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September 17, 2019
ACS Geriatric Surgery Verification Program
The American College of Surgeons (ACS) has developed a Geriatric Surgery Verification Program, aimed at improving surgical care and outcomes for the aging adult population.
The GSV Program provides hospitals with a validated list of 30 evidence-based and patient-centered standards for geriatric surgery that hospitals can implement to continuously optimize surgical care for this vulnerable population (ACS 2019). The standards were developed by the ACS in conjunction with over 50 stakeholder organizations, with support from the John A. Hartford Foundation.
Hospitals can formally enroll in the GSV program this October at the 2019 ACS Clinical Congress in San Francisco.
Hospitals must submit a letter of commitment from their CEO and demonstrate they have a Geriatric Surgery Director, Geriatric Surgery Coordinator, and Geriatric Surgery Quality Committee (roles of each are explained in the ACS document).
There is a requirement for geriatric-friendly patient rooms, which must include space for family and caregiver visitation and include directed elements for patient reorientation (for example, large clock or other display of date, day, and time; daily planned activity goals; any anticipated medical tests or procedures; names of care team; and so on). If space for visitation cannot be provided within the patient room, there must be an alternative communal visiting area.
Each surgical floor must have at least one Geriatric Surgery Nurse Champion (GSNC), whose responsibilities include not only leadership but also responsibility for nursing education, quality improvement, and continuing education.
Shared decision making is a key component of the standards. Deliberation over surgical decision making must allow older adults the opportunity to discuss the following with the surgeon:
After discussion, the surgeon needs to document the treatment plan and how it has been informed by shared discussion of the patient’s goals. Patient health goals relative to the surgical condition can be categorized broadly into (1) prolonging life, (2) preserving function or independence, (3) relieving symptoms, (4) curing a condition, or (5) establishing a diagnosis. Older adults should have the opportunity to identify an overall health goal that is personal and specific, such as “I want to be able to walk at my grandson’s wedding this summer.” This standard aims to distinguish between overall health goals and treatment goals specific to the current condition. Though overall health goals and health care treatment preferences are often aligned, this is not always the case; this standard aims to improve that alignment
Another standard is that code status and any existing advance directive must be reviewed preoperatively by the surgeon. Patients without a defined code status or an advance care plan must be offered the opportunity to establish an advance directive in addition to being provided with educational resources on advance care planning. All patients must have a health care representative, surrogate, or proxy identified with name and contact information clearly documented. For those without, there must be documentation of an effort to identify one. Educational materials must be provided to facilitate discussion between the patient and his or her surrogate about the patient’s overall health and treatment goals.
For patients with anticipated admission to the intensive care unit (ICU), there must be a discussion regarding the indications for, limitations of, and patient’s desire for life-sustaining treatments, including issues such as cardiopulmonary resuscitation, mechanical ventilation, feeding tubes, hemodialysis, and blood transfusion. These might be discussed as part of a standard anesthesia visit or preoperative admission process.
The patient and family/caregiver(s) must be offered the opportunity to reaffirm the initial surgical decision making, by an in-person visit, a telephone call, or a telehealth visit with surgical staff or a designated representative.
The standards put an important focus on the preoperative evaluation. Patients must be screened for the following high-risk characteristics to identify potential areas of vulnerability:
We are very pleased to see the focus on identifying delirium risk and the several factors that contribute to frailty. Moreover, the standards call for a documented management plan directed at positive findings from the screens.
In the elective setting, all patients identified as high risk based on the geriatric vulnerability screens must be evaluated with interdisciplinary input after the implementation of focused management plans and before surgery to reassess the indications, risks, and benefits of the proposed operation. This may be conducted in the form of an interdisciplinary conference or by obtaining input from at least the following health professionals:
Interdisciplinary conferences should arrive at documentation of a consensus treatment recommendation and ensure communication of recommendations to patients and their families/caregivers and other clinicians responsible for the care of the patients.
