ACS CQGS introduces course on care of the complex older patient

Older adults, defined here as individuals 65 years and older, comprise the fastest-growing demographic group in the U.S., and as such, the health care workforce has recognized the importance of adapting to this patient population’s specific needs.¹ At present, geriatric-specific curricula in medical school, residency, and continuing medical education are limited. As a result, many surgeons lack the requisite knowledge and experience to provide surgical care tailored to this growing population.^2,3

The American College of Surgeons (ACS) Coalition for Quality in Geriatric Surgery (CQGS) seeks to improve the quality of care delivered to older surgical patients through the development of a geriatric surgery quality improvement program. This quality program, like others established at the ACS over the past 100 years in trauma, bariatrics, cancer, and pediatrics, will be based on four principles: (1) set the standards, individualized to the patient and supported by the best evidence; (2) provide the right infrastructure; (3) measure outcomes using the right data; and (4) verify that the standards, infrastructure, and data are meeting expectations through external review. A critical component of this effort is providing a high-quality and accessible education program in geriatric surgery for clinicians who provide care to older surgical patients.

First presentation of new course

The CQGS Geriatric Surgery Quality Program is in its third year of development and scheduled for release in July 2019. As part of the educational program development, the ACS Geriatric Task Force and CQGS created a course designed for surgeons by surgeons—Management of the Complex Older Surgical Patient: Geriatric and Palliative Care. Presented for the first time at Clinical Congress 2017 in San Diego, CA, the course was taught by experts in the field of geriatric surgery and surgical palliative care, and surgeons who have created unique care models for geriatric surgical patients, including the following surgeons:

• Emily V. A. Finlayson, MD, MS, FACS, department of surgery, University of California, San Francisco
• Thomas Nichols Robinson, MD, FACS, Veterans Affairs Eastern Colorado Health Care System, department of surgery, Denver, CO
• Marcia M. Russell, MD, FACS, department of surgery, Veterans Affairs Greater Los Angeles Health Care System and David Geffen School of Medicine, University of California, Los Angeles
• Benjamin S. Brooke, MD, PhD, FACS, division of vascular surgery, department of surgery, University of Utah School of Medicine, Salt Lake City
• Fabian M. Johnston, MD, MHS, FACS, division of surgical oncology, department of surgery, Johns Hopkins, Baltimore, MD
• Anne C. Mosenthal, MD, FACS, department of surgery, Rutgers-New Jersey Medical School, Newark
• Zara Cooper, MD, MSc, FACS, department of surgery, Brigham and Women’s Hospital, Boston, MA
• Nadine B. Semer, MD, MPH, FACS, palliative medicine, Salinas Valley Memorial Healthcare System, Salinas, CA
• Emily B. Rivet, MD, MBA, FACS, FASCRS, departments of surgery and internal medicine, Virginia Commonwealth University, Richmond

The one-day course was divided into two half-day sessions: the first session focused on identification of geriatric syndromes and clinical intervention for geriatric-specific risk factors, and the second session focused on the communication skills required to provide quality care to this unique population (see Table 1 for the course outline). The course was based upon the CQGS standards, which describe best practices pertinent to the care of the older surgical patient.⁴

Table 1. Management of the complex older surgical patient: Geriatric and palliative care course structure

Best practices in geriatric surgical care

The first session covered best practices in the care of adult surgical patients through three phases of perioperative care: preoperative screening and optimization, inpatient care, and transitions of care. Common geriatric conditions, such as frailty, cognitive impairment, functional dependence, poor mobility, and malnutrition, put older adults at risk for increased morbidity, mortality, and loss of independence after surgery.^5-9 Participants gained hands-on experience using screening tools for functional and cognitive impairment and learned strategies for integrating these tools into their own preoperative clinic workflow.

Strategies for prevention and treatment of geriatric-specific complications in the hospital were discussed, particularly delirium prevention (see Table 2). Postoperative delirium, frequently seen in older adults, is highly morbid, difficult to treat, and costly.^10-13 For this reason, strategies to prevent delirium are essential. Nonpharmacologic care processes that target the predisposing and precipitating factors for delirium were described in the course, along with strategies for hospital implementation. A Cochrane systematic review published in March 2016 found reduction in the incidence of delirium in hospitalized older adults up to 30 percent with the use of multicomponent delirium prevention protocols.¹⁴

Table 2. Example of a multi-component delirium prevention protocol

The final activity in the first session focused on ensuring safe transitions of care for the older adult undergoing surgery. Disorganized care transitions are associated with postoperative complications and/or hospital readmission, particularly in older adults with multiple medical comorbidities.¹⁵ The CQGS standards on care transitions served as the focal point for the discussion. These standards outline how to ensure safe care transitions between each phase of care by improving communication among medical specialties, creating discharge treatment plans that target geriatric-specific conditions, and establishing a line of communication between hospitals and acute care facilities (see Table 3).⁴

Table 3. CQGS standards for transitions of care

Communication skills

The second session in the course focused on honing the communication skills necessary to provide the best care for the older adult patient. First, essential elements of the preoperative discussion around surgery were taught based on the CQGS standards on setting goals and making decisions in older adults around surgery (see sidebar).⁴

Because almost all older patients will lose decision-making capacity at some point during their surgical admission, before the operation it is important to identify a surrogate decision maker, establish advance directives, and explore desires for life-sustaining treatment. In addition, it is crucial to ensure that the patient and surgeon are both aware of the achievable goal for surgery—curative treatment, life prolongation, or alleviation of symptoms. The procedure goal should also align with the patient’s overall health care goals, such as maintaining independence, spending time at home, or having time with loved ones. Question prompts useful for eliciting a patient’s health care and treatment goals are shown in the sidebar.

