As part of the Geriatric Surgery Verification (GSV) program that’s being implemented by the Department of Surgery and the Section of Geriatrics in the Department of Internal Medicine at The Ohio State University Wexner Medical Center, older surgical candidates will receive specific preoperative assessments to help reduce complications, avoid disabilities and prevent the need for long-term care following surgery.
“With older adults comprising more than 40% of inpatient surgery patients, and having a 28% readmittance rate, it’s more important than ever that we have a specific program to care for this population,” says Courtney Collins, MD, a general surgeon and clinical associate professor of Surgery in The Ohio State University College of Medicine who was a driving force behind Ohio State’s adoption of GSV protocols. “We try to approach these vulnerable patients using a holistic approach that optimizes the entire care pathway from preoperative evaluation through discharge.”
“As a medical community, our current approach to geriatric care has been more reactive than proactive. With GSV preoperative evaluation, we will identify vulnerabilities early so that interventions can be implemented prior to surgery to avoid complications and disabilities and to maintain independence,” says Kavya Sreevalsan, MD, a geriatrician, internal medicine physician and clinical assistant professor of Internal Medicine in the Ohio State College of Medicine. “Assessment of vulnerabilities identified preoperatively must then be continued to be evaluated in the perioperative, postoperative and transition of care settings.”
Ohio State’s geriatric preoperative checklist serves as a guide for providers in the preoperative setting, as well as for inpatient providers caring for older patients after surgery, to improve mobility, decrease rates of postoperative delirium and improve discharge planning and coordination.
“The value of this checklist is significant,” Dr. Sreevalsan says. “It’s been added to our electronic medical records, and that gives everyone on the care team ready access to both universal and specialty-related tasks that we can add to each person’s personalized care plan to lower risk and optimize outcomes. This proactive approach and preventive care should lead to such positives as reduced falls and other injuries, shorter hospital stays, lower risks of delirium and even significant cost savings.”
As part of the preoperative evaluation, each senior is screened for:
- Impaired mobility/functional status
- Dysphagia
- Cognition
- Medication reconciliation with elimination of Beers medications when possible
- Frailty
- Depression
- Nutrition
- Smoking cessation
- Alcohol cessation
- Glycemic control (HbA1c)
- Palliative care
- Social support
“If patient has a positive screen in any category or is considered high-risk in any area, we’re able to place an outpatient referral – if time allows – or call for an inpatient consult with the appropriate specialists, including those in nutrition, physical therapy, occupational therapy, palliative care, gerontology, social work or other medical disciplines,” Dr. Sreevalsan says. “We already have so many geriatric-focused programs in place across the medical center, but the formal assessment process that’s part of the GSV program ensures more older adults are referred to the right services more quickly.”
Early involvement and collaboration across medical disciplines are key.
“So much of this patient-centered approach is toward ensuring everyone is communicating constantly,” Dr. Collins says. “We may each know what to do individually, but the entire team has to huddle and close the gaps when it comes to shifts, specialties, serial assessments of overall health status and changing issues related to the patient’s family and caregiver.”
As an example of the program’s positive influence, she shares that reducing the risk of delirium alone could save $20,000 per patient on average, not to mention sparing more patients a dangerous and potentially preventable ordeal.
“I think overall we have some great foundational pieces and now we’re proactively working to expand on these. The support from the top of the institution down has been amazing,” she says.