From the 2019 HVPAA National Conference
Dr. Oluwafemi Owodunni (Johns Hopkins Medical Institutions), Dr. Jerry Stonemetz (Johns Hopkins Medical Institutions), Ms. Dianne Bettick (Johns Hopkins Medical Institutions), Dr. Susan Gearhart (Johns Hopkins Medical Institutions)
Background
In July 2019, the American College of Surgeons (ACS) will offer a verification process for hospitals to become a Geriatric Surgery Center of Excellence. Currently, the Johns Hopkins Health System Surgical Clinical Community is implementing a Geriatric Surgery Pathway that aligns with recommendations from the ACS and the pathway objective is to enhanced care coordination for our high-risk patients. In March of 2018, we implemented a screening process within the health system to identify those older patients that would benefit from a Geriatric Surgery Pathway.
Objective
The purpose of this study is to examine the ability of our screening tool to predict discharge destination.
Methods
From 3/1/2018 through 3/1/2019, patients ³ 65 years undergoing elective inpatient surgery on the General, Gastrointestinal, Vascular, Orthopedic, Cardiothoracic, Urologic, Neurosurgery, and ENT services who completed the Edmonton Frail Scale (EFS) preoperatively were included. The EFS is an 11-item comprehensive scale, which includes a cognitive screen, a functional screen, and psychosocial determinants. A total of 17 points can be awarded. Demographics, case details, and discharge location (home, home with homecare, subacute nursing facility (SNF) or rehabilitation facility) were collected. Adjusted Logistic and pairwise regressions were utilized and a p<0.05 was considered significant.
Results
2,962 patients met the inclusion criteria and 1,047 (35%) completed the EFS. The majority of the procedures were major abdominal (27%). The median EFS was 3 (range 0 – 14). Older patients (73.5 years vs. 71 years, p<0.001) and patients with a higher EFS (7 vs. 3, P<0.001) were more likely to be discharged to a SNF/Rehabilitation facility than home. Independent of surgery type, patients with a higher EFS were more likely to go a SNF/rehabilitation facility upon discharge. Among the EFS screens it was also noted that patients screening positive for cognitive impairment (RRR: 2.3; CI: 1.14-4.45, p=0.019) and functional impairment (RRR: 5.2; CI: 4.1 -6.9, p<0.001) were the most likely to require placement in a SNF/rehabilitation facility.
Conclusions
Use of a preoperative screening assessment identified those older patients undergoing elective surgery that were more likelihood to be discharged to a SNF or rehabilitation facility.
Clinical Implications
Futures work will focus on processes to improve upfront care coordination for our high risk surgical patient.
