Geriatric Preoperative Optimization: A Review.

This review summarizes best practices for the perioperative care of older adults as recommended by the American Geriatrics Society, American Society of Anesthesiologists, and American College of Surgeons, with practical implementation strategies that can be readily implemented in busy preoperative or primary care clinics. In addition to traditional cardiopulmonary screening, older patients should undergo a comprehensive geriatric assessment. Rapid screening tools such as the Mini-Cog, Patient Health Questionnaire-2, and Frail Non-Disabled Survey and Clinical Frailty Scale, can be performed by multiple provider types and allow for quick, accurate assessments of cognition, functional status, and frailty screening. To assess polypharmacy, online resources can help providers identify and safely taper high-risk medications. Based on preoperative assessment findings, providers can recommend targeted prehabilitation, rehabilitation, medication management, care coordination, and/or delirium prevention interventions to improve postoperative outcomes for older surgical patients. Structured goals of care discussions utilizing the question-prompt list ensures that older patients have a realistic understanding of their surgery, risks, and recovery. This preoperative workup, combined with engaging with family members and interdisciplinary teams, can improve postoperative outcomes.

Perioperative Optimization of Senior Health (POSH): A Descriptive Analysis of Cancelled Surgery.

BACKGROUND: Geriatric collaborative care models improve postoperative outcomes for older adults. However, there are limited data exploring how preoperative geriatric assessment may affect surgical cancellations. METHODS: This is a single-center retrospective cohort analysis. Patients enrolled in the Perioperative Optimization of Senior Health (POSH) program from 2011 to 2016 were included. POSH is a collaborative care model between geriatrics, surgery, and anesthesiology. Baseline demographic and medical data were collected during the POSH pre-op appointment. Patients who attended a POSH pre-op visit but did not have surgery were identified, and a chart review was performed to identify reasons for surgical cancellation. Baseline characteristics of patients who did and did not undergo surgery were compared. RESULTS: Of 449 eligible POSH referrals within the study period, 33 (7.3%) did not proceed to surgery; cancellation rates within the POSH program were lower than institutional cancellation rates for adults over age 65 who did not participate in POSH. Patients who did not have surgery were significantly older, more likely to have functional limitations, and had higher rates of several comorbidities compared with those who proceeded to surgery (P < 0.05). Reasons for surgical cancellations included a similar number of patient- and provider-driven causes. CONCLUSIONS: Many reasons for surgical cancellation were related to potentially modifiable factors, such as changes in goals of care or concerns about rehabilitation, emphasizing the importance of shared decision-making in elective surgery for older adults. These results highlight the important role geriatric collaborative care can offer to older adults with complex needs.

Planning for a Safe Discharge: More Than a Capacity Evaluation.

Discharge decision making for hospitalized older adults can be a complicated process involving functional assessments, capacity evaluation, and coordination of resources. Providers may feel pressured to recommend that an older adult with complex care needs be discharged to a skilled nursing facility rather than home, potentially contradicting the patient's wishes. This can lead to a professional and ethical dilemma for providers, who value patient autonomy and shared decision making. We describe a discharge decision-making framework focused on interprofessional evaluation and management, longitudinal follow-up, and education and support for patients and families. By gathering and synthesizing information, eliciting goals and preferences, and identifying community resources, the healthcare team can help maximize independence for vulnerable older adults. J Am Geriatr Soc 68:859-866, 2020.

A novel curriculum to train physician assistant students how to write effective discharge summaries.

Background: Physician assistants (PAs) are an integral part of inpatient care teams, but many PAs do not receive formal education on authoring discharge summaries. High-quality discharge summaries can mitigate patient risk during transitions of care by improving inter-provider communication. Objective: To understand the current state of discharge summary education at our institution, and describe a novel curriculum to teach PA students to write effective discharge summaries. Design: Students completed a pre-survey to assess both knowledge and comfort levels regarding discharge summaries. They wrote a discharge summary and received feedback from two evaluators, an inpatient provider (IPP) familiar with the described patient and a simulated primary care provider (PCP). Students completed a post-survey reassessing knowledge and comfort. Results: Prior to instituting this curriculum, the majority of students (92.9%) reported rarely or never receiving feedback on discharge summaries. Eighty-four of 88 (95.5%) eligible students participated. There was discordance between IPP and simulated PCP feedback on their assessment of the quality of discharge summaries; simulated PCPs gave significantly lower global quality ratings (7.9 versus 8.5 out of 10, p = 0.006). Key elements were missing from >10% of discharge summaries. Student response was favorable. Conclusion: Clinically relevant deficiencies were common in students' discharge summaries, highlighting the need for earlier, structured training. IPPs and simulated PCPs gave discordant feedback, emphasizing differing needs of different providers during transitions of care. This novel curriculum improved students' knowledge and confidence.