BACKGROUND

A.  Definition

1. Perioperative nursing is defined as the “delivery of comprehensive care within preoperative, intraoperative and postoperative periods of the patient’s experience during operative and other invasive procedure” (Steelman, 2015, p. 1). The high-stake demands of perioperative patient care, the increasing number of older adults undergoing surgery, and the unique vulnerabilities of this population require the translation of science-based interprofessional collaboration. The use of the nursing process, critical thinking, and evidence-based practice models will ensure patient safety and quality for older adult patients and their families.

B.  Etiology/epidemiology

1. The demand for surgical procedures is expected to rise with the aging population.
2. In 2014, 10.1 million inpatient hospital stays involved operating room (OR) procedures, with a total of 14.2 million OR procedures (McDermont et al., 2017).
3. Procedures that place the patient at the most risk include those that involve general anesthesia or deep sedation (TJC, 2019b).
4. Failure-to-rescue was more than two times higher in patients older than 75 years compared with those younger than 75 years (26.0% vs. 10.3% at high-mortality hospitals, p less than 001; Sheetz et al., 2014).
5. Death (failure-to-rescue) among surgical inpatients with treatable serious complications and the percentage of major surgical inpatients who experience hospital-acquired complications (e.g., sepsis, pneumonia, gastrointestinal bleeding, shock/cardiac arrest, VTE) are nursing-sensitive measures and publicly reportable events (NQF, 2017).
6. A 10% increase in the proportion of staff nurses with a bachelor’s degree is associated with a 7% decrease in the risk of death among patients following common surgeries in an acute care setting (Aiken et al., 2014).
7. Lower postoperative VTE and shorter length of stay are associated with higher percentage of RNs with baccalaureate or higher degrees (Blegen et al., 2013).
8. Perioperative beta-blocker therapy is associated with a reduced risk of in-hospital death among high-risk, but not low-risk, patients undergoing major noncardiac surgery. Patient safety may be enhanced by increasing the use of beta-blockers in high-risk patients (Lindenauer et al., 2005).

PARAMETERS OF ASSESSMENT

A.  The ACS-NSQIP and the AGS’s Best Practices Guidelines for Optimal Preoperative Assessment of the Geriatric Surgical Patient recommend the following preoperative assessment parameters (Chow et al., 2012):

1. Assess the patient’s cognitive ability and capacity to understand the anticipated surgery.
2. Screen the patient for depression.
3. Identify the patient’s risk factors for developing postoperative delirium.
4. Screen for alcohol and other substance abuse/dependence.
5. Perform a preoperative cardiac evaluation according to the ACC/AHA algorithm for patients undergoing noncardiac surgery.
6. Identify the patient’s risk factors for postoperative pulmonary complications and implement appropriate strategies for prevention.
7. Document functional status and history of falls.
8. Determine baseline frailty score.
9. Assess the patient’s nutritional status and consider preoperative interventions if the patient is at severe nutritional risk.
10. Take an accurate and detailed medication history, and consider appropriate perioperative adjustments. Monitor for polypharmacy.
11. Determine the patient’s treatment goals and expectations in the context of the possible treatment outcomes.
12. Determine the patient’s family and social support system.
13. Order appropriate preoperative diagnostic tests based on unique clinical scenarios of elderly patients.

B.  For comprehensive preoperative evaluation, the provider should inquire about symptoms, such as angina, dyspnea, syncope, and palpitations, as well as history of heart disease, including ischemic, valvular, or myopathic disease; and history of hypertension, diabetes, chronic kidney disease, and cerebrovascular or peripheral artery disease (Bilimoria et al., 2013).

C.  For geriatric fracture patients, recommended preoperative optimization focus includes (Nicholas, 2014b):

1. Assurance of adequate intravascular volume
2. Medication adjustment in anticipation of intraoperative hypotension
3. Judicious continuation of beta-blockers and other antiarrhythmic chronotropic drugs for selected patients
4. Pain management
5. Prevention of polypharmacy and excessive laboratory testing

D.  Orthopedic surgery services should ensure that patients are operated on within 1 or 2 days of admission when cleared for surgery (Moja et al., 2012).

E.  In patients assessed to be at intermediate or high cardiovascular risk, a referral to a cardiologist for further evaluation is recommended (Fleisher et al., 2014).

