General Surgical Care

A.  Physiological changes of aging can significantly affect the recovery time of older adult surgical patients and put them at greater risk for postoperative complications (Makary et al., 2010).

B.  Older adults often present for elective and nonelective or emergent surgeries with a number of medical comorbidities that place them at further risk for postoperative morbidity and mortality (Dasgupta et al., 2009).

C.  The risk of complications and mortality increases with advancing age, with those aged 90 years and older experiencing twice the rate of mortality at less than 48 hours post surgery as compared with those younger than 65 years (Deiner et al., 2014).

D.  Longer lengths of stay have been consistently linked to increased postoperative adverse outcomes (Makary et al., 2010).

E.  Surgical patients at hospitals with a higher percentage of nurses with a baccalaureate or higher degree experienced shorter lengths of stay and fewer postoperative complications (Blegen et al., 2013).

F.   A proportionate increase in staff nurses with bachelor’s degrees decreases the risk of death among patients following common surgeries in acute care settings (Aiken et al., 2014).

BACKGROUND

A.  Definition

  1. The patient is discharged from the PACU following an established protocol, such as the Aldrete Score, a postanesthesia recovery score. Patients with scores of 9 or 10 may be discharged to the surgical or equivalent units, those with eight require further observation, and those with 7 or less require admission to the ICU (Aldrete & Kroulik, 1970). Another tool in use is the PADSS (Chung, Chan, & Ong, 1995). No matter which tool is used, collaborative ongoing assessment and clinical judgment are required.
  2. Nursing priorities when the patient arrives from the PACU to the surgical unit include high-quality handoff; focus on airway, breathing and circulation; assessment of vital signs based on specific protocol; monitoring of complications; and discharge readiness (Odom-Forren, 2015).

B.  Etiology/epidemiology

  1. In 2010, 19.2 million operative procedures were performed among older adults in acute care settings. These accounted for more than 37% of all procedures and 45% of total hospital days of care (CDC, 2010).
  2. Hospital stays that involve surgical procedures have been shown to be more costly, required longer lengths of stay, and resulted in higher morbidity and mortality (Weiss & Elixhauser, 2014).
  3. The need for comprehensive baseline status assessment and the use of an interdisciplinary team with surgical and geriatric expertise to follow the patient from preop to discharge are essential for achieving positive outcomes (McGory et al., 2009).
  4. Postoperative delirium can occur in up to 50% of high-risk older adult surgical patients, leading to prolonged and more costly hospitalizations, functional decline, and death (AGS, 2014).
  5. Older adult surgical patients are at higher risk for delirium resulting from medication side effects; immobility; infection; inadequate pain management; and cardiac, renal, and respiratory complications (Hughes et al., 2013).
  6. Hospitalized older adults are consistently less likely to receive adequate pain control compared with younger adult patients (Schofield, 2014).
  7. A lack of pain control for the older surgical patient can lead to delirium, depression, fluid imbalances, atelectasis, and fatigue (AGS, 2014; Bashaw & Scott, 2012).
  8. A large majority of hospitalized older adults are malnourished or at risk of malnutrition, placing them at risk of impaired skin integrity, wound or other infections, sepsis, and death (Kaiser et al., 2010; Lagoo-Deenadayalan et al., 2011; Scandrett et al., 2015).
  9. Approximately 1.5% of older surgical patients develop postoperative renal insufficiency, with a mortality rate of greater than 31% (Gajdos et al., 2013).
  10. Postoperative pulmonary complications occur in about 10% of older adult surgical patients, accounting for 40% of postoperative complications and 20% of preventable deaths (Lagoo-Deenadayalan et al., 2011).
  11. Among older surgical patients, SSI occurred in 8%, with a 7% mortality rate for those developing an SSI (Gajdos et al., 2013).
  12. Approximately 60% of SSIs are preventable. Developing an SSI can lead to an additional 11 postoperative hospital days and a two- to 11-fold increase in mortality risks (Anderson et al., 2014).
  13. The risk of developing CAUTI increases by 5% per day of catheterization (Bhardwaj et al., 2012; IHI, 2011a).
  14. CLABSI has been shown to double mortality risk, add up to 10 additional hospital days, and increase healthcare costs (Kaye et al., 2014).
  15. Postsurgical deconditioning can slow recovery, delay in restoring independence with ADL, and increase risk for VTE, delirium, incontinence, constipation, pressure injuries, and falls (Lagoo-Deenadayalan et al., 2011).
  16. The postsurgical period is a vulnerable time for increased risk of falls (Currie, 2008).
  17. Approximately 15% of hospitalized patients in hospitals at any given time have pressure injuries, with 60,000 dying per year (IHI, 2011b).
  18. The postsurgical older adult is at increased risk of VTE, which occurs in about 1 million patients each year (Bashaw & Scott, 2012; Dobesh, 2009).
  19. Restraint use increases the risk of falls, pressure injuries, and delirium, leading to increased morbidity, mortality, and length of stay (Baumgarten et al., 2008; Inouye et al., 2007; Shorr et al., 2002).