A very important point is that, for patients at high risk, the surgeon or surgeon’s representative must communicate the goals of care and decision-making discussion to the patient’s preferred primary care provider (PCP) or the provider designated by the patient as his or her “main doctor.”
Multiple standards apply to post-operative care. There is an emphasis on ensuring that patients’ personal sensory equipment (glasses, hearing aids, dentures, etc.) are collected and returned to the patient immediately postoperatively. We’ve discussed the importance of this in our many columns on preventing and managing delirium.
There must be processes, protocols, or policies in place to assess for and alert providers to the use of potentially inappropriate medications, using tools such as Beers Criteria®. The ACS suggests use of standardized order sets/bundles/pathways to protocolize medication management for geriatric patients or use of templated order sets with Beers medications removed and alternatives provided. Hospitals should also have ways for flagging and reviewing inappropriate medications when they are ordered (eg. daily pharmacy reviews, embedded decision support tools within the electronic health record that provide alerts when a potentially inappropriate medication is prescribed). They also stress provider education identifying surgically relevant Beers medications along with alternatives available within institutional formulary
They stress opioid-sparing, multimodality pain management for all postoperative patients. That includes opioid-sparing techniques like use of regional analgesia and use of pre-, intra-, or postoperative non-opioid analgesics. But it also stresses avoidance of other potentially inappropriate analgesics as defined by the AGS Beers Criteria, appropriate titration of medications for the increased sensitivity and altered physiology of the older adult, prophylactic pharmacologic bowel regimen, and use of non-medication-based strategies for pain control.
Standards really focus on prevention, identification, and management of postoperative delirium. There should be daily screening with a validated tool such as the CAM (confusion assessment method). Identifying and treating or discontinuing precipitating factors through non-pharmacologic and pharmacologic interventions (eg. correcting electrolyte derangements, treating infections, minimizing tethering devices, etc.) is important. There also needs to be attention to mobility, with a goal of ambulation or non-ambulatory mobilization by postoperative day one, fall prevention, daily evaluation of need for tethering devices, and daily assessment of pressure ulcer risk and skin integrity. Other factors needing special post-operative attention are nutrition and hydration (preferably via the enteral route), a bowel regimen (especially for those requiring opioid pain medications), and aspiration precautions (eg. elevated head-of-bed, upright post-prandial positioning). The above issues may be addressed through pathways, bundles, order sets, protocols, or a combination thereof.
The standards call for interdisciplinary care for all patients identified as high risk based on the geriatric vulnerability screens. Initial postoperative care must be provided by interdisciplinary health care professionals, including but are not limited to:
Recommendations by participating members of the interdisciplinary team must be documented daily.
Goals of care must be revisited when an older adult experiences an unexpected escalation of care to the ICU and must be readdressed at least every three days for all ICU patients.
Planning for discharge or other transitions of care is critical. All patients must undergo geriatric vulnerability screens at discharge to assess for changes in vulnerability during their hospital stay. An appropriate plan of action to address identified deficits must be documented in the medical record as part of the discharge documentation. Geriatric vulnerabilities to especially be assessed at discharge include impaired cognition. delirium risk, impaired functional status, impaired mobility, and malnutrition. Discharge documentation should also specifically identify any deficits discovered on pre-discharge screens along with the plan of action to address each vulnerability. Information regarding common geriatric syndromes, including risk factors for functional decline, falls, delirium, and how to respond to each if it occurs after discharge should be included. The contents of the discharge summary must be discussed with the patient and/or his or her caregiver, and a copy must be provided to:
There must be a process, protocol, or policy in place addressing the communication structure between the institution and post-acute care facilities.
The standards also include collection and review of data for all patients included within the scope of the GSV Program. Data must be reviewed at least quarterly by the GSQC to identify, trend, and address issues specific to geriatric surgical care. The GSV document discusses the metrics to review and the need for a process, protocol, or policy in place for feedback of the data collected and reviewed. The SV program mandates at least one quality improvement (QI)/performance improvement (PI) project annually pertinent to geriatric surgical care informed by the data collected and reviewed by the GSQC.
