It’s estimated that about 41% of all in-patient surgeries are performed on older adults—a number expected to grow as the population ages.
With that in mind, the American College of Surgeons (ACS) embarked on a project to develop new standards to improve surgical care for older patients.
The ACS released the 30 patient-centered standards at its 2019 Quality and Safety Conference held over the weekend in Washington, D.C. The Geriatric Surgery Verification (GSV) program was designed to encourage hospitals and healthcare systems around the country to adopt the standards to optimize surgery for patients who are 75 and older.
The standards include recommendations on a wide variety of issues including improving communications with patients before surgery, managing medications, screening for geriatric vulnerabilities, providing geriatric-friendly rooms and ensuring proper staffing is in place.
The ACS hopes hospitals across the country will adopt the new standards, Clifford Y. Ko, M.D., director of the division of research and optimal patient care at the ASC, said in an interview with FierceHealthcare.
“These are standards we think hospitals should have in place to take care of elder adults undergoing surgery,” said Ko, who is a professor of surgery at UCLA.
The standards are four years in the making. The ACS followed the same model it has used to create other standards for trauma care, cancer care, bariatric surgery, breast disease and pediatric surgery, Ko said.
The four-pronged approach includes developing standards, identifying the infrastructure that is needed to improve care, ensuring there is data available to access the current state of care and a verification process to ensure the standards are in place.
Just who are the elderly the ACS hopes to help? While Medicare kicks in at age 65, the ACS considers an elderly patient to be 75 or older. However, physicians and other clinicians need to consider a patient’s clinical condition as well as chronological age, Ko said. While one 65-year-old may be active and in good health, another may be frail and suffer cognitive impairment.
In developing the standards, the ACS got input from over 50 stakeholders, including representatives of patient, provider, payer and caregiver groups.
One of the most important standards addresses how physicians and clinicians communicate with patients, Ko said. For example, patient goals should align with their care, according to industry stakeholders.
Patients need to be offered care options based on their goals. A patient with a goal to live as long as possible may decide to opt for a major cancer surgery despite the risks, Ko said. Another patient’s goal may focus on the quality of life over quantity of time. That patient may wish that for whatever time he or she has left, they want to be without pain and be able to take a walk so they can enjoy the birds singing in the trees.
Depending on the patient’s goals, that person may choose a different surgery to treat his or her condition, Ko said.
Another standard addresses how clinicians screen patients before surgery to assess for such factors such as cognitive issues, potential delirium and strength and balance. After an operation, physicians will want to make sure their patient is clear and lucid, can avoid falls and be able to get out of bed and walk, Ko said. Identifying issues before surgery can help identify potential problems with recovery beforehand.
There are also steps hospitals can take to address patients' physical needs, such as having large print instructions and plenty of natural light. Staff can ensure that glasses and hearing aids get returned to patients as soon as possible after surgery.
The standards also address medication issues, including polypharmacy since the elderly tend to take multiple medications more so than other patients. Pre-surgery is a good time to evaluate what medications a patient is taking and identify any that might interact with anesthesia. If a patient has pain, physicians should consider the best ways to address that pain, trying to stay away from opiates, Ko said.
The ACS wants everyone to know about all of these evidence-based standards, Ko said.
“We think this is such an important area within healthcare and surgery,” he said.
Hospitals may choose to become a verified geriatric center, he said, and ask to be surveyed by the ACS to verify that they meet all of the standards.
The standards are now published on the ACS web site.
Hospitals that meet the standards will likely have improved outcomes, Ko said. “We need to have appropriate processes if we want to do the right thing for our patients," he said.
There will be a cost, yet to be determined, for a survey to verify compliance with the standards. “It’s usually a small amount,” he said.
However, a commitment to follow such standards can result in better outcomes, fewer complications, shorter lengths of stay in the hospital, and fewer rehospitalizations.
“Obviously, there is a return on the cost,” he said.
“In my humble opinion, nearly all hospitals will or are taking care of elderly adults undergoing surgery. This program is relevant to nearly all hospitals,” he said.
“This is such an important mission, not only for the ACS but for healthcare overall. We feel very strongly about the importance of this program and our commitment to put it in place to help elder adults undergoing surgery,” he said.
The standards may allow seniors and their families to make decisions in choosing where to get care. Ko said he often gets asked by patients which hospital is the best for their care. A hospital that follows the standards will probably be a better place to go for elder adults, he said.
“There’s a lot of concrete protocols that can help physicians take better care of their patients,” he said.
For an elderly adult undergoing surgery, there is a whole spectrum of care from pre-operative to post-operative care, as well as post-discharge. That care can involve doctors, nurses, hospitalists, occupational and physical therapists and geriatricians.
“It’s a whole team and the standards really go from A to Z,” he said.