Perioperative Care of the Older Adult   32  

Fidelindo Lim and Larry Z. Slater

OVERVIEW

The confluence of advancing age, geriatric syndromes, regulatory changes, and advances in medical technology has made perioperative care scenarios of older adults more complex. Surgical procedures performed on older adults are expected to rise. About one third of all procedures and one half of surgical procedures on the cardiovascular and digestive systems in nonfederal short-term hospitals are performed on inpatients aged 65 years and older (Hall, DeFrances, Williams, Golosinskiy, & Schwartzman, 2010). Factors, such as polypharmacy, diabetes, presurgical cognitive status, use of general anesthesia, and increasing number of procedures done in ambulatory care settings, will continue to impact postsurgical outcomes, particularly the development of postoperative delirium, a significant determinant of poor outcomes (Brooks, 2012).

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 procedures” (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.

The discussion about perioperative care of older adults comes at an opportune time, when there is growing recognition that the educational background of nursing staff directly impacts mortality of surgical patients. Aiken et al. (2014) found that a 10% increase in the proportion of staff nurses holding 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. This finding supports earlier evidence of lower mortality among surgical patients when there is a higher proportion of bachelor’s-prepared nurses on staff (Aiken, Clarke, Cheung, Sloane, & Silber, 2003). Lower rates of postoperative deep vein thrombosis (DVT) or pulmonary embolism (PE) and shorter length of stay have also been found in hospitals with a higher percentage of registered nurses (RNs) with baccalaureate or higher degrees (Blegen, Goode, Park, Vaughn, & Spetz, 2013).

As fall rate remains high in medical–surgical units and a predictor of poorer outcomes, it is important to note that there is an inverse relationship between nurse certification and fall rate (Boltz, Capezuti, Wagner, Rosenberg, & Secic, 2013).

The improvement of care outcomes in older adult surgical patients will draw from an array of evidence not only from clinical studies but also from research in nursing policy, management, and health professions education. Specific safety and quality benchmarks for the general surgical care of older adults are described in Chapter 33, “General Surgical Care of the Older Adult.” The inevitable aging of the population will result in greater demand for surgical care. Comprehensive geriatric assessment that takes into account patient’s participation is an established clinical approach in optimizing positive outcomes for the perioperative older adult patient (Partridge, Harari, Martin, & Dhesi, 2014).

BACKGROUND AND STATEMENT OF PROBLEM

The number and type of surgical procedures performed in the past decade vary according to the body systems involved. A total of 51.4 million all-listed procedures for discharges from short-stay hospitals were performed in 2010 (Centers for Disease Control and Prevention [CDC], 2010). Of these, 19.2 million were performed among patients 65 years and older (CDC, 2010). In 2011, more than 15 million operating room (OR) procedures were performed in U.S. hospitals (Weiss & Elixhauser, 2014). Earlier estimates reported that patients aged 65 years and older were two to three times more likely to experience OR procedures (Elixhauser & Andrews, 2010). The authors reported that more than 4 million major operations are performed annually in the United States in patients 65 years and older. However, those who are 85 years and older are noted to be less likely to undergo an OR procedure compared with younger older adults (Weiss & Elixhauser, 2014). The following are the highlights of the characteristics of OR procedures in U.S. hospitals in 2011(Weiss & Elixhauser, 2014):

Although trends in operative procedures vary over time, trends in U.S. hospitals operative procedures between 2001 and 2011 show that the current mix may disproportionately affect older adults (except caesarian section and circumcision).

Going for surgery, whether an outpatient or inpatient procedure, emergent or elective, marks an important health care transition, particularly among vulnerable older adults, because of the increased morbidity and mortality risks. A study involving 24,216 patients reported that failures-to-rescue were 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 < .001; Sheetz et al., 2014). It is interesting to note that higher nurse–patient ratio (odds ratio [OR]: 0.99, 95% confidence interval [CI] [0.98–1.00]) did not influence failure-to-rescue (Sheetz et al., 2014).

Overall mortality among older adults presenting with trauma is higher among those older than 74 years than in younger geriatric cohorts (Hashmi et al., 2014). Furthermore, severe and extremely severe injuries and systolic hypotension at presentation are associated with significant mortality risks (Hashmi et al., 2014). Higher mortality trends have also been noted among older adults who had cardiac surgery (Sepehri et al., 2014), kidney transplant (Knoll, 2013), hip-fracture surgery (Carpintero et al., 2014), and colectomy (Visser, Keegan, Martin, & Wren, 2009), and among surgical oncology patients (Korc-Grodzicki et al., 2014). Among cardiac surgical patients, age more than 75 years is an independent risk factor for intensive care unit (ICU) mortality, and these patients have a higher risk of multiorgan dysfunction syndrome (MODS; Curiel-Balsera et al., 2013).

