Perioperative Care of the Older Adult

 

OVERVIEW

A. In 2018, the most commonly performed operative procedures among persons older than 65 were knee arthroplasty, PCI, hip arthroplasty, spinal fusion, saphenous vein harvest, femur fixation, and colectomy (McDermott & Liang, 2021a).

B. Each 10-percentage point reduction in the proportion of professional nurses is associated with an 11% increase in the odds of death among surgical patients (Aiken et al., 2017).

C. Lower rates of postoperative VTE and shorter LOS have also been found in hospitals with a higher percentage of RNs with baccalaureate or higher degrees (Blegen et al., 2013).

D. Comprehensive preoperative geriatric assessment correlates with positive postoperative outcomes in older patients (Miller et al., 2022).

 

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 (Cuming, 2019). 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.

B. Etiology/epidemiology

  1. The demand for surgical procedures is expected to rise with the aging population.
  2. In 2018, 9.6 million inpatient stays involved OR procedures, totaling $210.3 billion in aggregate costs (McDermott & Liang, 2021a).
  3. Procedures that place the patient at the most risk include those that involve general anesthesia or deep sedation (TJC, 2022).
  4. Failure-to-rescue was more than two times higher in patients older than 75 years compared with those younger than 75 years (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. 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.

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 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 older adult patients.

B. For comprehensive preoperative evaluation, the provider should inquire about history of diabetes, heart failure, dyspnea, smoking, COPD, dialysis, acute renal failure, dialysis, steroid use, ascites, and cancer (Hornor et al., 2020).

C. Enhanced Recovery After Surgery (ERAS) Society key recommendations for total hip and knee replacement surgery include (Wainwright et al., 2020):

  1. Alcohol and smoking cessation
  2. Correction of preoperative anemia
  3. Intake of clear liquids until 2 hours before anesthesia induction and 6-hour fast for solid food
  4. Preoperative carbohydrate loading
  5. Avoidance of routine administration of sedatives to reduce anxiety preoperatively
  6. Spinal opioids not recommended for routine use
  7. Multimodal PONV prophylaxis and treatment
  8. Maintenance of normothermia throughout the perioperative period and active warming of patients intraoperatively

D. 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).

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

F. Implement the SCIP Core Measure Set (TJC, 2010).

  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. Maintenance of normothermia throughout the perioperative period
  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 to 24 hours after surgery

G. Improve medication safety within the perioperative settings through the following measures (TJC, 2022):

  1. Label all medications, medication containers, and other solutions on and off the sterile field in the 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.

H. Implement SSI prevention guidelines (TJC, 2022).

  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.

I. Consistently implement TJC’s Time Out and Universal Protocol guidelines, which include the following (TJC, 2022):

  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-practice guidelines provides collaborative nursing opportunities across the perioperative continuum.

A. Preoperative

  1. Perform a comprehensive assessment, such as 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 the patient and their family.
  3. Review, document, and interpret pertinent laboratory and diagnostic findings specific to the 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 the patient and the 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 metformin, after an angiogram).
  6. Conduct medication reconciliation (TJC, 2022), focusing on the Beers Criteria for potentially inappropriate medication use in older adults (AGS Beers Criteria® Update Expert Panel, 2019).
  7. Evaluate use of cardiac drugs throughout the perioperative continuum. In particular, the guidelines for perioperative use of beta-blockers (Fleisher et al., 2014) recommend the following:
    • Inform the patient or the caregiver to bring all home medications on the day of procedure, especially for outpatient same-day surgery.
    • Reinforce appropriate VTE prophylaxis within 24 hours before surgery (TJC, 2022).
    • Facilitate appropriate hair removal before surgery (TJC, 2022).
    • Implement POSH interventions for elective surgery patients (McDonald et al., 2018).
    • Provide carbohydrate loading as per hospital protocol (Fawcett & Ljungqvist, 2017).
    • Calculate risk using the ACS NSQIP Surgical Risk Calculator.

B. Intraoperative

  1. Participate in high-quality interprofessional Time Out and handoff (TJC, 2022).
  2. Administration of antibiotic prophylaxis more than 120 minutes before incision or after incision is associated with a higher risk of SSI than administration less than 120 minutes before incision (de Jonge et al., 2017).
  3. Safely administer beta-blocker perioperatively if applicable (Blessberger et al., 2018).
  4. Assess and manage patient temperature intraoperatively (e.g., active warming to maintain desired temperature based on type of surgery).
  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 et al., 2017).
  7. Follow the procedure and policy related to prevention on unintended retention of foreign objects intraoperatively.
  8. Follow CDC infection control guidelines in handling infectious materials (e.g., specimen, equipment).
  9. Increased supraphysiological oxygen administration during surgery is associated with a higher incidence of kidney, myocardial, and lung injury (McIlroy et al., 2022).
  10. Implement pressure injury prevention measures.