 PARAMETERS OF ASSESSMENT

A.  The PSIs are the key drivers of assessment and screening of surgical older adult patients. PSIs that are relevant to surgical patients include (AHRQ, 2014):

  1. Death among surgical inpatients
  2. CVC-related bloodstream infection
  3. Postoperative hemorrhage or hematoma, physiological and metabolic derangements, respiratory failure, pulmonary embolism or DVT, sepsis, and wound dehiscence
  4. Transfusion reaction

B.  A seamless synthesis of various practice guidelines, such as those recommended in the Assessing Care of Vulnerable Elders-3 (ACOVE) Quality Indicators (AGS, 2007), Beers Criteria for Potentially Inappropriate Medication Use in Older Adults (AGS, 2014), and Clinical Practice Guideline for Postoperative Delirium in Older Adults (AGS, 2014), will be essential in achieving positive outcomes. All older adult postsurgical patients must be assessed and screened for:

  1. Falls (AGS, 2007)
  2. Frailty (AGS, 2007)
  3. Inappropriate medication use (AGS, 2012)
  4. Postoperative atelectasis (AGS, 2007)
  5. Postoperative delirium (AGS, 2007, 2014)
  6. Postoperative ileus (AGS, 2007)
  7. PONV (ASPAN, 2006)
  8. Postoperative pain (AGS, 2007, 2014)
  9. Pressure injuries (AGS, 2007)
  10. SSI (TJC, 2019)
  11. VTE (AGS, 2007; AHRQ, 2012)
  12. Restraint use (McGory et al., 2009)

C.  Other epidemiologically significant assessment parameters, depending on the specific patient scenario, would include screening patients for CAUTI, CLABSI, and VAP. The nurse is encouraged to be familiar with the current best practices related to these HAIs.

NURSING CARE STRATEGIES

A.  Unit admission

  1. Provide for high-quality handoff to include the following information:
    • Preoperative assessment of cognitive and functional status
    • List of comorbidities and preoperative home medications
    • Preoperative assessment for falls and pressure injuries
    • Course of surgery, including any surgical complications and interventions for such, blood loss, blood transfusions, and intraoperative fluid use
    • Description of surgical sites, including dressings and instructions for care
    • Identification of invasive lines, including arterial and/or venous catheters, urinary catheters, GI tubes, chest tubes, and any other drainage devices (e.g., Jackson–Pratt, t-tube)
    • Patient’s respiratory, cardiovascular, and cognitive status before transfer
    • Patient’s current pain level and description of pharmacological and nonpharmacological interventions (used since surgery) before transfer
  2. Perform comprehensive admission assessment to include:
    • Airway, breathing, circulation, and cognitive status
    • Pain and/or PONV, with immediate intervention if necessary
    • Surgical site or surgical dressing if in place and intact
    • Invasive lines, including line patency and visual inspection of site and dressing
    • Thorough skin examination, particularly on bony prominences that may have been damaged during surgery
    • ROM, mobility, and functional status
  3. Discuss plan of care with patient and caregivers, addressing pain management, mobility, nutrition, hydration, and functional status.
  4. Advocate for older adult patients who are unable to fully engage in their own care and for their designated caregiver.