The standards go on to discuss other potential quality improvement collaborative opportunities and to discuss the ongoing educational requirements and recommendations for physicians, nurses, and other healthcare professionals. Also required is a community outreach project focused on issues pertinent to geriatric surgical care, and it must be conducted at least annually. This project may take the form of awareness, prevention, or education. The GSV also strongly urges participation in research or work toward advancement of geriatric surgical knowledge and care.
Many of the standards are also in keeping with a findings of a recent study on factors that lead to successful care of older patients on medical wards (Baxter 2019). Those researchers hypothesized there were 14 care team factors that contributed to patient safety on the wards:
They focused on five characteristics that healthcare professionals considered to be most salient in successful care of older patients. These included the relational aspects of teamworking, specifically regarding staff knowing one another and working together in truly integrated multidisciplinary teams. The cultural and social context of successful wards was perceived to influence the way in which practical tools (eg, safety briefings and bedside boards) were implemented.
The findings of the Baxter study mesh well with the GSV focus on teamwork and interdisciplinary collaboration in caring for the older surgical patient.
One other program we’ve previously mentioned is the American College of Surgeons’ Strong for Surgery program. That program is intended for all surgical patients, but its components are equally applicable to the older surgical patient. This program is intended to optimize patients’ overall status prior to surgery and provides a toolkit with checklists. “Strong for Surgery” empowers hospitals and clinics to integrate checklists into the preoperative phase of clinical practice for elective operations. The checklists are used to screen patients for potential risk factors that can lead to surgical complications, and to provide appropriate interventions to ensure better surgical outcomes.” The checklists in the Strong for Surgery Toolkit target eight areas known to be influential determinants of surgical outcomes:
There’s no reason the concepts from the ACS Strong for Surgery program cannot be used in conjunction with the new ACS Geriatric Surgery Verification Program,
References:
ACS (American College of Surgeon). Geriatric Surgery Verification Quality Improvement Program. Optimal Resources for Geriatric Surgery2019 Standards. ACS 2019
https://www.facs.org/-/media/files/quality-programs/geriatric/geriatricsv_standards.ashx?la=en
Baxter R, Taylor N, Kellar I, et al. A qualitative positive deviance study to explore exceptionally safe care on medical wards for older people BMJ Quality & Safety 2019; 28: 618-626
https://qualitysafety.bmj.com/content/28/8/618
ACS (American College of Surgeons). Strong for Surgery. Updated November 2018
https://www.facs.org/quality-programs/strong-for-surgery
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September 2019
We’ve published multiple columns on the risks of sedation for dental procedures (see list below). The AAP (American Academy of Pediatrics) and the AAPD (American Academy of Pediatric Dentistry) recently updated their joint “Guideline for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures” (Cote 2019). This is a comprehensive guideline that notes how pediatric procedural sedation differs from that in adults and focuses on multiple facets of procedural sedation in pediatric patients:
The principles really apply to pediatric procedural sedation in a variety of settings and venues, but the purpose of this updated report was to unify the guidelines for sedation used by medical and dental practitioners and to add clarifications regarding monitoring modalities, particularly regarding continuous expired carbon dioxide measurement, and other refinements.
A group of 6 healthcare organizations has recently endorsed those new guidelines for pediatric dental sedation. The 6 include the American Academy of Pediatrics, the American Academy of Pediatric Dentistry (AAPD), the American Society of Anesthesiologists (ASA), the Society for Pediatric Anesthesia, the American Society of Dentist Anesthesiologists, and the Society for Pediatric Sedation.
Perhaps the most important item in the guideline is a requirement that such procedures be done in the presence of two qualified individuals. That means that the dentist or oral surgeon performing the dental or oral surgery procedure cannot be the individual administering and monitoring the sedation. This ensures that individuals are attending to one primary task and not involved in two different tasks simultaneously.
