January, 2021
By Sandra Gordon for ASA
At Keck Medical Center of USC, roughly 40% of the patient population is over age 65. In 2018, the hospital began implementing a Perioperative Brain Health Initiative (PBHI) for surgical patients age 65 and older.
“We're still forging our pathway and trying to streamline everything,” says Justyne Decker, MD, assistant professor of anesthesiology, geriatric anesthesiologist, and lead for the USC Perioperative Brain Health Initiative at Keck Medical Center of USC. “But we've had a great team that came together and has generated success going forward.”
Here, Decker and fellow PBHI team member Carol J. Peden, MD, MPH, adjunct clinical professor of anesthesiology at Keck School of Medicine and Chair of the American Society of Anesthesiologists Perioperative Brain Health Initiative, offer these practical tips for implementing a PBHI based on their experience.
It takes teamwork. Recruit champions—those with a common passion to improve outcomes for older surgical patient population—such as nurses and surgeon who work in service lines where the incidence of delirium may be relatively high are integral to any successful PBHI. “You can't do this on your own. Get colleagues to work with you on implementing a perioperative brain health initiative because even if you do it on your own and it's initially successful, it won’t be sustainable because you'll wear out,” Peden says.
Keep delirium screening simple. “As anesthesiologists, there’s a tendency to want to use high-technology tools, such as EEG monitoring. It’s great if you have access to that, but there are very simple things you can do that will reduce the incidence of postoperative delirium that don't cost very much,” Peden says, such as implementing Mini-Cog screening in the preop clinic for all surgical patients 65 and older. Of the numerous cognitive screening tools available, the Mini-Cog is recommended as the tool of choice in the best practice guidelines for preoperative assessment of the older surgical patients by the American College of Surgeons and American Geriatric Society.
“Just by screening patients and recording the patient’s Mini-Cog score in the EHR can increase the awareness of post-operative delirium and change anesthesiologists’ behavior,” Peden says. With that information, anesthesiologists are more likely to avoid medications, such as benzodiazepines and to give the patient their glasses and hearing aids in the PACU.
Get IT involved early on. If you have electronic health records (EHR), team up with the IT department early to automate PBHI clinical information. “Changing alerts or anything in the electronic medical record takes time. The sooner you involve IT, the better,” Decker says. Build sustainability into your PBHI by working with IT to tweak the EHR so that PBHI information, such as the patient’s Mini-Cog score, is integrated into current workflows so that perioperative providers can access the information without having to do an additional task. “In our hospital workflow, for example, our hospitalists will often look at our preop evaluation notes when they're consulting for medical co-management postoperatively,” Decker says. That’s where PBHI notes go. Hospitalists will then input their assessment and plan delirium precautions and risk mitigation strategies.
Track easy surrogate markers. To measure the PBHI’s patient impact, decide which metrics to track. Delirium incidence can be challenging to measure because it may not be reported or documented accurately in the patients’ medical record. “If a metric is hard to measure, you probably won't do it, so find something else that's easier to track,” Peden says, such as length of stay and the use of certain medications.
Use these surrogate markers to determine your patient population’s true incidence of post-operative delirium. “Then, you can have a discussion with the billing and coding team about why postoperative delirium is being missed and what can be done to more accurately reflect it in the EHR,” Decker says.
Don’t think cognitive screening will offend patients. Although offending patients with cognitive screening is a common fear, “very few patients have had a concern or questions about the Mini-Cog,” Decker says. “For the ones who do, I explain why we provide this screening test for everyone over 65—'to make sure we're identifying people at increased risk so that we can give you additional resources around the time of surgery,’ they're usually fine with it,” Decker says.
Patients flagged at higher risk for delirium, with a Mini-Cog score of ≤2, or those who report previous issues with delirium or memory loss postoperatively are likely to welcome a discussion about the resources available to them. “You may be the first person to discuss cognitive risk for older surgical patients and validate that risk for them,” Decker says. “By broaching the subject, you’re showing them you’re concerned and want to take specific steps around the time of surgery to make sure their risk is reduced.”
Empower family members. During a discussion about surgery in older patients and cognitive risk, patients may be accompanied by a family member or friend. Use this opportunity to educate family members about post-operative changes in cognition or difficulty with memory and concentration in their loved one and what they can do to help, such as alerting a care team member after surgery if signs appear, and why it’s important to be there after surgery to help reorient their loved one, even if it’s just on Facetime, which is a tactic Keck Hospital’s PBHI team transitioned to during COVID.
Focus on discharge planning and transition to home. Engage the pharmacist for a discharge review of medications to make sure patients aren’t being sent home with high-risk medications. Then, reach out to patients’ primary care providers. “Create that bridge by letting them know patients have screened positive for postoperative delirium or cognitive impairment and that a more formal evaluation and a plan for patient and their family may be needed going forward,” Peden says.
Meet weekly. To maintain momentum for your PBHI, schedule a standing meeting with your PBHI team at the same time every week for even just 30 minutes. “Just meet every week with whoever can make it at that time,” Decker says. Use the meetings to discuss strategy and short and long-term strategies and solutions for issues that have arisen as you’re rolling out the program. “Meeting weekly keeps the momentum going,” Decker says.
ASA and the PBHI does not endorse specific hospital procedures, policies, or programs outlined in this content. All research and clinical material published in this article (above) by ASA and the PBHI is for informational purposes only. Readers are encouraged to confirm the information contained herein with other sources and consider applications within the context of their local environment. Patients and consumers should review the information carefully with their professional health care provider. This information is not intended to replace medical advice offered by physicians. ASA and PBHI will not be liable for any direct, indirect, consequential, special, exemplary, or other damages arising therefrom.