B.  Duration of stay—comprehensive management to prevent postoperative complications and sentinel events

  1. Postoperative delirium/cognitive and sensory function
    • Use a validated tool to assess for delirium at least once per shift for up to 3 days postop.
    • Provide for continuity of care (familiar residents, nurses, and care technicians).
    • Provide continuous environmental and personal orientation.
    • Adequately manage pain (see Pain Management in subsequent discussion).
    • Avoid delirium-inducing medications such as benzodiazepines and anticholinergics (see also the AGS Beers Criteria; AGS, 2012).
    • Avoid use of routine sedation.
    • Provide for adequate fluid and nutrition intake (see Nutrition and Hydration in the following text).
    • Avoid use of restraints (see Restraints).
    • Avoid urinary catheterization or ensure prompt removal if in place (see HAIs in the following discussion).
    • Promote adequate sleep, including involving family and caregivers in managing daytime sleepiness.
    • Promote appropriate use of glasses, hearing aids, and other assistive devices.
    • Provide for adequate communication as necessary, including the use of pen/paper, nonverbal communication, or translators.
    • Minimize noise and patient care activities, as much as possible, during nighttime hours.
  2. Pain management
    • Perform comprehensive pain assessment during hourly rounding or, at a minimum, with each set of vital signs.
      • Rating of intensity (numeric, verbal, or visual scales)
      • Pain description to include location, characteristics, and impact of pain on function
      • Observation of signs of pain
      • Use appropriate scales (e.g., PAINAD) for patients with dementia
    • For pain scores greater than 5, initiate comprehensive pain management plan.
      • Pharmacological strategies
        • Preferable use of nonopioid pain medications
        • Address medication side effects, as necessary (e.g., morphine and constipation)
        • Avoid NSAIDs, if possible
      • Nonpharmacological strategies (e.g., massage, acupuncture, cognitive behavioral therapy, and distraction)
      • See Chapter 18, Preventing Functional Decline in the Acute Care Setting, for specific protocols on the management of pain in older adults
    • Reassess pain post intervention.
      • At 15 minutes, for IV medication interventions
      • At 1 hour for by-mouth medication interventions
      • Within 4 hours, at a minimum, for other interventions
  3. Nutrition and gastrointestinal complications
    • Assess for postoperative dysphagia.
      • Assessment by speech therapist if patient is at high risk for aspiration
      • Modification of diet as necessary (e.g., alteration in food consistency)
    • Assess for and aggressively manage PONV.
    • Implement a comprehensive nutrition plan.
      • Assessment by a registered dietitian specializing in geriatric care
      • Include adequate nutritional intake with supplementation as necessary
    • Implement a collaborative feeding plan, involving care technicians, family, and caregivers.
      • Maintain upright position while feeding and for at least 1 hour after.
      • Provide comprehensive oral care.
      • See Chapter 10, Assessment of Physical Function in the Older Adult and Chapter 25, Urinary Incontinence in the Older Adult for further discussion on nutrition and mealtime difficulties in older adults, respectively.
    • Assess for and manage constipation.
      • Avoid excessive use of anticholinergics and opioid medications, with quick transition to acetaminophen for mild to moderate pain.
      • Administer bowel stimulants (e.g., senna and bisacodyl) and osmotic agents (e.g., polyethylene glycol) as needed.
      • Provide adequate hydration (see Hydration).
      • Promote early ambulation and mobilization (see Mobility).
    • Assess for and manage diarrhea.
      • Maintain adequate hydration (see Hydration) and nutritional intake.
      • Collect stool samples, as ordered, to assess for C. difficile infection.
      • Provide prompt treatment if positive for C. difficile, including implementation of contact precautions and maintenance of adequate hand-hygiene regimens.
    • Manage postoperative ileus for GI surgery patients.
      • Promote early feeding and mobilization.
      • If NG decompression is used, continuously monitor for aspiration and postoperative pulmonary complications.
  4. Hydration and renal complications
    • Initiate oral hydration as soon as feasibly possible.
      • Promptly manage PONV.
      • Provide adequate hydration through IV fluids or tube feedings if oral hydration is not possible.
      • Provide comprehensive oral care.
    • Monitor fluid status at least once per shift for the first 5 days postop.
      • Weigh patient daily.
      • Accurately assess and document intake and output.
      • Assess for changes in blood pressure, mental status, and new-onset atrial fibrillation that could indicate dehydration.
    • Perform routine screening of serum electrolytes, urea nitrogen, and creatinine.
  5. Respiratory complications
    • Implement an aggressive pulmonary toilet regimen.
      • Promote use of incentive spirometer 10 times/hr.
      • Perform turn, cough, and deep-breathing exercises every 2 hours.
      • Provide chest percussion or chest physiotherapy as needed.
      • Promote early mobilization and ambulation (see Mobility).
      • Maintain head of bed in an elevated position.
      • Adequately manage pain (see earlier section on Pain Management).
      • Avoid excessive use of narcotics and sedatives.
    • Prevent VAP for intubated patients.
      • Implement a VAP bundle, including:
        • Elevation of the head of the bed between 30° and 45°
        • Daily sedative interruptions and assessment of readiness to extubate
        • Peptic ulcer disease prophylaxis
        • DVT prophylaxis
        • Daily oral care with chlorhexidine
  6. Infection prevention
    • Implement unit-wide HAI prevention programs.
      • Continuing education on the appropriate use of guidelines for HAI prevention
      • Enforce universal precaution and contact precaution protocols
      • Hand-hygiene protocols, including hand rubbing with alcohol-based products or scrubbing with soap and water if hands are visibly soiled:
        • Before touching the patient
        • Before clean and aseptic procedures
        • After contact with body fluids
        • After touching a patient
        • After touching a patient’s surroundings
    • Assess for signs/symptoms of infection.
      • Local signs/symptoms, including redness, tenderness, swelling, and warmth
      • Systemic signs/symptoms, including:
        • Fever greater than 38.0°C after postop day 2
        • Altered mental status, agitation, respiratory distress, tachycardia, and hypotension
        • Elevated white blood cell count
    • SSI
      • Perioperative prevention protocols, including prophylactic antibiotics and proper hair removal before incision (see Chapter 32, HIV Prevention and Care for the Older Adult on the perioperative care of older adult surgical patients)
      • For closed surgical incisions
        • Maintain sterile dressing for closed surgical incisions up to 48 hours.
        • Perform dressing changes using sterile technique.
        • Remove dressing after 48 hours, unless instructed otherwise.
      • For open surgical incisions
        • Pack wound with sterile gauze and cover with sterile dressing.
        • Consult with wound ostomy continence nurse for dressing-change regimen, which may continue post discharge.