In general, high surgical mortality among older adults is closely linked with increased risk of falls, prolonged hospitalization, and frailty (Green et al., 2012; Sepehri et al., 2014). However, advanced age alone does not correlate or predict higher mortality postsurgery (Green et al., 2012). Similar findings have been noted among patients in critical care settings (Balas et al., 2012). This is important for nurses to consider in their assessment and they should be aware of personal or professional biases (e.g., ageism) that might impact the overall quality of care provided among older adult perioperative patients. Consideration of the overall health scenario, including the typical age-related physiologic changes, baseline health status, severity of present illness, and potential risks of perioperative complications, rather than age alone, should guide the realistic care decisions for perioperative older adult patients (Oresanya, Lyons, & Finlayson, 2014).

Failure-to-rescue, resulting in death 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, DVT/PE) are nursing-sensitive measures and publicly reportable events (National Quality Forum [NQF], 2004). As a result, there have been numerous collaborative safety initiatives, both from governmental and nonregulatory agencies, in the past decade.

ASSESSMENT OF PROBLEM AND NURSING CARE STRATEGIES

Preoperative Considerations

Successful perioperative care of the older adult begins at the time surgery has been determined to be a safe option. What distinguishes older adults from their younger counterparts is the former’s loss of functional reserve and a general decline in organ function (White, Khan, & Smitham, 2011). Older patients may present with a host of comorbidities involving any organ system and these must be evaluated and optimized before surgery to improve the postoperative outcome. This highlights the crucial roles played by anesthetists, geriatricians, and nurses in the preoperative management of this challenging patient population. Functional and cognitive impairment, malnutrition, facility residence, and frailty have been associated with adverse surgical outcomes (Oresanya et al., 2014).

As part of the comprehensive preoperative assessment of older patients, “it is useful to determine whether a patient is physiologically ‘young’ (i.e., exhibiting only changes associated with normal aging) or ‘old’ (i.e., exhibiting aging effects due to comorbidities in addition to normal aging)” (White et al., 2012, p. 1191).

Consent for Surgery

Determining the patient’s capacity to consent for surgery is another challenge for the provider. Age alone does not predict incapacity to consent for surgery (Oresanya et al., 2014). It is important to view capacity within a continuum. It can be evanescent, and can be optimized with careful consideration of situational, psychosocial, medical, psychiatric, and neurological factors (Sessums, Zembrzuska, & Jackson, 2011). Reliable capacity assessment can also be influenced by problematic relationships between patients and providers, as well as cultural, linguistic, and educational barriers (Ivashkov & Van Norman, 2009). It is best to assume that patients have the capacity to make medical decisions unless proven otherwise (Barton, Mallik, Orr, & Janofsky, 1996). From a legal and medical standpoint, competence to consent to treatment may require the following criteria (Appelbaum & Grisso, 1995; Welie & Welie, 2001):

The use of validated tools, such as the Standardized Mini-Mental State Examination (SMMSE) or the Mini-Cog must be used to evaluate the medical decision-making capacity of the patient (see Chapter 4, “Health Care Decision Making,” and Chapter 6, “Assessing Cognitive Function”). A review of 43 prospective studies to determine the prevalence of incapacity and assessment accuracy in adult medical patients without severe mental illnesses found that only 2.8% of healthy older adult control subjects lacked decision-making capacity, compared with 20% in those with mild cognitive impairment and 54% among persons with Alzheimer’s disease (Sessums et al., 2011). The authors also noted that SMMSE scores of less than 20 are associated with increased likelihood of incapacity (Likelihood ratio [LR]: 6.3; 95% CI [3.7–11]). Other validated tools that can be used to assess capacity are the Aid to Capacity Evaluation (ACE) tool, the Hopkins Competency Assessment Test, and the Understanding Treatment Disclosure (Sessums et al., 2011). Competency to use any assessment tools is paramount. Therefore, clinicians must have sufficient training and ongoing validation on how to use these tools.

