Redesigning the surgical pathway: optimizing PReOperative assessMent in anesthesia clinic for adulT surgical patients (PROMoTE)

Stephen Choi MD, FRCPC, MScStephen Choi MD, FRCPC, MSc
Associate Professor, Department of Anesthesia, Sunnybrook Health Sciences Centre, University of Toronto

Dr. Choi’s project is entitled: “Redesigning the surgical pathway: optimizing PReOperative assessMent in anesthesia clinic for adulT surgical patients (PROMoTE).”

Background: Globally, over 300 million surgeries are performed yearly. Risk stratification and monitoring for cardiorespiratory complications are well established to allow early identification and management. Unfortunately, perioperative neurocognitive disorders (PND) which includes postoperative delirium (POD) and postoperative neurocognitive disorders (P-NCD) are frequently missed. Approximately 25% of patients suffer from POD and experience excess morbidity and mortality.1 POD increases healthcare costs by ~$32.9 billion ($44,291 per patient) annually in the United States.

Importantly, a significant proportion of POD is preventable. Several intraoperative strategies have been trialed with limited success. This includes pharmacotherapeutics, increased regional anesthesia, and anesthetic depth monitoring each with limited success. Multimodal non-pharmacologic strategies (CHASM from Hospital Elderlife Program [HELP]) are safe and consistently demonstrate large reductions in delirium (OR 0.47).2 Despite this, implementation is suboptimal, and POD remains stubbornly high, actually increasing between 2003 and 2019.3

Barriers to delirium friendly care include institutional pressure to reduce length of stay and being unaware of high-risk individuals. Among the biggest risk factors for POD is any degree of pre-existing cognitive impairment (pre-CI). Pre-CI is common in the surgical population (29%) and associated with an increased risk of POD (OR 2-3).4 Routine assessment for pre-CI is rare in preoperative clinics. Indeed without systematic objective screening pre-CI is missed. A recent study of 215 preoperative patients identified only 2 with pre-CI during routine assessment, yet 121 had pre-CI when screened with simple cognitive screening.5

Individuals at high risk for POD (pre-CI), a common complication with major negative consequences, are not identified and are not managed with a known, safe and effective intervention (CHASM from HELP). The perioperative team (anesthesiologists, surgeons, nurses) are not ignorant of best practices, nonetheless implementation is suboptimal. Importantly, awareness of high-risk status can positively impact behavior. Evidence comes from the dementia realm where knowledge of impaired cognitive status led to multiple increased interventions from health care workers including additional assessments and referral.

Aims: This project aims to reduce POD incidence and severity. By proactively identifying patients with pre-CI, a comprehensive program can target these high-risk individuals. The program will engage patients, caregivers, perioperative physicians, and nursing/allied health staff to utilize delirium friendly practices (eg. minimize benzodiazepines, regional analgesia where possible, minimize opioids, anesthetic depth monitoring, reduce urinary catheter usage, educational sessions to reinforce CHASM). Additionally flagging high-risk individuals to all team members will promote adherence to POD friendly best practices. This comprehensive approach, from identification to collaborative care, will reduce the incidence of POD in surgical patients. This will be prospectively assessed with a 2 phase, observational study (pre/post implementation).

Implications: POD continues to be a problem. It has effects on morbidity, mortality, and quality of life beyond the immediate perioperative period. A large proportion of the population presenting for surgery is elderly and will increase with demographics. Without a concerted effort to address POD, the problem will only get worse. Introducing a comprehensive program in high-risk POD patients that combines multiple aspects of POD friendly care – patient/family engagement, perioperative team awareness and application of best practices – is necessary. However, without identifying high-risk patients before the onset of POD, care that will help patients, cannot be initiated. Identification will facilitate awareness and the opportunity to target those most at risk.

REFERENCES

  1. Evered L, Silbert B, Knopman DS, et al. Recommendations for the Nomenclature of Cognitive Change Associated with Anaesthesia and Surgery-2018. Anesthesiology. 2018;129(5):872-879.
  2. Hshieh TT, Yang T, Gartaganis SL, Yue J, Inouye SK. Hospital Elder Life Program: Systematic Review and Meta-analysis of Effectiveness. Am J Geriatr Psychiatry. 2018;26(10):1015-1033.
  3. Silva AR, Regueira P, Albuquerque E, et al. Estimates of Geriatric Delirium Frequency in Noncardiac Surgeries and Its Evaluation Across the Years: A Systematic Review and Meta-analysis. J Am Med Dir Assoc. 2021;22(3):613-620 e619.
  4. Greaves D, Psaltis PJ, Ross TJ, et al. Cognitive outcomes following coronary artery bypass grafting: A systematic review and meta-analysis of 91,829 patients. Int J Cardiol. 2019;289:43-49.
  5. Smith NA, Yeow YY. Use of the Montreal Cognitive Assessment test to investigate the prevalence of mild cognitive impairment in the elderly elective surgical population. Anaesth Intensive Care. 2016;44(5):581-586.

Funding: $150,000 (January 1, 2022-December 31, 2023). The grant was designated as the APSF/ American Society of Anesthesiologists (ASA) President’s Research Award.