The guideline also clarifies that deep sedation or general anesthesia must be administered by a qualified anesthesia provider (a physician anesthesiologist, certified registered nurse anesthetist, dentist anesthesiologist or second oral surgeon). Because children commonly pass from an intended sedation level to an unintended deeper level of sedation, practitioners of sedation must have the skills to rescue the patient from a deeper level than that intended for the procedure. The ability to rescue means that practitioners must be able to recognize the various levels of sedation and have the skills and age- and size-appropriate equipment necessary to provide appropriate cardiopulmonary support if needed.
The guideline includes discussion on monitoring and documentation before, during, and after the procedure. There is good discussion on capnography for continuous expired carbon dioxide measurement.
The guideline also emphasizes caution, as we have in multiple columns, regarding the use of devices such as “papooses” that might restrict chest movement or obstruct airways.
We are also pleased to see the guideline emphasizes the need, for nonhospital facilities, for a protocol for the immediate activation of the EMS system for life threatening complications. We’ve previously advised that drills and simulations include even front office staff so they can facilitate such emergency responses.
There is far more in the updated guideline than we can fit is a short column. We encourage you to read the guideline in its entirely.
Some of our previous columns on dental patient safety issues:
March 15, 2016 “Dental Patient Safety”
August 2016 “Guideline Update for Pediatric Sedation”
March 28, 2017 “More Issues with Dental Sedation/Anesthesia”
August 8, 2017 “Sedation for Pediatric MRI Rising”
November 28, 2017 “More on Dental Sedation/Anesthesia Safety”
July 2019 “Dental Prescribing Called Into Question”
References:
Coté CJ, Wilson S, American Academy of Pediatrics, American Academy of Pediatric Dentistry. Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures. Pediatrics 2019; 143(6): June 2019
https://pediatrics.aappublications.org/content/143/6/e20191000
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The Leapfrog Group’s “Never Event Policy” (Leapfrog Group 2019) calls on healthcare organizations to do the following when a never event has occurred in their facility/organization:
The first 5 elements have been in place since 2007 but the last 4 items were added in 2017. There was some drop off in hospital compliance with the standards after the 4 latter elements were added. Overall, about 75% of both teaching and non-teaching hospitals most recently have met all the standards.
The Leapfrog report mentions a couple key resources to aid organizations comply with the standards: the AHRQ’s CANDOR toolkit (see our June 2016 What's New in the Patient Safety World column “Disclosure and Apology: The CANDOR Toolkit”) and the NPSF RCA2 tool (see our July 14, 2015 Patient Safety Tip of the Week “NPSF’s RCA2 Guidelines”).
Some of our prior columns on Disclosure & Apology:
July 24, 2007 “Serious Incident Response Checklist”
June 16, 2009 “Disclosing Errors That Affect Multiple Patients”
June 22, 2010 “Disclosure and Apology: How to Do It”
September 2010 “Followup to Our Disclosure and Apology Tip of the Week”
November 2010 “IHI: Respectful Management of Serious Clinical Adverse Events”
April 2012 “Error Disclosure by Surgeons”
June 2012 “Oregon Adverse Event Disclosure Guide”
December 17, 2013 “The Second Victim”
July 14, 2015 “NPSF’s RCA2 Guidelines”
June 2016 “Disclosure and Apology: The CANDOR Toolkit”
August 9, 2016 “More on the Second Victim”
January 3, 2017 “What’s Happening to “I’m Sorry”?”
October 2017 “More Support for Disclosure and Apology”
April 2018 “More Support for Communication and Resolution Programs”
August 13, 2019 “Betsy Lehman Center Report on Medical Error”
Other very valuable resources on disclosure and apology:
Some of our prior columns on RCA’s, FMEA’s, response to serious incidents, etc:
July 24, 2007 “Serious Incident Response Checklist”
March 30, 2010 “Publicly Released RCA’s: Everyone Learns from Them”
April 2010 “RCA: Epidural Solution Infused Intravenously”
March 27, 2012 “Action Plan Strength in RCA’s”
March 2014 “FMEA to Avoid Breastmilk Mixups”
July 14, 2015 “NPSF’s RCA2 Guidelines”
July 12, 2016 “Forget Brexit – Brits Bash the RCA!”