F.   Adjust dose of medications according to renal function using GFR parameters.

G.  Implement the 2014 SCIP Core Measure Set (TJC, 2014).

1. Prophylactic antibiotic received within 1 hour before surgical incision
2. Prophylactic antibiotics discontinued within 24 hours after surgery end time
3. Cardiac surgery patients with controlled postoperative blood glucose
4. Surgery patients with appropriate hair removal
5. Urinary catheter removed on POD 1 or 2 with day of surgery being day 0
6. Perioperative temperature management
7. Those who were under beta-blocker therapy before arrival received a beta-blocker during the perioperative period.
8. Received appropriate VTE prophylaxis within 24 hours before surgery to 24 hours after surgery

H.  Improve medication safety within the perioperative settings through the following measures: (TJC, 2019b)

1. Label all medications, medication containers, and other solutions on and off the sterile field in perioperative and other procedural settings.
2. Label medications and solutions that are not immediately administered. This applies even if there is only one medication being used.
3. Label any medication or solution transferred from the original packaging to another container.
4. Verify all medication or solution labels both verbally and visually.
5. Label each medication or solution as soon as it is prepared, unless it is immediately administered.
6. Discard immediately any medication found unlabeled.
7. Remove all labeled containers on the sterile field, and discard their contents at the conclusion of the procedure.
8. Review all medications and solutions both on and off the sterile field.

I.   Implement SSI prevention guidelines (TJC, 2019b)

1. Educate staff and licensed independent practitioners involved in surgical procedures about SSIs and the importance of prevention.
2. Educate patients who are undergoing a surgical procedure and their families about SSI prevention as needed.
3. Implement policies and practices aimed at reducing the risk of SSI.
4. Conduct periodic risk assessments for SSI.
5. Select SSI measures using best practices or evidence-based guidelines.
6. Monitor compliance with best practices or evidence-based guidelines.
7. Evaluate the effectiveness of prevention efforts.

J.   Consistently implement TJC’s Time Out and Universal Protocol guidelines that include the following (TJC, 2019b):

1. Implement a preprocedure process to verify the correct procedure, for the correct patient, at the correct site. Involve the patient in the verification process when possible.
2. Identify the items that must be available for the procedure, and use a standardized list to verify their availability.
3. Match the items that are to be available in the procedure area to the patient.
4. Identify those procedures that require marking of the incision or insertion site. At a minimum, sites are marked when there is more than one possible location for the procedure and when performing the procedure in a different location would negatively affect quality or safety.
5. Mark the procedure site before the procedure is performed and, if possible, with the patient involved.

NURSING CARE STRATEGIES

Synthesis of perioperative best practices guidelines (AORN, 2006; Bratzler et al., 2013; Chow et al., 2012; Fleisher et al., 2014; TJC, 2019b) provides collaborative nursing opportunities across the perioperative continuum.

A.  Preoperative

1. Perform a comprehensive assessment: History and physical examination, cognitive and functional assessment, medication reconciliation, nutrition, advance directives, and so on, using validated tools and checklists (Chow et al., 2012).
2. Collect nursing-sensitive data during interview with patient and family.
3. Review, document, and interpret pertinent laboratory and diagnostic findings, specific to patient’s clinical scenario.
4. Assess, review, and document vital signs, including glucose finger stick (e.g., blood sugar goal) and other disease-specific lab values as appropriate.
5. Educate patient and family using teach-back method on routine (e.g., consent, fasting requirement [2 hours for clear liquid and 6 hours for light meal], patient escort) and special topics (e.g., bowel preparation or withholding specific drugs, such as metformin, after an angiogram).
6. Conduct medication reconciliation (TJC, 2019b), focusing on Beers Criteria for potentially inappropriate medication use in older adults (AGS, 2015).
7. Evaluate use of cardiac drugs throughout perioperative continuum. In particular, the guidelines for perioperative use of beta-blockers recommend to (Fleisher et al., 2014):
   • Continue beta-blockers, particularly those with independent cardiac indications such as arrhythmia or history of myocardial infarction.
   • Continue beta-blockers in patients undergoing intermediate risk or vascular surgery with known coronary artery disease or with multiple clinical risk factors for ischemic heart disease.
   • Titrate to a heart rate of 60 to 80 beats/min in the absence of hypotension.
   • Titrated rate control with beta-blockers should continue during the intraoperative and postoperative periods.
   • Beta-blockers should be tapered off slowly to minimize risk of withdrawal.
8. Inform patient or caregiver to bring all home medications on the day of procedure, especially for outpatient same-day surgery.
9. Reinforce appropriate VTE prophylaxis within 24 hours before surgery (Cataife et al., 2014; TJC, 2019b).
10. Facilitate appropriate hair removal before surgery (TJC, 2019b).
11. Implement POSH interventions for elective surgery patients (McDonald et al., 2018).
12. Provide carbohydrate loading as per hospital protocol (Bilku et al., 2014).
13. Calculate risk using the Surgical-Risk Calculator (http://riskcalculator.facs.org/RiskCalculator/PatientInfo.jsp; Bilimoria et al., 2013).

