Introduction Our purpose was to determine the relationship between pre-operative frailty and the occurrence of postoperative complications following colorectal and cardiac operations. Study Design Patients ≥65 years undergoing elective colorectal or cardiac surgery were enrolled. Seven baseline frailty traits were measured pre-operatively: Katz Score ≤5, Timed Up-and-Go ≥15 seconds, Charlson Index ≥3, anemia<35%, Mini-Cog score ≤3, albumin<3.4gm/dL and ≥1 fall within six-months. Patients were categorized by the number of positive traits: non-frail: 0–1 trait, pre-frail: 2–3 traits and frail: ≥4 traits. Results 201 subjects (age 74±6 years) were studied. Preoperative frailty was associated with increased postoperative complications following colorectal (non-frail 21%, pre-frail 40% and frail 58%; p=0.016) and cardiac operations (non-frail 17%, pre-frail 28% and frail 56%; p<0.001). This finding in both groups was independent of advancing age. Frail individuals in both groups had longer hospital stays and higher 30-day readmission rates. Receiver operating characteristic curves examining frailty’s ability to forecast complications were: colorectal (0.702; p=0.004) and cardiac (0.711; p<0.001). Conclusion A simple pre-operative frailty score defines older adults at higher risk for postoperative complications across surgical specialties.
Background Pre-operative risk stratification is commonly performed by assessing end organ function (such as cardiac and pulmonary) to define post-operative risk. Little is known about impaired pre-operative cognition and outcomes. The purpose of this study was to evaluate the impact of baseline impaired cognition on post-operative outcomes in geriatric surgery patients. Study Design Prospectively, subjects 65 years and older undergoing a planned elective operation requiring post-operative ICU admission were recruited. Pre-operative baseline cognition was assessed using the validated Mini-Cog test. Impaired cognition was defined as a Mini-Cog score of ≤3. Delirium was assessed using the Confusion Assessment Method-ICU by a trained research team. Adverse outcomes were defined using the Veterans Affairs Surgical Quality Improvement Program definitions. Results 186 subjects were included with an average age of 73±6 years. Eighty-two subjects (44%) had baseline impaired cognition. The impaired cognition group had the unadjusted outcomes: increased incidence of ≥1 post-operative complication (41% versus 24%; p=.011), higher incidence of delirium (78% versus 37%; p<.001), longer hospital stays (15±14 versus 9±9 days; p=.008), higher rate of discharge institutionalization (42% versus 18%; p=.001) and higher six-month mortality (13% versus 5%; p=.040). Adjusting for potential confounders determined by univariate analysis, logistic regression found impaired cognition was still associated to the occurrence of one or more post-operative complications (odds ratio 2.401; 95% confidence interval 1.185, 4.865; p=0.015). Kaplan-Meier survival analysis revealed higher mortality in the impaired cognition group (Log-Rank p =.008). Conclusions Baseline cognitive impairment in older adults undergoing major elective operations is related to adverse post-operative outcomes including increased complications, length of stay and long-term mortality. Improved understanding of baseline cognition and surgical outcomes may aid surgical decision-making in older adults.
Objective The purpose of this study was to determine the relationship between the timed up-and-go test and postoperative morbidity and one-year mortality, and to compare the timed up-and-go to the standard-of-care surgical risk calculators for prediction of postoperative complications. Methods In this prospective cohort study, patients 65 years and older undergoing elective colorectal and cardiac operations with a minimum of one-year follow-up were included. The timed up-and-go test was performed preoperatively. This timed test starts with the subject standing from a chair, walking ten feet, returning to the chair, and ends after the subject sits. Timed up-and-go results were grouped: Fast≤10 sec, Intermediate=11-14 sec, Slow≥15 sec. Receiver operating characteristic curves were used to compare the three timed-up-and-go groups to current standard-of-care surgical risk calculators at forecasting postoperative complications. Results This study included 272 subjects (mean age of 74±6 years). Slower timed up-and-go was associated with an increased postoperative complications following colorectal (fast-13%, intermediate-29% and slow-77%;p<0.001) and cardiac (fast-11%, intermediate-26% and slow-52%;p<0.001) operations. Slower timed up-and-go was associated with increased one-year mortality following both colorectal (fast-3%, intermediate-10% and slow-31%;p=0.006) and cardiac (fast-2%, intermediate-3% and slow-12%;p=0.039) operations. Receiver operating characteristic area under curve of the timed up-and-go and the risk calculators for the colorectal group was 0.775 (95% CI:0.670,0.880) and 0.554 (95% CI:0.499,0.609), and for the cardiac group was 0.684 (95% CI:0.603,0.766) and 0.552 (95% CI:0.477,0.626). Conclusions Slower timed up-and-go forecasted increased postoperative complications and one-year mortality across surgical specialties. Regardless of operation performed, the timed up-and-go compared favorably to the more complex risk calculators at forecasting postoperative complications.
Background Hospital-acquired pressure ulcers (HAPUs) are a costly and largely preventable complication occurring in a variety of acute care settings. Because they are considered preventable, stage III and IV HAPUs are not reimbursed by Medicare. Objectives To assess the effectiveness of a formal, year-long HAPU prevention program in an adult intensive care unit, with a goal of achieving at least a 50% reduction in 2013, compared with 2011. Methods Planning for the prevention program began in 2012, and the program was rolled out in the first quarter of 2013. Program components included use of Braden scores, a revised skin care protocol, fluidized repositioners, and silicone gel adhesive dressings. Efforts were made to educate and motivate staff and encourage them to be more proactive in detecting patients at risk of HAPUs. Results Incidence of HAPUs in the unit was reduced by 69% (n = 17; 3% of patients in 2013 vs n = 45, 10% of patients in 2011), despite a 22% increase in patient load. The potential cost saving as a result of this decrease was approximately $1 million. Conclusions A comprehensive, proactive, collaborative ulcer prevention program based on staff education and a focus on adherence to protocols for patient care can be an effective way to reduce the incidence of HAPUs in intensive care units.
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