Preoperative Optimization

It is ideal if the process of obtaining an informed consent includes a discussion of treatment goals, risks, and benefits, with full participation of the patient, family, and other caregivers. If surgery is unlikely to satisfy the patient’s goals and preferences, nonoperative treatments may be pursued (Oresanya et al., 2014). A comprehensive geriatric assessment is called for not only for its benefits in reducing adverse postoperative outcomes, but to aid clinicians in optimizing function before surgery (Oresanya et al., 2014; Partridge et al., 2014). Experts recommend the following four domains as the focus of preoperative optimization: cognition, functional status, nutrition, and frailty (Oresanya et al., 2014). Evidence suggests that poor functional status (e.g., inability to climb two flights of stairs or walk four blocks) is associated with an increased risk of postoperative cardiopulmonary complications after major noncardiac surgery (Girish, Trayner, Dammann, Pinto-Plata, & Celli, 2001).

For older adults with hip fractures, optimization requires estimating perioperative risks and performing the surgery early, as well as focusing on intravascular volume restoration, pain management, and prevention of perioperative hypotension (Nicholas, 2014a). Advanced preoperative cardiac testing (e.g., echocardiography and stress testing) does not seem to improve outcomes and may inappropriately delay surgical repair (Nicholas, 2014b). Regardless of the surgery needed, older adults with active cardiac conditions, such as unstable coronary syndromes, decompensated heart failure, significant arrhythmia, and severe valvular disease, require evaluation and treatment before nonurgent or noncardiac surgery (Fleisher et al., 2014).

Admission

Unless the patient is coming in for an elective or ambulatory surgery, inpatient surgeries usually necessitate a visit to the emergency department (ED), partly because of the nature of clinical scenarios requiring surgical interventions (e.g., hip fracture, gastrointestinal bleeding, subdural hematoma, etc.). The time spent in the ED, particularly among vulnerable older adults, is an important consideration because of its positive correlation with negative patient-oriented outcomes, from worse patient satisfaction to higher inpatient mortality rates (Singer, Thode, Viccellio, & Pines, 2011).

A retrospective cohort study (N = 41,256 with 37% of subjects older than 65 years) reported higher mortality correlates with increased ED boarding time (2.5% inpatients boarded less than 2 hours; 4.5% inpatients boarded 12 hours or more (p < .001; Singer et al., 2011). The authors also noted longer hospital stay correlates with longer boarding time in the ED. On average, those who stayed in the ED for less than 2 hours had 5.6 days of hospitalization (SD ± 11.4) compared with 8.7 days (SD ± 16.3 days) for those who boarded for more than 24 hours (Singer, Thode, Viccellio, & Pines, 2011). Similar negative findings have been reported in ED nursing case studies of older adult patients (Donatelli, Gregorowicz, & Somes, 2013). Among orthopedic patients, surgical delay is associated with a significant increase in the risk of death and pressure sores (Moja et al., 2012)—both are nursing-sensitive indicators. Clinical and administrative nursing personnel play a pivotal role in expediting patient transfer from the ED to the surgical unit or the OR and in facilitating timely performance of diagnostic procedures and other inpatient preoperative screening to minimize unwanted delays.

Assessment of Surgical Risk

Comprehensive preoperative assessment of older adults needs to consider calculating surgical risks in order for the patient and his or her family and the provider to come up with an informed decision to operate. Although there are currently no validated tools specific to the older adult population, various available surgical-risk calculators may be applied, particularly in evaluating cardiac risk before noncardiac surgery (Bilimoria et al., 2013). The Assessment of an Older Patient With a Condition Potentially Amenable to Surgery is an algorithm intended to guide the surgeon and the patient in determining the appropriateness of surgery (Oresanya et al., 2014). Table 32.1 shows examples of surgical-risk assessment tools and their descriptions.

Based on the synthesis of existing evidence, the following clinical factors have been associated with increased perioperative risk of a cardiovascular event (Fleisher et al., 2014): history of ischemic heart disease, heart failure, cerebrovascular disease, insulin-dependent diabetes mellitus, preoperative serum creatinine greater than 1.5 mg/dL, increasing age, American Society of Anesthesiologists (ASA) class, and preoperative functional status. Emergency surgery is associated with higher risk, as cardiac complications are two to five times more likely than with elective procedures (Fleisher et al., 2014). Frailty and resiliency are two vital concepts to consider in the comprehensive assessment of older surgical patients. Use of a validated frailty scoring tool can be used in preoperative assessment where applicable (Chow, Rosenthal, Merkow, Ko, & Esnaola, 2012).