      • Continue to assess for local and systemic signs/symptoms of infection
      • Aggressively treat SSI
        • Reopening and drainage of incision
        • Wound culture
        • Antibiotic treatment of infection if it becomes systemic
        • Contact precautions and adequate cleaning and disinfecting of equipment/environment if infectious agent is an MDRO
    • CAUTI
      • Implement CAUTI bundle.
        • Avoid unnecessary catheterizations.
        • Insert catheters using an aseptic technique, using the smallest possible catheter.
        • Review catheter necessity daily and remove promptly if use is no longer indicated.
      • Remove catheters placed during surgery by postop day 3. If not removed, provide documentation of the need for continued use.
      • Provide bedpan, urinal, bedside commode, and/or ambulation to the bathroom as an alternative to catheterization.
      • Involve the patient, family, and caregivers in catheter plan of care.
      • Continue to assess for local and systemic signs/symptoms of infection.
      • See Chapter 26, Prevention of Catheter-Associated Urinary Tract Infection, for further information on the prevention of CAUTI.
    • CLABSI
      • Implement a CLABSI bundle.
        • Maintain adequate hand-hygiene regimens.
        • Provide maximal barrier precautions when inserting lines.
        • Use chlorhexidine skin antiseptic before insertion.
        • Optimize site selection, avoiding the use of the femoral vein.
        • Review necessity of line daily and provide for prompt removal if no longer indicated.
      • Institute appropriate dressing-change regimens.
        • Use sterile gauze and a transparent, semipermeable dressing to cover the site.
        • Replace dressing if it becomes damp, loosened, or visibly soiled.
        • Replace gauze dressings every 2 days and transparent dressings every 7 days for short-term sites.
        • Use chlorhexidine-impregnated sponge dressing for temporary catheters if other measures are not working.
      • Replace administration sets at appropriate intervals.
        • At least every 7 days (but not less than 96 hours) for continuous or secondary infusion tubing
        • Within 24 hours for tubing involving blood, blood products, or fat emulsions
        • Every 6 to 12 hours for propofol infusion tubing
      • Disinfect (scrub) using an appropriate antiseptic when accessing catheter hubs, needleless injectors, and injection ports, using only sterile devices/equipment.
      • Educate the patient and monitor to prevent submersion of CVC sites in water during showering or bathing.
      • Continue to assess for local and systemic signs/symptoms of infection.
  7. Mobility, function, and frailty
    • Work with interprofessional team to develop a plan for re-enablement after surgery.
    • Incorporate the patient, family, and caregivers in the development of the plan of care for re-enablement.
    • Address barriers to plan, including lack of understanding of roles among healthcare team members, patient dependence and daytime sleepiness, scheduling conflicts, and patient care equipment (e.g., IV tubing, catheters, and SCDs).
    • Ensure physical therapy provides early assessment of the patient postsurgery and develops a mobility and strengthening plan, including the need for assistive devices.
    • Provide ambulation by postop day 2.
      •  If ambulation is not possible, then documentation should be provided as to why ambulation did not occur.
      • Provide ROM exercises for patients unable to ambulate.
      • If ROM exercises cannot be performed, then documentation should be provided as to why they did not occur.
    • Assist patient with ADL and IADL, while allowing for as much independence as possible.
  8. Fall prevention
    • Routine screening of fall risk, at least once per shift, using validated assessment tools
    • Use a multipronged approach to address falls, including:
      • Fall-risk screening on admission
      • Injury and injury risk-factors screening on admission
      • In-depth admission screening for any positive findings
      • Communication and education about the patient’s fall risk
      • Standardized interventions (e.g., armband identification, bed alarms, exercise and toileting regimens, pain relief) for any positive findings
      • Customized interventions for those at highest risk
    • If a fall occurs, perform a comprehensive fall evaluation within 24 hours to include the presence or absence of any signs/symptoms of injury and a review of medications that may have contributed to the fall.
    • See Chapter 19, Late-Life Depression, for a more detailed discussion on fall prevention in the older adult.
  9. Skin integrity
    • Address pressure injury prevention from admission to discharge, including:
      • Perform a comprehensive skin assessment and adequately document findings on admission to the unit.
      • Complete a pressure injury risk assessment at least daily using a validated assessment tool (e.g., Braden Scale).
      • Daily comprehensive assessment of skin integrity
      • Moisture management
        • Skin cleaning routinely and at times of soiling with mild cleansing agents
        • Use of skin moisturizers for dry skin
        • Use of absorbent underpads for excessive incontinence, perspiration, or wound drainage
      • Maintenance of adequate nutrition and hydration (see earlier sections Nutrition and Hydration)
      • Minimize pressure on skin and bony prominences
        • Turn and reposition the patient every 2 hours.
        • Use mattresses and cushions to redistribute pressure.
        • Address pressure from medical devices.
      • Use care when removing dressings, pads, tape, or leads in order to prevent skin tears.
    • See Chapter 28, Preventing Pressure Injuries and Skin Tears, for further information on the prevention of pressure injuries in older adults.
  10. VTE prevention
    • Institute VTE prophylaxis, including:
      • Assessment of VTE risk factors using validated measures (e.g., Caprini Risk Score)
      • Patient education about VTE risk
      • Early ambulation (see earlier section, Mobility)
      • Mechanical prophylaxis
        • Use of SCDs
        • Caution when using compression stockings as tight fit may impair circulation and lead to complications
        • ROM exercises for patients unable to ambulate
      • Pharmacological prophylaxis
        • Use of LMWH or LDUH, as indicated
        • Monitor for signs/symptoms of bleeding
  11. Restraint use
    • Restraint use should be avoided if at all possible.
    • If restraints must be used, address the target behavioral or safety issue with the patient and caregivers and document in the chart.
    • Use and document methods other than restraints that can be used as part of the plan of care.
    • Seek early removal of devices or lines that will allow for the discontinuation of restraint use.
    • Implement a care plan for the management of the patient in restraints.
      • Release from restraints and reposition every 2 hours.
      • Perform face-to-face assessment at least every 4 hours (with physician assessment before renewal of restraint order).
      • Provide 15-minute observations, more frequently if warranted by the patient’s condition.
      • Perform nurse-related interventions every 2 hours to address nutrition, hydration, toileting, personal hygiene, and ROM.
    • See Chapter 27, Physical Restraints and Side Rails in Acute Care and Critical Care Settings, for further information on the use of restraints in the hospitalized older adult.

