care even as it becomes increasingly complex, and patient safety science may provide a helpful paradigm. Training materials are needed to build staff capacity for clinical assessment and communication, thereby improving care processes. Designed to develop curricular materials, this study used focus groups to determine how experienced nurses and aides assess and communicate about resident clinical changes. Four focus groups were conducted, and interviews were analyzed for themes in an iterative process by multidisciplinary team members. Staff reported that consistent caregiving enables detection of subtle clinical changes; aides further noted the importance of affective bonding. Aides and nurses alike regarded all clinical changes as potentially significant, while nursing staff lacked a consistent approach to assessment. Using a patient safety framework, structural changes and process elements were identified as important topics for further training to support clinical communication and improve resident and facility outcomes.

Feasibility and effectiveness of the NEST13+ as a screening tool for advanced illness care needs.

BACKGROUND: A comprehensive whole-person approach might improve processes and outcomes of care for patients with cancer. OBJECTIVE: To assess the ability of NEST13+ (Needs of a social nature; Existential concerns; Symptoms; and Therapeutic interaction), a screening and assessment tool, to identify social, emotional, physical, and care-system needs and to improve clinical outcomes for cancer patients in tertiary care. DESIGN, SETTING, PATIENTS: A controlled trial involving 451 patients hospitalized for cancer care at a comprehensive cancer center. INTERVENTION: Patients responded to 13 screening questions regarding possible care needs. When an individual response exceeded threshold levels, additional in-depth questions for the relevant need were asked. For patients in the intervention arm, clinical recommendations for each dimension of need were generated based on a previously developed NEST-response-driven menu, and were reported to the clinical team. MEASUREMENTS: Documented needs, clinician response, patient perception of goals alignment, and overall quality of palliative care. RESULTS: Using the NEST13+ tool in the clinical setting facilitated greater documentation of illness-related needs than routine clinical assessment. Improvement in secondary outcomes was attenuated: changes in the clinician response were modest; changes in outcomes were not significant. CONCLUSION: The NEST13+ tool facilitated identification of a wider range of important needs than traditional evaluation, while care outcomes were not improved. Traditional evaluation may need improvement. Future trials of the NEST13+ should focus on more intensive clinician-directed interventions.