Intraoperative Considerations

Anesthesia

The physiological changes that accompany aging may put the older adult surgical patient at risk of adverse effects of anesthetics. Loss of skeletal muscle mass, decrease in total body water and increased adipose tissue, especially in women, can lead to an expansion of the lipid reservoir for centrally active anesthetic drugs (e.g., benzodiazepines, volatile agents, opioid analgesics, and sedative hypnotics) contributing to delayed elimination and increased duration of action of these drugs (White et al., 2012). Among malnourished older adults with hypoalbuminemia there is a higher risk of toxicity for albumin-bound anesthetic agents, such as propofol and diazepam, because of increased free-drug concentrations, contributing to increased sensitivity to these drugs (Aymanns, Keller, Maus, Hartmann, & Czock, 2010). Anesthetic agents are also known to decrease cardiac output, arterial pressure, and microvascular perfusion (Bentov & Reed, 2014), which can further strain the patient’s limited physiologic reserve.

TABLE 32.1

Examples of Surgical Risk Assessment Tools

To assess postoperative risks, the ASA Classification of Physical Health remains the most common tool used in appraising preoperative health of surgical patients. The patient’s preoperative health is categorized into five classes (I–V). An “E” for emergency surgery is placed after the Roman numeral (Dripps, 1963):

An ASA score of VI is designated for patients who are declared brain dead and coming to the OR for organ procurement. An ASA score of III or higher is a predictor of greater blood loss and need for transfusion in total hip replacement patients (Grosflam, Wright, Cleary, & Katz, 1995). The ASA score has been shown to have a predictive value in long-term mortality after a hip fracture (Bjorgul, Novicoff, & Saleh, 2010). In a prospective study of 1,635 patients with hip fracture, survival for those rated with ASA I was 8.5 years versus only 1.6 years for those rated as ASA IV (Bjorgul et al., 2010). A prospective study of 168 hip-fracture patients (age range: 50–98 years) reported that an ASA score of III or higher is a predictive factor of postoperative delirium (Zakriya et al., 2002).

Although this grading system is widely used, there has been notable criticism of its value. Variations of the classification systems are available. Perioperative nurses need to inform themselves of what system is used in their facility. Use of the ASA classification to predict postoperative mortality risk can be further enhanced by complementing it with the Short Potable Mental Status Questionnaire (SPMSQ) for assessing cognitive function. Söderqvist et al. (2009), in a prospective cohort study of 1,944 patients aged 66 years or older, reported that the combination of ASA score and SPMSQ provides greater information about survival times compared with the ASA score alone. Nurses are encouraged to be an active participant in evaluating the patient’s surgical risk and in communicating with the provider any changes in patient’s condition that may impact the use of anesthetics. In order to safely monitor patients, nurses need to have a stable knowledge of pharmacokinetics and pharmacodynamics of the common anesthetic agents used and the unique precautions related to older adults.

Intraoperative Medication Safety

Although the exact number of medication errors taking place throughout the perioperative continuum cannot be fully known, medication safety continues to be a challenge (Treiber & Jones, 2012). Based on voluntary sentinel event reporting, 428 medication errors resulting in death or permanent loss of function were reported between 2004 and 2014 (The Joint Commission [TJC], 2014a). Potential factors in medication errors include medications in unlabeled containers or removed from their original containers and placed into unlabeled containers. This unsafe practice neglects basic principles of safe medication management, yet it is routine in many organizations (TJC, 2015). In one qualitative study, preoperative medication errors were the most frequently reported perioperative medication error (Treiber & Jones, 2012). To maintain medication safety within the perioperative settings see Protocol 32.1 for details of TJC’s guidelines.

Antibiotic Prophylaxis

The high prevalence of surgical site infection (SSI) is an ongoing challenge. Among the many strategies to prevent SSI is the use of antibiotic prophylaxis. The current guidelines are an interprofessional collaboration espoused by the American Society of Health-System Pharmacists (ASHP), the Infectious Diseases Society of America (IDSA), the Surgical Infection Society (SIS), and the Society for Healthcare Epidemiology of America (SHEA). The guidelines include specific recommendations for various surgeries (e.g., neurosurgery, cardiac, thoracic, gastroduodenal, bowel, and biliary) that disproportionately affect older adults. The key recommendation is to administer intraoperative antibiotic within 60 minutes before surgical incision. Antibiotics requiring longer infusion times, such as fluoroquinolones and vancomycin, should begin within 120 minutes before surgical incision (Bratzler et al., 2013).