C.  Discharge

  1. Assess the need for social support or home healthcare expected after discharge.
  2. Perform comprehensive discharge assessment of cognition and function (mobility, ADL, IADL) and compare with preoperative levels.
  3. Assess nutritional status before discharge.
  4. Perform comprehensive medication reconciliation.
    • Address both prior-use and new medications.
    • Facilitate education for new medications, including purpose of the drug, how to take it, expected side effects, and adverse side effects.
  5. Provide detailed explanation to patient, family, and caregivers about the plan of care, including:
    • Home health visits
    • Physical or occupational therapy appointments
    • Follow-up appointments
    • Education on the use of new equipment or devices, and activity
    • Education using teach-back strategies on performance of activities such as dressing changes, wound care, and medication administration

EVALUATION/EXPECTED OUTCOMES

A.  Patient outcomes

  1. Maintain patient safety across the postoperative continuum.
  2. Assess patient decision-making capacity and honor patient and family care decision choices.
  3. Receive a comprehensive unit admission screening and ongoing assessment, including, but not limited to, the following domains: cognitive and behavioral, cardiopulmonary, functional status, nutrition, medication, and frailty.
  4. Receive adequate pain control through implementation of a patient-centered pain management plan.
  5. Restore mobility and functioning to preoperative levels before discharge.
  6. Receive timely and accurate information related to plan of care, including transitional care and long-term follow-up.
  7. Patient will not develop postop complications such as delirium, HAI, VTE, cardiopulmonary adverse events, GI or renal complications, and pressure injuries.
  8. Patient will be free from adverse events such as medication errors and falls.
  9. Comprehensive discharge planning, including discharge assessment of cognitive, functional, and nutritional status; medication reconciliation; discharge location; and home health or other follow-up care.

B.  Provider outcomes

  1. Receive education and ongoing training on best practices in the care of the geriatric surgical patient.
  2. Assess patient’s and family’s decision-making capacity and involve the patient and family in the development of the plan of care.
  3. Provide patient and caregivers with timely and accurate information of patient’s condition and plan of care, including transitions.
  4. Participate in high-quality interprofessional collaboration throughout the postoperative stay, including rounding, handoff, pain management, early mobility, nutrition and hydration, medication reconciliation, and transitional care.
  5. Use an evidence-based teamwork system to improve communication and teamwork skills (e.g., TeamSTEPPS) for patient safety (AHRQ, n.d.).
  6. Employ consistent and accurate documentation throughout the postoperative stay.
  7. Apply teach-back method in all patient and family education encounters that are culturally competent and patient centered.
  8. Staff nurses achieve a minimum of a bachelor’s degree and obtain practice-specific certification (e.g., gerontological nursing).
  9. Organize and participate in unit-based practice and quality-improvement councils.
  10. Receive education and undergo competency verification that addresses the specialized knowledge and skills related to the care of older adults (AORN, 2015).