B.  Intraoperative

1. Participate in high-quality interprofessional Time Out and handoff procedure (TJC, 2019b).
2. Safely administer antibiotics within 60 minutes before surgical incision. For some agents that require longer administration time, such as fluoroquinolones and vancomycin, infusion can begin 120 minutes before incision. Redosing of antibiotic is recommended if the procedure exceeds two half-lives of the drug or if there is excessive blood loss during surgery (Bratzler et al., 2013).
3. Safely administer beta-blocker during the perioperative period if applicable (Blessberger et al., 2018).
4. Assess and manage patient temperature intraoperatively (e.g., active warming to maintain greater than or equal to 96.8°F 30 minutes before anesthesia or 15 minutes post anesthesia end time).
5. Maintain asepsis and sterility of the operative field.
6. Keep OR doors closed during surgery except as needed for passage of equipment, personnel, and the patient (Berríos-Torres, 2009).
7. Monitor intraoperative systems processes throughout the procedure.
8. Follow procedure and policy related to prevention on unintended retention of foreign objects intraoperatively.
9. Follow CDC infection control guidelines in handling infectious materials (e.g., specimen, equipment).
10. Use supplemental oxygen judiciously during the perioperative period (Wetterslev et al., 2015).
11. Implement pressure injury prevention measures (Spruce, 2017).

C.  Postoperative

1. Perform high-quality handoff during care transitions (e.g., between the OR and PACU using standardized forms or checklists; TJC, 2019b).
2. Maintain patient safety during transfer and handoff.
3. Monitor vital signs per institution protocol, including hemodynamic profile and glucose finger stick, if applicable.
4. Assess and document pain, including pharmacologic and nonpharmacologic interventions.
5. Maintain patient temperature at greater than or equal to 96.8°F.
6. Monitor blood sugar as clinically applicable (e.g., SCIP measure for cardiac surgery patients is to keep serum glucose greater than or equal to 200 mg/dL 18 to 24 hours postoperation; Fry, 2008).
7. Monitor patient’s GFR, assess patient’s urine output and weight, and follow protocol/procedures in administering nephrotoxic medications.
8. Coordinate medication reconciliation, with special attention to beta-blockers (TJC, 2019b) and antidiabetic medications.
9. Implement safe VTE prophylaxis within 24 hours before surgery or 24 hours postoperation (e.g., compression stockings or pneumatic compression devices, heparin, low-dose heparin; Buesing et al., 2015; TJC, 2019b).
10. Protect primary closure incisions with sterile dressing for 24 to 48 hours post operation (Fry, 2008).
11. Discontinue antibiotics within 24 hours after surgery end time (48 hours for cardiac surgery; Fry, 2008).
12. Provide timely and accurate information to patient and family members.
13. Resume diet as clinically appropriate.
14. Avoid medications that induce delirium postoperatively (e.g., anticholinergics, sedative-hypnotics, diphenhydramine; American Geriatrics Society [AGS], 2012).
15. Use validated delirium screening instruments (AGS, 2014).
16. Implement early mobility protocol (Goldfarb, Afilalo, Chan, Herscovici, & Cercek, 2018).
17. Implement nonpharmacologic interventions to improve sleep (Tamrat, Huynh-Le, & Goyal, 2014).
18. Coach patient to use incentive spirometer.

EVALUATION/EXPECTED OUTCOMES

A.  Patient outcomes

1. Maintain patient safety across the perioperative continuum.
2. Assess patient decision-making capacity, and honor patient and family care decision choices.
3. Receive a comprehensive preoperative screening, including, but not limited to, the following domains: Cognitive and behavioral, cardiopulmonary, functional status, nutrition, medication, and frailty.
4. Undergo clinically relevant preoperative testing (e.g., blood, urine, radiologic, EKG, etc.) based on best practice evidence (see ACS-NSQIP/AGS Best Practice Guidelines Optimal Preoperative Assessment of the Geriatric Surgical Patient).
5. Optimize function across the perioperative continuum.
6. Receive timely and accurate information related to plan of care, including transitional care and long-term follow-up.
7. Patient will not develop postoperative complications such as SSI, DVT, cardiopulmonary adverse events, falls, and pressure injuries.
8. Patient will be free from adverse events such as medication errors, wrong site-procedure events, anesthesia-related events, and issues.

B.  Provider outcomes

1. Receive education and ongoing training on best practices in the care of the geriatric surgical patient.
2. Assess patient’s decision-making capacity and obtain informed consent.
3. Implement latest guidelines for antimicrobial prophylaxis in surgery (e.g., receive antibiotics within 60 minutes before surgical incision).
4. Participate in high-quality interprofessional collaboration across the perioperative continuum, including rounding, handoff, Time Out/Universal Protocol, pain management, SSI prevention, early mobility, nutrition, 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. Apply teach-back method in all patient education encounters that are culturally competent and patient-centered.
7. Employ consistent and accurate documentation of care throughout the perioperative continuum.
8. Provide patient and caregivers with timely and accurate information of patient’s condition and plan of care, including care transitions.
9. Perioperative nurses achieve a minimum of bachelor’s degree and obtain practice-specific certification (e.g., gerontological nursing, CNOR).
10. Organize and participate in unit-based practice and quality-improvement councils.