Even when preoperative discussions are diligently conducted with the patient’s goals in mind, the patient and clinician will continue to make difficult decisions in response to unexpected changes in prognosis. The program attendees were given tools to formulate prognosis, as well as communication strategies for managing prognostic uncertainty, responding to emotion, addressing hope, and describing the range of likely outcomes with context that patients and caregivers understand.

Session two also included role-playing exercises that strengthened communication skills like breaking bad news, responding to emotion, eliciting goals and values, and making recommendations. Five drills were performed in which participants played the role of either clinician or patient in five difficult scenarios and then swapped roles. This structure allowed attendees to first learn the content didactically, then hear examples, and finally complete the task on their own.

Next steps

Instructors and attendees considered this course a success. Management of the Complex Older Surgical Patient: Geriatric and Palliative Care will be offered as a preconference course at future Clinical Congresses and will likely become a part of the CQGS geriatric quality educational program.

References

1. 1. Rowe JW, Allen-Meares P, Altman S, et al. Retooling for an Aging America: Building the Health Care Workforce. Washington, DC: The National Academies Press; 2008.
2. Petronovich J, Wade TJ, Denson K, Webb TP. Elderly surgical patients: Are there gaps in residency education? J Surg Education. 2014;71(6):825-828.
3. Heflin MT, Bragg EJ, Fernandez H, et al. The Donald W. Reynolds Consortium for Faculty Development to Advance Geriatrics Education (FD~AGE): A model for dissemination of subspecialty educational expertise. Acad Med. 2012;87(5):618-626.
4. Berian JR, Rosenthal RA, Baker TL, et al. Hospital standards to promote optimal surgical care of the older adult: A report from the Coalition for Quality in Geriatric Surgery. Ann Surg. 2017;267(2):280-290.
5. Berian JR, Mohanty S, Ko CY, Rosenthal RA, Robinson TN. Association of loss of independence with readmission and death after discharge in older patients after surgical procedures. JAMA Surg. 2016;151(9):e161689.
6. Seib CD, Rochefort H, Chomsky-Higgins K, et al. Association of patient frailty with increased morbidity after common ambulatory general surgery operations. JAMA Surg. October 11, 2017 [Epub ahead of print].
7. Robinson TN, Wallace JI, Wu DS, et al. Accumulated frailty characteristics predict postoperative discharge institutionalization in the geriatric patient. J Am Coll Surg. 2011;213(1):37-42.
8. Robinson TN, Wu DS, Pointer L, Dunn CL, Cleveland JC, Jr., Moss M. Simple frailty score predicts postoperative complications across surgical specialties. Am J Surg. 2013;206(4):544-550.
9. Robinson TN, Wu DS, Pointer LF, Dunn CL, Moss M. Preoperative cognitive dysfunction is related to adverse postoperative outcomes in the elderly. J Am Coll Surg. 2012;215(1):12-17.
10. Leslie DL, Marcantonio ER, Zhang Y, Leo-Summers L, Inouye SK. One-year health care costs associated with delirium in the elderly population. Arch Intern Med. 2008;168(1):27-32.
11. Rudolph JL, Inouye SK, Jones RN, et al. Delirium: An independent predictor of functional decline after cardiac surgery. J Am Geriatri Soc. 2010;58(4):643-649.
12. Saczynski JS, Marcantonio ER, Quach L, et al. Cognitive trajectories after postoperative delirium. N Engl J Med. 2012;367(1):30-39.
13. Zywiel MG, Hurley RT, Perruccio AV, Hancock-Howard RL, Coyte PC, Rampersaud YR. Health economic implications of perioperative delirium in older patients after surgery for a fragility hip fracture. J Bone Joint Surg Am. 2015;97(10):829-836.
14. Siddiqi N, Harrison JK, Clegg A, et al. Interventions for preventing delirium in hospitalised non-ICU patients. Cochrane Database Syst Rev. March 11, 2016. Available at: www.cochrane.org/CD005563/DEMENTIA_interventions-prevent-delirium-hospitalised-patients-not-including-those-intensive-care-units. Accessed January 23, 2018.
15. Brooke BS, Stone DH, Cronenwett JL, et al. Early primary care provider follow-up and readmission after high-risk surgery. JAMA Surg. 2014;149(8):821-828.