Time Out/Universal Protocol

In a 10-year period between 2004 and 2014, the TJC reported 1,071 sentinel events related to wrong-patient, wrong-site, wrong-procedure events (TJC, 2014a). Seen within the overall number of surgeries done annually (51.4 million procedures performed in the United States in 2010 [CDC, 2010]), these incidences are considered rare, though they have very serious consequences. Older adults can be seen as having high vulnerability for such events because of higher prevalence of cognitive or memory impairment, which might affect their full participation in the Time Out procedure.

A Cochrane Review that evaluated the effectiveness of organizational and professional interventions for reducing wrong-site surgery reported that preoperative verification using Universal Protocol, site marking, Time Out, and targeted educational interventions has been demonstrated to reduce the incidence of wrong-site surgery events (Algie et al., 2015). Recognizing the complexities of the work processes involved in Universal Protocol, TJC offers some guidelines for its implementation (see Protocol 32.1 for details).

POSTANESTHESIA CARE UNIT CONSIDERATIONS

Perioperative Delirium

Delirium is a high-impact, high-volume complication of surgery among older adults that is associated with a host of negative outcomes (Brooks, Spillane, Dick, & Stuart-Shor, 2014). Underlying cognitive impairment predisposes the patient to postoperative delirium, which cascades to a host of adverse care trajectories such as longer hospitalization and ICU stay, higher costs, increased mortality, greater use of continuous sedation and physical restraints, increased unintended removal of catheters and self-extubation, functional decline, new institutionalization, and new onset of cognitive impairment (Balas et al., 2012; Brooks, 2012). A narrative review of 54 studies of surgical patients older than 60 years reported an adjusted OR of 17 (CI [1.2–239.8]; p < .05), associating preoperative cognitive impairment with postoperative delirium (Oresanya et al., 2014).

Current best practice guidelines recommend the use of validated clinical protocols to assist in preventing episodes of delirium. Specialized delirium units that concentrate on assessment of delirium risk factors and targeted risk-factor modification represent a best practice model and should be a mainstay of clinical care (Sieber & Barnett, 2011). Because of its significant impact, preoperative discussions among patients, their families, and providers may include the use of preoperative delirium prophylaxis. Findings from a meta-analysis suggest that perioperative use of prophylactic antipsychotics may effectively reduce the overall risk of postoperative delirium in the elderly (Teslyar et al., 2013). In all decisions, patients’ preference must be taken into account. See Chapter 17, “Delirium: Prevention, Early Recognition, and Treatment,” for more detailed discussion and current guidelines.

Pain Management

There is evidence that pain management of older adults is inadequate, particularly among the cognitively impaired and those with altered mental states, in spite of the availability of validated tools for pain assessment and management (Schofield, 2014). High compliance with implementation of assessment tools will result in increased identification of postoperative pain as well as delirium (Brooks et al., 2014). The American Society of PeriAnesthesia Nurses (ASPAN) has issued guidelines on how to manage pain and promote comfort (ASPAN, 2003). Please refer to Chapter 18, “Pain Management,” for a detailed discussion of pain in older adults.

Medication Reconciliation and Perioperative Beta Blocker

Medication reconciliation of perioperative older adults should pay close attention to making sure that beta blockers are part of the patient’s ongoing medications. The Beers Criteria for Potentially Inappropriate Medication Use in Older Adults (American Geriatrics Society [AGS], 2012) should be used as a guide in reviewing medications during medication reconciliation and bedside rounds. The continuation of beta blocker therapy perioperatively decreases the 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). For patients who cannot take oral beta blockers, the intravenous equivalent needs to be given.

Postoperative and Postdischarge Nausea and Vomiting

The ASPAN has published practice guidelines on how to manage the common perioperative complication of nausea and vomiting. Potential trajectories of postoperative nausea and vomiting (PONV) and postdischarge nausea and vomiting (PDNV) include aspiration, wound dehiscence, prolonged postoperative hospital stays, unanticipated hospital admission after outpatient surgery, delayed return of a patient’s functional ability in the 24-hour period after surgery, and lost time from work for patients and care providers at home (ASPAN, 2006). A weblink to the ASPAN guidelines is provided in Protocol 32.1 practice guidelines section.

