Pre-operative Identification of the “At Risk” Elderly Surgical Patient Penticton Regional Hospital Presenters: Jennifer Lindsay Sarah Paul

87 years old Scheduled for elective inpatient surgery – expected LOS 1 day Pre-operative documentation from pre-screening clinic Dementia HTN COPD Bypass grafting x4 Frail Elderly Coping poorly at home ASA 4 MR. T

Discharged POD 1 and readmitted POD 6 post fall / hip fracture Returned to Operating Room on POD 7 Developed UTI 2 nd admission 43 days WHAT WAS MR. T’S OUTCOME?

92 years Scheduled for elective inpatient surgery – expected LOS 1 day Pre-operative documentation from Pre-screening: Frail elderly Compromised mobility requiring assist with ADL’s HTN A-Fib Albumin 32 Anemia requiring transfusions MR. R

Returned to operating room on POD 0 to control bleeding Discharged POD 2 Readmitted POD 7 for Acute Coronary Syndrome 2 nd admission 28 days Discharged to hospice for end of life care WHAT WAS MR. R’S OUTCOME?

82 years Scheduled for elective day surgery Pre-operative documentation from pre-screening Walker and wheelchair dependent Parkinson’s HTN Pitting edema to lower legs (lower legs bandaged for cellulitis) CVA with residual RT sided deficit IDDM Multiple Falls MR. W

Admitted for day surgery and transferred back to LTC Readmitted on POD 14 with urosepsis, bacteremia and acute renal failure Discharged to LTC for end of life care WHAT WAS MR. W’S OUTCOME?

NSQIP defines “elderly” as >65 years of age DSM is Death and Serious Morbidity Serious morbidity includes wound infections, urinary tract infections, renal failure/ progressive renal insufficiency, major cardiac events (MI & cardiac arrest), a return to the OR, pneumonia, and sepsis. WHAT IS ELDERLY DSM?

NSQIP data identified PRH as a high outlier for the measure of DSM Pre-surgical Screening /Internal Medicine initiative launched July 2013 A working group was established : PSSC nurses, Internal Medicine physicians, Family practice GP, PT and RT practice leaders, OR Manager, NSQIP SCR and SC and site Quality consultant WHERE WE STARTED

Elderly Patient PSSC RN Internal Medicine Family Practice NSQIP SCR OR Manager NSQIP Surgeon Champion PT and RT Quality Consultant

Internal Medicine specialist contribution is a key element Participated in the development of an assessment tool IM physicians were available for consults generated through PSSC As the initiative evolved, a partnership between the surgical specialties and internal medicine developed ROLE OF INTERNAL MEDICINE

WHERE ARE WE NOW?

“We have definitely made some gains and I really want to capitalize and improve further” Dr. David Kincade Internal Medicine Penticton Regional Hospital