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New script for the older set: OR guidelines for aging Americans get a revamp

Monday February 11, 2013
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In a surgical suite, age is more than a number; it is a factor that helps formulate processes from the perioperative stages to postop care. As the country’s 65 and older population steadily climbs, along with increased numbers of surgical interventions in this age group, so has the need to tailor surgical services to fit their specific needs. To provide higher-quality care for these patients, the American College of Surgeons and the American Geriatrics Society have issued new guidelines for the preoperative care of elderly patients.

“The guidelines are absolutely terrific,” said Barbara Resnick, RN, PhD, CRNP, FAAN, FAANP, chair of the board of the American Geriatrics Society, a peer reviewer of the guideline article and a professor at the University of Maryland School of Nursing in Baltimore. “The guidelines can help raise awareness that you have to think differently with this population.”

The U.S. Census Bureau projects that by 2030 the 65 years and older group will have grown from 13% of the total population in 2010 to more than 20% of the citizenry. The guideline authors stated that in 2006 elderly patients represented 35% of inpatient procedures and 32% of outpatient procedures.

“We believe the quality of healthcare delivered to older adults is not as optimal as it could be,” said Marcus R. Escobedo, MPA, a program officer at the John A. Hartford Foundation, which provided the geriatrics society grants to develop the guidelines as part of a team-based, patient-centered project. “There is room for improvement in both processes and outcomes for geriatric patients.”

The two-year guideline-development process entailed synthesizing available evidence and drafting recommendations for a team approach to preoperative assessment and care. The guidelines recognize that cognition and physical functioning require a thorough nursing assessment in addition to a history and physical, all of which can assist the recovery and postop team in returning older surgical patients to baseline or better.

“It’s critical nurses have a good understanding of what to look for and what to report,” Resnick said. “I cannot emphasize enough the nursing responsibility of optimizing the recovery.”

A comprehensive assessment

JoAnn Coleman, RN, DNP, ACNP, AOCN, clinical coordinator for the Sinai Center for Geriatric Surgery, a new outpatient center for elective surgery patients ages 75 and older at Sinai Hospital in Baltimore, says the geriatric assessment is comprehensive and goes beyond the traditional heart, lungs, kidneys and airway evaluation. The assessment focuses on frailty, activities of daily living, delirium risk, fall risk, cognition, memory, functional status and mobility, among other things.

“It’s looking at all those other factors not normally looked at from an anesthesia perspective, and many of these things are predictive of how the person will do afterward,” Coleman said.

Nurses at Sinai check for hearing deficits. They also evaluate caregiver burden and may refer to social workers to screen for abuse or to recommend additional resources. Patients at risk for delirium receive a neurology consult.

Coleman estimated the entire assessment only takes about 20 minutes to 25 minutes to complete. “It’s a quick assessment, but you get a real feel for things,” Coleman said. Also, patients appreciate the more holistic approach and the extra attention they receive that demonstrates the staff is interested in them and not just their surgery, she added.

Depending on the assessment findings, the Sinai nurse may alert the surgeon or primary care physician of a concern that may need to be addressed postoperatively.
At Sinai, the assessment information is documented electronically, so postop nurses can access it and know what the person might need. Perhaps a hearing aid needs to be in place before attempting to communicate, or a family member needs to be present at the bedside if the patient has dementia, for example. “It’s preventive measures to forestall any postop issues,” Coleman said.

Why the extra focus on geriatric patients?

The normal processes associated with aging, necessitates rewriting care plans to fit older adults’ needs. “Older adults’ tissue changes [as they age], so they don’t have much flexibility,” said Marie Bashaw, RN, MS, NEA-BC, CNOR, assistant clinical professor and associate director of the Master’s in Nursing Administration program at Wright State University College of Nursing and Health in Dayton, Ohio, and author of the article “Surgical Risk Factors in Geriatric Perioperative Patients” in the July 2012 AORN (Association of periOperative Registered Nurses) Journal.

Bashaw also said they do not have as much adipose tissue and nerves can be closer to the surface, both of which require additional attention when positioning. Skin tissue is more friable, and bones may be less dense and tendons less tight, necessitating that nurses use caution not to exert too much pressure on the body and to keep the patient in proper alignment.

Nurses may need to get older adults up more quickly after a procedure. “One day in bed has a greater impact on an older adult than for a younger person,” Resnick said. “The challenge of the surgery pushes the limits. And when you have less reserve, it makes it harder.”

As people age, their senses of hearing, sight, smell and taste often decrease, Bashaw said. Postoperatively, they may not recognize the taste or aroma of food and not eat as well as needed for healing. “They become disoriented very easily,” Bashaw said. “You have to pay attention not to do things too fast. You have to be calm and speak distinctly to them. Make sure to have their attention.”

Slower clearance of medications in an older person also may increase their confusion. Bashaw recommended that nurses pay attention to patient weight and start with a low dose of medication and titrate up slowly.

Resnick explained that the older adult may have underlying cognitive changes that friends or family had not picked up on before surgery.

Many older adults may repeat themselves, and their ability to keep up often is not there, Bashaw added. Therefore, the nurse should give information in smaller bites.

“The ability to process and retain is diminished [in some older adults],” she said.
Still the question remains: Should the geriatric patient undergo surgery? A 2002 New England Journal of Medicine-reported study, “Understanding the Treatment Preferences of Seriously Ill Patients,” reported that elderly people would forego surgery if they knew it would result in severe functional or cognitive impairment.
“There is still more that needs to be done,” Escobedo said.

The next step is to develop tools and resources to mitigate risks and determine when surgery may not be the best option.

“I tell patients that going into surgery electively in your 80s and 90s needs to be thought about carefully,” Resnick said. “You may do beautifully, but you may not.”


Debra Anscombe Wood, RN, is a freelance writer. Post a comment below or email specialty@nurse.com.
Preoperative Assessment checklist

The new guideline checklist recommends, in addition to the history and physical, performing an assessment that includes:

Asking the patient to draw a clock and set it to 1:50 and to remember three words

Determining their understanding and expectations of the upcoming surgery

Screening for depression and alcohol and substance abuse

Identifying delirium risk factors, such as dehydration, anemia or hypoxia

Evaluating functional status, with grip strength and gait speed determinations and fall history

Completing a baseline frailty scale

A Nutritional evaluation and implementation of preop interventions for severe nutritional risk

A review of medications

A determination of family support
The guidelines out-line how to assess each item and include scripts for what to say to the patient.

Source: American College of Surgeons National Surgical Quality Improvement Program/American Geriatrics Society Best Practice Guidelines