C. Postoperative

  1. Perform high-quality handoff during care transitions using standardized forms or checklists (TJC, 2022).
  2. Maintain patient safety during transfer and handoff.
  3. Monitor vital signs per protocol, including hemodynamics and glucose finger stick.
  4. Assess and document pain, including pharmacological and nonpharmacological interventions.
  5. Maintain patient temperature at greater than or equal to 96.8°F (Fry, 2008).
  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 18–24 hours post operation; Fry, 2008).
  7. Monitor the patient’s GFR, assess the patient’s urine output and weight, and follow protocol/procedures in administering nephrotoxic medications.
  8. Conduct medication reconciliation, with special attention to beta-blockers (TJC, 2022) and antidiabetic medications.
  9. Implement safe VTE prophylaxis within 24 hours before surgery or 24 hours postoperation (e.g., pneumatic compression devices, low-dose heparin; TJC, 2022).
  10. Close incisions with sterile dressing for 24 to 48 hours postop (Fry, 2008).
  11. Discontinue antibiotics as per protocol (Fry, 2008).
  12. Provide timely and accurate information to the patient and family members.
  13. Resume diet as clinically appropriate.
  14. Implement protocol for PONV and PDNV.
  15. Avoid medications that induce delirium postoperatively (e.g., anticholinergics, sedative-hypnotics, diphenhydramine; American Geriatrics Society Beers Criteria® Update Expert Panel, 2019).
  16. Use validated delirium screening instruments.
  17. Implement early mobility protocol (Goldfarb et al., 2018).
  18. Implement nonpharmacological interventions to improve sleep.
  19. Coach the 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, cognitive and behavioral, cardiopulmonary, functional status, nutrition, medication, and frailty.
  4. Undergo clinically relevant preoperative testing (e.g., blood, urine, radiological, EKG) based on best-practice evidence.
  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. Prevent postoperative complications such as SSI, DVT, cardiopulmonary adverse events, falls, and pressure injuries.
  8. Be free from adverse events such as MEs, 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 the patient’s decision-making capacity and obtain informed consent.
  3. Implement the latest guidelines for antimicrobial prophylaxis in surgery (e.g., receive antibiotics within 60–120 minutes before surgical incision).
  4. Participate in high-quality interprofessional collaboration.
  5. Use an evidence-based teamwork system to improve communication and teamwork skills (e.g., TeamSTEPPS) for patient safety.
  6. Apply teach-back method in all patient education encounters that are culturally competent and patient-centered.
  7. Employ accurate documentation of care throughout the perioperative continuum.
  8. Provide the patient and caregivers with timely and accurate information of the 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. Align existing institutional policies and procedures with latest national standards.
  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, and VTE prophylaxis.
  5. Establish a system of reporting patient safety issues (e.g., falls, MEs, unintended retention of foreign object, wrong patient, wrong site, wrong procedure) 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, artificial intelligence, and personnel oversight.
  7. Develop ongoing quality improvement initiatives consistent with SCIP core measures.
  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.
  10. Support interprofessional unit-based practice and quality improvement council.
  11. Demonstrate a commitment to culture of safety based on openness and mutual trust (e.g., patient safety leadership walk rounds).
  12. Monitor hospital-acquired perioperative pressure injuries.

RELEVANT PRACTICE GUIDELINES

A. AORN Guidance Statement: Safe Medication Practices in Perioperative Settings Across the Life Span (Association of periOperative Registered Nurses, 2006)

B. The American Society of Enhanced Recovery and Society for Ambulatory Anesthesia Consensus Guidelines for the Management of PONV

C. 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery (Fleisher et al., 2014)

D. 2012 ACS-NSQIP and the AGS Best Practices Guidelines for Optimal Preoperative Assessment of the Geriatric Surgical Patient (Chow et al., 2012)

E. AORN Guidelines for Perioperative Practice: https://www.aorn.org/guidelines-resources/guidelines-for-perioperative-practice

F. American Society of Anesthesiologists 2017 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

G. American Society of Hematology 2019 Guidelines for Management of VTE: Prevention of VTE in Surgical Hospitalized Patients

