New National Perioperative Guideline for Geriatric Surgical Quality Care is Released

Responding to the needs of the country's growing older adult population, a new collaborative best practices guideline was released today for optimal care of older adults immediately before, during, and after surgical operations (a timeframe known as the "perioperative" period). The new consensus-based guideline was developed by the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®) and the American Geriatrics Society's (AGS) Geriatrics-for- Specialists Initiative (GSI), with support from The John A. Hartford Foundation. With more than 40 million older adults living in the U.S. today--and with that number expected to nearly double to 89 million by 2050*--providing expert guidance on surgical care is key since the need for surgical services increases with age and targeted guidance during the perioperative period can speed recovery.

"Optimal Perioperative Management of the Geriatric Patient: A Best Practices Guideline" from ACS and AGS has been published online on the Journal of the American College of Surgeons (JACS) website and will appear in print edition of JACS and the Journal of the American Geriatrics Society later this year. A free standing volume of this perioperative guideline has also been released today in tandem with publication in JACS, and is available for download at https://www.facs.org/quality-programs/acs-nsqip/geriatric-periop-guideline

Building on a successful collaboration in 2012 on joint guidelines addressing the preoperative care of older patients before admittance to a hospital or surgery center, the ACS and AGS once again partnered with The John A. Hartford Foundation in the development of this new best practices guideline examining the next phase of surgical care.

The new guideline addresses the perioperative care of all surgical patients 65-years-old and older as defined by Medicare regulations. The guideline provides a framework for thinking about the complex issues these patients face since they are more prone to experience postoperative complications and prolonged recovery with advanced age. The ACS Geriatric Surgery Task Force developed the guideline with an expert multidisciplinary panel, which evaluated current evidence and best practices in the medical literature to arrive at a set of expert recommendations targeting surgeons, anesthesiologists, and allied health care professionals who work with older adults. While this consensus-based guideline is "not a substitute for clinical judgment and experience," the authors explain, they can do much to support tailored, comprehensive geriatrics evaluations.

"It's inspiring to see our collaboration achieve this next milestone. This new interdisciplinary guideline provides us with another meaningful tool for improving geriatric surgical care. We now have expert recommendations in place for older patients that range from preoperative assessment to perioperative management," says guideline coauthor Clifford Y. Ko, MD, MSHS, FACS, director of ACS NSQIP, and Principal Investigator of the Coalition for Quality in Geriatrics Surgery (CQGS) Project.

"Representing more than 6,000 health professionals committed to high-quality, person-centered care for older adults, the AGS recognizes that expanding geriatrics expertise means ensuring that all healthcare professionals--not just geriatrics experts--know and can employ principles of excellence in eldercare," adds Nancy E. Lundebjerg, MPA, CEO of the AGS. "This collaboration builds on the legacy of our Geriatrics-for-Specialists Initiative, which itself underscores the unique importance of geriatrics awareness for surgeons and related medical specialists."

"More than ever, 80-, 90-, and even 100-year-olds are undergoing surgery. Our exciting partnership with ACS and AGS has produced another tool that will result in safer care and better outcomes for the growing number of older surgical patients," notes Terry Fulmer, PhD, RN, FAAN, president of The John A. Hartford Foundation.

The perioperative guideline is organized into three distinct sections and addresses multiple issues that need to be considered when caring for older adults facing surgery:

•Immediate Preoperative Management 
This section addresses patient goals, preferences, and advance directives; preoperative fasting; antibiotic prophylaxis; venous thromboembolism prevention; and medication management.

•Intraoperative Management 
This section provides a management checklist for the "intraoperative" period during surgery itself, addressing the use of anesthesia in older adults; perioperative analgesia in older adults; perioperative nausea and vomiting; patient safety; strategies to prevent postoperative complications and hypothermia; fluid management; and targeting physiologic parameters.

•Postoperative Management 
This section provides a postoperative rounding checklist, covering postoperative delirium; methods for preventing pulmonary complications; fall risk assessment and prevention; postoperative nutrition; ways to prevent urinary tract infections; functional decline; and pressure ulcer prevention and treatment.

A final section of the document guides clinicians in managing transition to care following surgery and provides helpful appendices on a wide range of important issues, from advance directive position statements to perioperative risk factors for delirium.

"We searched the medical literature in developing this guideline, to find the best available evidence and the most relevant peer developed position statements," says guideline coauthor Ronnie Rosenthal, MD, MS, FACS, chair of the Geriatric Surgery Task Force, co-principal investigator of the CQGS Project, and chief of surgery at the VA Connecticut Healthcare System. "We also included several appendices that provide examples of tools that can be used to assist the clinician in assessing risk factors and developing treatment plans and care models. In doing so, we feel that we've developed a fully comprehensive resource that is now readily accessible via the web, and can be used immediately by all clinicians and caregivers who treat and work with older surgical patients."

"As a start, this guideline functions as an unprecedented educational resource, one that organizes all of the components of perioperative care of the older adult in one place. Moving forward, perhaps it will one day play an important role in informing us about process, and providing us with insightful metrics on outcomes for geriatric surgical patients," concluded guideline coauthor Sanjay Mohanty, MD, a general surgery resident at Henry Ford Hospital, and an ACS/AGS James C. Thompson Geriatrics Surgical Fellow.

In addition to Drs. Ko, Rosenthal, and Mohanty, Marcia M. Russell, MD, FACS; Mark D. Neuman, MD, MsC; and Nestor F. Esnaola, MD, MPH, FACS, served as coauthors of the guideline.

This guideline was developed by the ACS Geriatric Surgery Task Force, formed in 2004. Further work of the task force, a joint effort of ACS and the AGS supported by The John A. Hartford Foundation, led to a 2015 ACS-John A. Hartford Foundation initiative, The Coalition for Quality in Geriatric Surgery Project, which includes the AGS as a stakeholder organization. The CQGS Project aims to launch a broad-reaching quality program designed to systematically improve care and outcomes for the older adult surgical patient in 2019.

Reference: Optimal Perioperative Management of the Geriatric Patient: A Best Practices Guideline. Journal of the American College of Surgeons. DOI: ACS_8139: 10.1016/j.jamcollsurg.2015.12.026

*Werner C. The Older Population: 2010. Washington, DC: U.S. Census Bureau; November 2011.

Source: American College of Surgeons