May 23, 2017 “Trolling the RCA”
References:
Leapfrog Group. Never Events Report. 2019
https://www.leapfroggroup.org/never-events-report-2019
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We’ve done many columns on alarm fatigue and alarm management (see full list below) but the focus has been in ICU’s, med/surg units, and the OR. One venue largely ignored has been the emergency room.
Now a new study (Fleischman 2019) has analyzed alarms in the emergency department and confirmed that, like in all other venues, many alarms are clinically irrelevant and only contribute to the problem of alarm fatigue. The study was based on 53 hours of observation by an ED physician and recorded patient characteristics, alarm type, staff response, whether the alarm was likely real or false, and whether it changed clinical management. There was a median of 18 alarms per hour of observation, and the median number of alarms per patient was 4. Amazingly, alarms changed clinical management in only 8 out of 1049 observed alarms (0.8%) and in 5 out of the 146 patients (3%). Moreover, staff did not observably respond to most alarms (63%).
The authors suggest that efforts at improving the clinical significance of alarms could focus on widening alarm thresholds, customizing alarms parameters for patients' clinical status, and on utilizing monitoring more selectively.
Prior Patient Safety Tips of the Week pertaining to alarm-related issues:
References:
Fleischman, William et al. Emergency department monitor alarms rarely change clinical management: An observational study. The American Journal of Emergency Medicine 2019; Published online July 30, 2019
https://www.ajemjournal.com/article/S0735-6757(19)30500-5/fulltext
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Prior to performance of magnetic resonance imaging patients are screened for the presence of metallic or ferromagnetic items that might be safety hazards because they can migrate in the presence of a strong magnetic field or become heated and result in burns. They may also produce artifacts that interfere with interpretation of studies. Still other devices might malfunction under exposure to the magnetic field.
Typical items screened for are jewelry, pacemakers, clips, implanted pumps, electrodes, wires, medication patches, and many others. But some more unusual items have received attention. In our April 2, 2019 Patient Safety Tip of the Week “Unexpected Events During MRI” we discussed tattoos, which may be made with color pigments containing ferrous particles that may interact with the magnetic resonance, potentially leading to burns.
Now here’s another new one: magnetic eyelashes! Magnetic eyelashes are a relatively new cosmetic product. Researchers recently used a phantom to study possible role that magnetic eyelashes might have in producing MRI image artifact (Slonimsky 2019). They found that the eyelashes could produce artifacts and reduce image quality, in addition to being pulled off by the magnetic field. In fact, the artifact created from the magnetic eyelashes was significantly larger than the distortions created by some aneurysm clips.
The researchers did not assess the risk of heating on these eyelashes because they were using a phantom. However, the reason they chose to study this on a phantom rather than a human volunteer was that they were concerned the eyelashes could heat significantly and cause burns.
The authors strongly recommend inserting a line about magnetic eyelashes on the MRI safety questionnaire and adding stops in the screening system to prevent the entry of anyone with these lashes, including staff, into the MRI scanner room.
Some of our prior columns on patient safety issues related to MRI:
References:
Slonimsky E, Mamourian A. Magnetic Eyelashes: A New Source of MRI Artifacts. American Journal of Roentgenology 2019;: 1-3 Posted online on 24 Jul 2019.
https://www.ajronline.org/doi/10.2214/AJR.19.21550
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Print “September 2019 What's New in the Patient Safety World (full column)”
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Print “September 2019 Leapfrog’s Never Events Policy”
Print “September 2019 Alarm Fatigue in the Emergency Room”
Print “September 2019 New MRI Hazard: Magnetic Eyelashes”
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PO Box 1230
Grantham, NH 03753
ph: 716-550-1106
btruax