C.  Systems outcomes

  1. Uphold patient safety and quality in the care of older adults through policy and social statements (e.g., safety language in hospital’s mission).
  2. Review and align existing institutional policies and procedures with the latest national standards (see Relevant Practice Guidelines section).
  3. Facilitate and sustain interprofessional geriatric care teams.
  4. Establish a system of reporting patient safety issues (e.g., falls, medication errors, HAI, restraint use, etc.) across the postoperative continuum to identify opportunities for improvement.
  5. Adopt specific patient safety initiatives for older adults that include use of informatics, algorithms, checklists, and personnel oversight.
  6. Develop ongoing quality-improvement initiatives consistent with practice guidelines.
  7. Facilitate clinical rotations for nursing students across postoperative units to promote experiential learning for prelicensure students.
  8. Enforce SSI, CAUTI, CLABSI, and VAP prevention policies, and conduct SSI surveillance based on CDC and TJC guidelines.
  9. Organize and support interprofessional unit-based practice and quality-improvement councils (IHI, n.d.).
  10. Demonstrate a commitment to culture of safety based on openness and mutual trust (e.g., patient safety leadership walk rounds; IHI, n.d.).

RELEVANT PRACTICE GUIDELINES

A.  ACS NSQIP and the AGS’s Best Practices Guidelines for Optimal Preoperative Assessment of the Geriatric Surgical Patient (2012): https://www.facs.org/~/media/files/quality%20programs/nsqip/acsnsqipagsgeriatric2012guidelines.ashx

B.  AGS Clinical Practice Guideline for Postoperative Delirium in Older Adults (2014): http://onlinelibrary.wiley.com/doi/10.1111/jgs.13281/epdf

C.  AGS Assessing Care of Vulnerable Elders-3 Quality Indicators (2007)

D.  AORN Position Statement on Care of the Older Adult in Perioperative Settings (2015): https://www.aorn.org/guidelines/clinical-resources/position-statements

E.  CDC—Guideline for Prevention of Surgical Site Infection (2017): https://jamanetwork.com/journals/jamasurgery/fullarticle/2623725

F.   Evidence-Based Guidelines for Selected Hospital-Acquired Conditions: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Downloads/2016-HAC-Report.pdf

G.  IHI—How-to Guide: Prevent Surgical Site Infections: http://www.ihi.org/resources/Pages/Tools/HowtoGuidePreventSurgicalSiteInfection.aspx

H.  The Joint Commission. (2019). National Patient Safety Goals: https://www.jointcommission.org/assets/1/6/NPSG_Chapter_HAP_Jan2019.pdf.

I.   Surgical Care Improvement Guidelines (2014): http://www.jointcommission.org/assets/1/6/SCIP-FactSheet_010114v4.3.pdf

J.   SCIP Core Measure Set. (2014): http://www.jointcommission.org/assets/1/6/SCIP-Measures-012014.pdf

K.  Enhanced Recovery After Surgery (ERAS) Guidelines: http://erassociety.org/guidelines/list-of-guidelines

L.  VTE Prophylaxis Guidelines for Surgical Patients: https://www.clinicalkey.com/#!/content/playContent/1-s2.0-S0039610914002126

ABBREVIATIONS

ACS            American College of Surgeons

ADL            Activities of daily living

AGS            American Geriatrics Society

CAUTI        Catheter-associated urinary tract infections

CDC            Centers for Disease Control and Prevention

CLABSI      Central line–associated bloodstream infections

CVC            Central venous catheter

DVT            Deep vein thrombosis

ERAS          Enhanced recovery after surgery

GI                Gastrointestinal

HAI             Hospital-acquired infection

IADL          Instrumental activities of daily living

ICU             Intensive care unit

IV                Intravenous

LDUH         Low-dose unfractionated heparin

LMWH        Low-molecular-weight heparin

MDRO        Multidrug-resistant organisms

NG              Nasogastric

NSAIDs      Nonsteroidal anti-inflammatory drugs

NSQIP        National Surgical Quality Improvement Program

PACU         Postanesthesia care unit

PADSS        Postanesthetic discharge scoring system

PAINAD     Patient assessment in advanced dementia

PONV         Postoperative nausea and vomiting

PSI              Patient safety indicators

QOL            Quality of life

ROM           Range of motion

SCD            Sequential compression device

SCIP            Surgical care improvement project

SSI              Surgical site infection

TJC              The Joint Commission

VAP            Ventilator-associated pneumonia

VTE             Venous thromboembolism

WHO           World Health Organization

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Boltz PhD, RN, GNP-BC, FGSA, FAAN, M., Capezuti PhD, RN, FAAN, E., Zwicker DrNP, APRN, BC, D., & Fulmer PhD, RN, FAAN, T. T. (2020). Evidence-Based Geriatric Nursing Protocols for Best Practice (6th ed.). Springer Publishing. Retrieved November 4, 2020, from https://www.springerpub.com/evidence-based-geriatric-nursing-protocols-for-best-practice-9780826188144.html#description

REFERENCES

Agency for Healthcare Research and Quality. (2012). Venous thromboembolism prophylaxis (Guideline NGC-9541). Bloomington, MN: Institute for Clinical Systems Improvement. Evidence Level I.