GENERAL PERIOPERATIVE CONSIDERATIONS

A Culture of Safety

Maintaining safety and quality patient care in a high-stress environment, such as the perioperative unit, enables the unit to flourish in a culture of safety based on nonpunitive principles. The use of an evidence-based teamwork system to improve communication and collaborative skills (e.g., TeamSTEPPS) will empower staff to self-advocate for safety (Agency for Healthcare Research and Quality [AHRQ], n.d.). Nurse-led initiatives, such as unit practice councils and appointing “champions” for specific perioperative core measures, are essential in this process (Institute for Healthcare Improvement [IHI], n.d.). Hardwiring a culture of safety would require a concerted systematic approach across all levels of care.

Handoff Communication

The transition between preoperative (preop) to postoperative (postop) is a high-stake event that might require multiple location changes (from the admitting area to the holding area, from the OR to the postanesthesia care unit [PACU], from the PACU to the surgical ward or specialty care units, from the surgical inpatient unit to a rehabilitation unit and other transitions). Essential to safe transition is high-quality handoff. This is defined as “the process of transferring primary authority and responsibility for providing clinical care to a patient from one departing caregiver to one oncoming caregiver” (Patterson & Wears, 2010, p. 53). Handoff communication has now become a proxy measure of the overall communication quality among providers (Riesenberg, Leisch, & Cunningham, 2010).

The Joint Commission accreditation evaluates the effectiveness of communication among caregivers as part of its National Patient Safety Goals (TJC, 2015). Perioperative sentinel event (e.g., resulting in death or permanent loss of function) data root-cause analysis from 2004 to 2014 reveals communication failure and human factors as leading causes of errors (greater than 60%) in anesthesia-related events, wrong-site/procedures; operative and postoperative complications, transfer-related events, transfusion-related events, and unintended retention of foreign object events (TJC, 2014a). Communication skills have been measured as the worst aspect of teamwork behavior in the OR (Wahr et al., 2013).

Although handoff varies according to unique institution process (e.g., use of electronic health record), it is imperative to use a standardized form or checklist coupled with preoperative and postoperative debriefings (Wahr et al., 2013). The Association of periOperative Registered Nurses (AORN) website has extensive resources and tools to guide design and implementation of quality handoff (AORN, 2012). For guidance on how to implement quality-improvement projects in handoff, the Handoff Communications Targeted Solutions Tool by TJC is an excellent starting point (see the Resources section for the website).

SSI Prevention

SSIs are reported to be the most prevalent health care–associated infections (HAIs), accounting for 31% of all HAIs among hospitalized patients (Magill et al., 2012). HAI is estimated to affect 2% to 5% of inpatient surgery, with 3% mortality, while increasing the risk of death two to 11 times compared to those who did not acquire an SSI (Anderson et al., 2014). Staphylococcus aureus is the most common pathogen causing SSIs, accounting for 30% of SSIs in the United States (Bratzler et al., 2013). Standards and guidelines to prevent SSI have been espoused by the Surgical Care Improvement Project (SCIP) supported by key stakeholders. Comprehensive SSI prevention strategies include well-established measures, such as surgical hand asepsis and other collaborative measures, such as antibiotic prophylaxis, glycemic control, maintaining normothermia, and skin and bowel prep (Fry, 2008). A comprehensive policy on SSI prevention includes environmental and engineering policies such as keeping the OR doors closed during surgery except as needed for passage of equipment, personnel, and the patient (Berríos-Torres, 2009). The CDC standard and transmission-based precautions should be followed where applicable. See Protocol 32.1 for SSI practice guidelines.

Deep Vein Thrombosis Prophylaxis

Venous thromboembolism (VTE) is defined as having either a DVT and/or a PE (He et al., 2014). The rate of postoperative VTE after hip-fracture surgery is low, estimated at 1.34%, 95% (CI [1.04–1.64]) with PE actuarial rate of 0.25% at 3 months; however, the overall mortality is 14.7% (Rosencher et al., 2005). Indeed, hip fracture patients belong to a vulnerable group of old people with comorbid diseases that put them at a high risk of postoperative VTE morbidity and mortality. Residents in long-term care (LTC) facilities and hospitals account for about 60% of diagnosed VTE events (Heit et al., 2002).