ABBREVIATIONS

ACC/AHA        American College of Cardiology/American Heart Association

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

AGS                 American Geriatrics Society

AORN              Association of periOperative Registered Nurses

CDC                 Centers for Disease Control and Prevention

CNOR              Operative Nursing Certification

COPD               chronic obstructive pulmonary disease

DVT                 deep venous thrombosis

GFR                 glomerular filtration rate

LOS                 length of stay

ME                   medication error

OR                   operating room

PCI                   percutaneous coronary intervention

POD                 postoperative day

PONV/PDNV    postoperative and postdischarge nausea and vomiting

POSH               Perioperative Optimization of Senior Health

RN                   registered nurse

SCIP                 surgical care improvement project

SSI                   surgical site infection

TJC                  The Joint Committee

VTE                 venous thromboembolism

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Updated: January 2025

Boltz PhD, RN, GNP-BC, FGSA, FAAN, M., Capezuti, PhD, RN, FAAN, E.A., & Fulmer PhD, RN, FAAN, T. T. (2025). Evidence-Based Geriatric Nursing Protocols for Best Practice (7th ed.). Springer Publishing. Retrieved December 17, 2024, from https://www.springerpub.com/evidence-based-geriatric-nursing-protocols-for-best-practice-9780826152763.html#tableofcontents

Chapter 36, Lim, F., Slater, L.Z. & Stoffan, P. (2025) Perioperative Care of the Older Adult

 

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Park, C. M., Inouye, S. K., Marcantonio, E. R., Metzger, E., Bateman, B. T., Lie, J. J., Lee, S. B., Levin, R., & Kim, D. H. (2022). Perioperative gabapentin use and in-hospital adverse clinical events among older adults after major surgery. JAMA Internal Medicine, 182(11), 1117–1127. https://doi.org/10.1001/jamainternmed.2022.3680. Evidence Level IV.

Raats, J. W., van Eijsden, W. A., Crolla, R. M., Steyerberg, E. W., & van der Laan, L. (2015). Risk factors and outcomes for postoperative delirium after major surgery in elderly patients. PloS One, 10(8), e0136071. https://doi.org/10.1371/journal.pone.0136071. Evidence Level IV.

Seidelman, J. L., Mantyh, C. R., & Anderson, D. J. (2023). Surgical site infection prevention: A review. JAMA, 329(3), 244–252. https://doi.org/10.1001/jama.2022.24075. Evidence Level IV.

Sepehri, A., Beggs, T., Hassan, A., Rigatto, C., Shaw-Daigle, C., Tangri, N., & Arora, R. C. (2014). The impact of frailty on outcomes after cardiac surgery: A systematic review. Journal of Thoracic and Cardiovascular Surgery, 148(6), 3110–3117. https://doi.org/10.1016/j.jtcvs.2014.07.087.Evidence Level I.

Sheetz, K. H., Guy, K., Allison, J. H., Barnhart, K. A., Hawken, S. R., Hayden, E. L., Englesbe, M. J. (2014). Improving the care of elderly adults undergoing surgery in Michigan. Journal of the American Geriatrics Society, 62(2), 352–357. https://doi.org/10.1111/jgs.12643. Evidence Level IV.

Singer, A. J., Thode, H. C., Jr., Viccellio, P., & Pines, J. M. (2011). The association between length of emergency department boarding and mortality. Academic Emergency Medicine, 18(12), 1324–1329. https://doi.org/10.1111/j.1553–2712.2011.01236.x.Evidence Level IV.

The Joint Commission. (2010). Surgical Care Improvement Project (SCIP). Retrieved March 6, 2023, from https://manual.jointcommission.org/releases/archive/TJC2010B/SurgicalCareImprovementProject.html. Evidence Level VI.

The Joint Commission. (2022). 2022 Hospital National Patient Safety Goals. https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2022/simple_2022-hap-npsg-goals-101921.pdf. Evidence Level VI.

Vacas, S., Cole, D. J., & Cannesson, M. (2021). Cognitive decline associated with anesthesia and surgery in older patients. JAMA, https://doi.org/10.1001/jama.2021.4773. https://doi.org/10.1001/jama.2021.4773. Evidence Level IV.

Wahr, J. A., Prager, R. L., Abernathy, J. H., III, Martinez, E. A., Salas, E., Seifert, P. C., & Nussmeier, N. A. (2013). Patient safety in the cardiac operating room: Human factors and teamwork: A scientific statement from the American Heart Association. Circulation,128(10), 1139–1169. https://doi.org/10.1161/CIR.0b013e3182a38efa. Evidence Level VI.

Wainwright, T. W., Gill, M., McDonald, D. A., Middleton, R. G., Reed, M., Sahota, O., Yates, P., & Ljungqvist, O. (2020). Consensus statement for perioperative care in total hip replacement and total knee replacement surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Acta Orthopaedica, 91(1), 3–19. https://doi.org/10.1080/17453674.2019.1683790. Evidence Level V.

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