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 latest national standards (see “Practice Guidelines” section).
3. Facilitate and sustain interprofessional geriatrics care teams.
4. Monitor, evaluate, and disseminate hospital performance in perioperative benchmarks such as Time Out/Universal Protocol, antibiotic prophylaxis, DVT prophylaxis, and other site-specific parameters.
5. Establish a system of reporting patient safety issues (e.g., falls, medication errors, unintended retention of foreign object, wrong-patient, wrong-site, wrong-procedure, etc.) across the perioperative continuum to identify opportunities for improvement.
6. Adopt specific patient safety initiatives for older adults that include use of informatics, algorithms, checklists, and personnel oversight.
7. Develop ongoing quality-improvement initiatives consistent with SCIP core measures and other practice guidelines.
8. Facilitate clinical rotation for nursing students across the perioperative units to promote experiential learning for prelicensure students.
9. Enforce SSI prevention policies and conduct SSI surveillance based on CDC and TJC guidelines.
10. Organize and support interprofessional unit-based practice and quality-improvement councils (IHI, n.d.).
11. Demonstrate a commitment to culture of safety based on openness and mutual trust (e.g., patient safety leadership walk rounds; IHI, n.d.).
12. Monitor hospital-acquired perioperative pressure injuries.

VII. RELEVANT PRACTICE GUIDELINES

A.  AORN Guidance Statement (2006). Safe Medication Practices in Perioperative Settings Across the Life Span: https://aornjournal.onlinelibrary.wiley.com/doi/full/10.1016/S0001-2092%2806%2960495-X?sid=nlm%3Apubmed

B.  Fleisher, L. A., Fleischmann, K. E., Auerbach, A. D., Barnason, S. A., Beckman, J. A., Bozkurt, B., … Wijeysundera, D. N. (2014). 2014 ACC/AHA Guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery. Retrieved from http://www.onlinejacc.org/content/64/22/e77

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

D.  ASHP (2013). Antimicrobial Prophylaxis in Surgery: https://www.ashp.org/-/media/assets/policy-guidelines/docs/therapeutic-guidelines/therapeutic-guidelines-antimicrobial-prophylaxis-surgery.ashx

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

F.   PeriAnesthesia Pain and Comfort Clinical Guidelines (ASPAN): www.aspan.org/Clinical-Practice/Clinical-Guidelines/Pain-and-Comfort

G.  PONV/PDNV Guidelines: www.aspan.org/Portals/6/docs/ClinicalPractice/Guidelines/PONV-PDNV_Clinical_Guideline_Aug_2006_JoPAN.pdf

H.  2014 SCIP Core Measure Set: www.jointcommission.org/assets/1/6/SCIP-Measures-012014.pdf

I.   AORN (2015). Guidelines for Perioperative Practice: www.aorn.org/guidelines/#NewIn2015

J.   American Society of Anesthesiologists Committee on Standards and Practice Parameters. (2011). Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures: an updated report by the American Society of Anesthesiologists Committee on Standards and Practice Parameters, Anesthesiology, 114(3) 495–511. doi:10.1097/ALN.0b013e3181fcbfd9.

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

ABBREVIATIONS

ACC/AHA        American College of Cardiology/American Heart Association

ACS-NSQIP    American College of Surgeons—National Surgical Quality Improvement Program

ADE                  Adverse drug event

AGS                  American Geriatrics Society

AORN              Association of periOperative Registered Nurses

ASA                  American Society of Anesthesiologists

ASHP                American Society of Health-System Pharmacists

ASPAN             American Society of PeriAnesthesia Nurses

CDC                  Centers for Disease Control and Prevention

CNOR               Operative Nursing Certification

DVT                  Deep vein thrombosis

GFR                  Glomerular filtration rate

HAI                   Hospital-acquired infection

ME                    Medication error

OR                    Odds ratio

PACU               Postanesthesia care unit

POD                  Postoperative day

PONV/PDNV   Postoperative and postdischarge nausea and vomiting

QOL                  Quality of life

SCIP                 Surgical Care Improvement Project

SSI                    Surgical site infection

TJC                    The Joint Commission

VTE                  Venous thromboembolism

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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

Chapter 38:  Lim, F. & Slater, L. (2021) Perioperative Care of the Older Adult.  In M. Boltz, E. Capezuti, D. Zwicker & T. Fulmer (eds.).  Evidence-Based Geriatric Nursing Protocols for Best Practice (6th ed. pp 697 - 720).   New York: Springer.