Agency for Healthcare Research and Quality. (2014). Fact sheet on patient safety indicators. Retrieved from http://www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/a1b_psifactsheet.pdf. Evidence Level V.

Aiken, L. H., Sloane, D. M., Bruyneel, L., Van de Heede, K., Griffiths, P., Busse, R., … Sermeus, W. (2014). Nurse staffing and education and hospital mortality in nine European countries: A retrospective observational study. Lancet, 383(9931), 1824–1830. doi:10.1016/S0140–6736(13)62631–8. Evidence Level IV.

Aldrete, J., & Kroulik, D. A. (1970). Postanesthetic recovery score. Anesthesia and Analgesia, 49(6), 924–934. doi:10.1213/00000539-197011000-00020. Evidence Level II.

American Geriatrics Society. (2007). Assessing care of vulnerable elders-3 quality indicators. Journal of the American Geriatrics Society, 55(Suppl. 2), S464–S487. doi:10.1111/j.1532-5415.2007.01329.x. Evidence Level VI.

American Geriatrics Society. (2012). American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society, 60(4), 616–631. doi:10.1111/j.1532–5415.2012.03923.x. Evidence Level I.

American Geriatrics Society. (2014). Clinical practice guideline for postoperative delirium in older adults. Retrieved from http://geriatricscareonline.org/ProductAbstract/american-geriatrics-society-clinical-practice-guideline-for-postoperative-delirium-in-older-adults/CL018. Evidence Level I.

American Society of PeriAnesthesia Nurses. (2006). ASPAN’S evidence-based clinical practice guideline for the prevention and/or management of PONV/PDNV. Journal of PeriAnesthesia Nursing, 21(4), 230–250. doi:10.1016/j.jopan.2006.06.003. Evidence Level I.

Anderson, D. J., Kaye, K. S., Classen, D., Arias, K. M., Podgorny, K., Burstin, H., … Yokoe, D. S. (2014). Strategies to prevent surgical site infections in acute care hospitals. Infection Control and Hospital and Epidemiology, 35(6), 605–627. doi: 10.1086/676022. Evidence Level V.

Association of periOperative Registered Nurses. (2015). AORN Position statement on care of the older adult in perioperative -settings. Retrieved from https://www.aorn.org/guidelines/clinical-resources/position-statements. Evidence Level VI.

Bashaw, M., & Scott, D. N. (2012). Surgical risk factors in geriatric perioperative patients. AORN Journal, 96(1), 58–73. doi: 10.1016/j.aorn.2011.05.025. Evidence Level V.

Baumgarten, M., Margolis, D. J., Localio, A. R., Kagan, S. H., Lowe, R. A., Kinosian, B., … Mehari, T. (2008). Extrinsic risk factors for pressure ulcers early in the hospital stay: A nested case–control study. Journal of Gerontology, 63(4), 408–413. doi:10.1093/gerona/63.4.408. Evidence Level III.

Bhardwaj, R., Pickard, R., Carrick-Sen, D., & Brittain, K. (2012). Patients’ perspectives on timing of urinary catheter removal after surgery. British Journal of Nursing, 21(18), S4–S9. doi:10.12968/bjon.2012.21.Sup18.S4. Evidence Level IV.

Blegen, M. A., Goode, C. J., Park, S. H., Vaughn, T., & Spetz, J. (2013). Baccalaureate education in nursing and patient outcomes. Journal of Nursing Administration, 43(2), 89–94. doi:10.1097/NNA.0b013e31827f2028. Evidence Level IV.

Centers for Disease Control and Prevention. (2010). National Center for Health Statistics National hospital discharge survey 2010. Retrieved from http://www.cdc.gov/nchs/data/nhds/4procedures/2010pro4_numberprocedureage.pdf. Evidence Level IV.

Chung, F., Chan, V., & Ong, D. (1995). A post anaesthetic discharge scoring system for home readiness after ambulatory surgery. Journal of Clinical Anesthesia, 7(6), 500–506. doi:10.1016/0952–8180(95)00130-A. Evidence Level II.

Currie, L. (2008). Fall and injury prevention. In R. G. Hughes (Ed.), Patient safety and quality: An evidence-based handbook for nurses (Chapter 10). Rockville, MD: Agency for Healthcare Research and Quality. Evidence Level V.

Dasgupta, M., Rolfson, D. B., Stolee, P., Borrie, M. J., & Speechley, M. (2009). Frailty is associated with postoperative complications in older adults with medical problems. Archives of Gerontology and Geriatrics, 48(1), 78–83. doi:10.1016/j.archger.2007.10.007. Evidence Level IV.

Deiner, S., Westlake, B., & Dutton, R. P. (2014). Patterns of surgical care and complications in elderly adults. Journal of the American Geriatrics Society, 62(5), 829–835. doi:10.1111/jgs.12794. Evidence Level IV.