Well-known risk factors for VTE include advanced age; obesity; trauma; hypertension; those with a diagnosis of cancer, congestive heart failure, chronic obstructive pulmonary disease, or chronic kidney disease, especially nephrotic syndrome; trauma; and those undergoing major surgery, including laparoscopic surgery (Buesing, Mullapudi, & Flowers, 2015). Appropriate screening using evidence-based clinical decision rules (CDRs) is warranted among perioperative older adults (Siccama et al., 2011) in the light of the 2008 Surgeon General’s office call to action to prevent the estimated 350,000 to 600,000 annual VTE cases in the United States (Leavitt, 2008). To maintain the safety and reduce harm, nurses need to observe TJC’s guidelines related to the use of anticoagulants (TJC, 2015). VTE prophylaxis should be initiated 24 hours before surgery and continued thereafter as clinically indicated (Cataife, Weinberg, Wong, & Kahn, 2014; TJC, 2014b).

Special Population: Bariatric Surgery

Current U.S. estimates indicate approximately one third of persons older than 65 years are obese (CDC, 2012). As result, there is a consequent rise of bariatric surgery among this age group (Dorman et al., 2012). Although there has been some debate on the safety of bariatric surgery among older adults, a systematic review and meta-analysis declared the procedure to be safe for those 55 years and older (Lynch & Belgaumkar, 2012). VTE prophylaxis is essential in the perioperative management of bariatric surgery patients (Buesing et al., 2015).

Preoperative Fasting Guidelines

Traditional practice of not letting patients eat or drink after midnight (“NPO after midnight”) before general anesthesia aims to reduce the volume and acidity of stomach contents during surgery, thus reducing the risk of regurgitation or aspiration. Prolonged fasting has been associated with adverse physical and psychological perioperative complications such as irritability, headache, dehydration, emesis, hypotension, hypovolemia, and hypoglycemia (Brady, Kinn, & Stuart, 2003).

Current guidelines recommend fasting of 2 hours for clear liquid and 6 hours for a light meal (ASA, 2011). Nurses need to get familiarized with institutional fasting procedures and be proactive in evaluating outdated policies that might impact the well-being of older adult patients. Another important consideration is determining which medications (e.g., beta blockers) the patient should continue taking in spite of fasting requirements.

Surgery and Do-Not-Resuscitate Orders

Although information on advance directives, such as health care proxies, is now routinely collected during patient interviews, the discussion on do not resuscitate (DNR) orders remains a sensitive topic. This highlights the importance of clear communication among the patient or designated surrogate and the provider. According to a position statement by the American College of Surgeons (ACS):

The nursing staff provides high-quality care regardless of the patient’s DNR status. Nurses need to communicate advance directive information during handoff and care transitions. In patient teaching, nurses may interpret for the patient and designated surrogate unfamiliar language of advance directives and related institutional policies.

CASE STUDY

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Mr. P is an 85-year-old male patient who was brought in by ambulance after falling in his apartment, where he lives alone. He reported to have slipped while getting out of bed. He remained conscious but felt pain on his right hip. He denied headache, loss of consciousness, chest pain, palpitation, and dizziness. After he managed to get up from the floor, he called his son on the phone who, in turn, called the emergency medical service (EMS). Mr. P’s past medical history includes coronary artery disease (CAD), coronary artery bypass graft in 2005, atrial fibrillation (on Coumadin), permanent pacemaker, peripheral vascular disease, end-stage renal disease (ESRD; on hemodialysis on Mondays, Wednesdays, and Fridays), and anemia of chronic disease. He has an allergy to sulfa drugs (rash). Mr. P is a resident of an assisted living facility.

On arrival to the ED, he was awake, alert, and oriented to self and place, but not to time. His right arm and forehead have multiple bruises and abrasions. Up until very recently, he has been mostly independent in performing his activities of daily living (ADL) and can ambulate using a walker. He gets physical therapy at home five times a week and his last hospitalization was 6 months ago for pneumonia.

In the ED, his vital signs were as follows: blood pressure (BP): 124/76 mmHg, heart rate (HR): 60 per minute (paced rhythm), respiratory rate (RR): 17 regular, temperature: 36.9°C, and his oxygen saturation was 97% on room air. His current body mass index (BMI) is 25. His physical examination was unremarkable other than an external rotation and abduction of his right leg and exertional pain on the right hip area (6/10) as well as bruising on the hip area. An x-ray of the right hip revealed a comminuted intertrochanteric fracture with mild displacement of bone fragments. The head CT scan showed no evidence of acute intracranial trauma. Mr. P has a right brachial arteriovenous fistula for dialysis. His baseline lab values are shown in Table 32.2.

 

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