Dobesh, P. P. (2009). Economic burden of venous thromboembolism in hospitalized patients. Pharmacotherapy, 29(8), 943–953. doi:10.1592/phco.29.8.943. Evidence Level V.

Gajdos, C., Kile, D., Hawn, M., Finlayson, E., Henderson, W. G., & Robinson, T. N. (2013). Advancing age and 30-day adverse outcomes after nonemergent general surgeries. Journal of the American Geriatrics Society, 61(9), 1608–1614. doi:10.1111/jgs.12401. Evidence Level IV.

Hughes, S., Leary, A., Zweizig, S., & Cain, J. (2013). Surgery in elderly people: Preoperative, operative and postoperative care to assist healing. Best Practice & Research: Clinical Obstetrics & Gynecology, 27(5), 753–765. doi:10.1016/j.bpobgyn.2013.02.006. Evidence Level I.

Inouye, S. K., Zhang, Y., Jones, R. N., Kiely, D. K., Yang, F., & Marcantonio, E. R. (2007). Risk factors for delirium at discharge: Development and validation of a predictive model. Archives of Internal Medicine, 167(13), 1406–1413. doi:10.1001/archinte.167.13.1406. Evidence Level III.

Institute for Healthcare Improvement. (2011a). How-to guide: Prevent catheter-associated urinary tract infections. Cambridge, MA: Author. Evidence Level V.

Institute for Healthcare Improvement. (2011b). How-to guide: Prevent pressure ulcers. Cambridge, MA: Author. Evidence Level V.

The Joint Commission. (2019). 2019 Hospital national patient safety goals. Retrieved from https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2019_hap_npsgs_final2.pdf?db=web&hash=D549154BF89A129B026D9F853D889F69. Evidence Level VI.

Kaiser, M. J., Bauer, J. M., Rämsch, C., Uter, W., Guigoz, Y., Cederholm, T., … Sieber, C. C. (2010). Frequency of malnutrition in older adults: A multinational perspective using the Mini Nutritional Assessment. Journal of the American Geriatrics Society, 58(9), 1734–1783. doi:10.1111/j.1532–5415.2010.03016.x. Evidence Level IV.

Kaye, K. S., Marchaim, D., Chen, T., Baures, T., Anderson, D. J., Choi, Y., … Schmader, K. E. (2014). Effect of nosocomial bloodstream infections on mortality, length of stay, and hospital costs in older adults. Journal of the American Geriatrics Society, 62(2), 306–311. doi:10.1111/jgs.12634. Evidence Level IV.

Lagoo-Deenadayalan, S. A., Newell, M. A., & Pofahl, W. E. (2011). Common perioperative complications in older patients. In R. A. Rosenthal, M. E. Zenilman, & M. R. Katlic (Eds.), Principles and practice of geriatric surgery (pp. 361–376). New York, NY: Springer Publishing Company. Evidence Level V.

Makary, M. A., Segev, D. L., Pronovost, P. J., Syin, D., Bandeen-Roche, K., Patel, P., … Fried, L. P. (2010). Frailty as a predictor of surgical outcomes in older patients. Journal of the American College of Surgeons, 210(6), 901–908. doi:10.1016/j.archger.2007.10.007. Evidence Level IV.

McGory, J. L., Kao, K. K., Shekelle, P. G., Rubenstein, L. Z., Leonardi, M. J., Parikh, J. A., … Ko, C. Y. (2009). Developing quality indicators for elderly surgical patients. Annals of Surgery, 250(2), 338–347. doi:10.1097/SLA.0b013e3181ae575a. Evidence Level I.

Odom-Forren, J. (2015). Concepts basic to perioperative nursing. In J. C. Rothrock (Ed.), Alexander’s care of the patient in surgery (15th ed., pp. 270–294). St. Louis, MO: Mosby. Evidence Level VI.

Scandrett, K. G., Zuckerbraun, B. S., & Peitzman, A. B. (2015). Operative risk stratification in the older adult. Surgical Clinics of North America, 95(1), 149–172. doi:10.1016/j.suc.2014.09.014. Evidence Level IV.

Schofield, P. A. (2014). The assessment and management of peri-operative pain in older adults. Anaesthesia, 69(Suppl. 1), 54–60. doi:10.1111/anae.12520. Evidence Level V.

Shorr, R. I., Guillen, M. K., Rosenblatt, L. C., Walker, K., Caudle, C. E., & Kritchevsky, S. B. (2002). Restraint use, restraint orders, and the risk of falls in hospitalized patients. Journal of the American Geriatrics Society, 50(3), 526–529. doi: 10.1046/j.1532-5415.2002.50121.x. Evidence Level III.

Weiss, A. J., & Elixhauser, A. (2014). Trends in operating room procedures in U.S. hospitals, 2011–2011 (HCUP Statistical Brief No. 171). Retrieved from https://www.hcup-us.ahrq.gov/reports/statbriefs/sb171-Operating-Room-Procedure-Trends.pdf. Evidence Level VI.