C.Y. Ko

Postoperative Delirium in Older Adults: Best Practice Statement from the American Geriatrics Society

Disclosure Information: Disclosures for the members of t Geriatrics Society Postoperative Delirium Panel are listed in Support: Supported by a grant from the John A Hartford Fou to the Geriatrics-for-Specialists Initiative of the American Geri (grant 2009-0079). This article is a supplement to the American Geriatrics Soci Practice Guidelines for Postoperative Delirium in Older Adu at the American College of Surgeons 100 Annual Clinic San Francisco, CA, October 2014.

American Geriatrics Society abstracted clinical practice guideline for postoperative delirium in older adults

The abstracted set of recommendations presented here provides essential guidance both on the prevention of postoperative delirium in older patients at risk of delirium and on the treatment of older surgical patients with delirium, and is based on the 2014 American Geriatrics Society (AGS) Guideline. The full version of the guideline, American Geriatrics Society Clinical Practice Guideline for Postoperative Delirium in Older Adults is available at the website of the AGS. The overall aims of the study were twofold: first, to present nonpharmacologic and pharmacologic interventions that should be implemented perioperatively for the prevention of postoperative delirium in older adults; and second, to present nonpharmacologic and pharmacologic interventions that should be implemented perioperatively for the treatment of postoperative delirium in older adults. Prevention recommendations focused on primary prevention (i.e., preventing delirium before it occurs) in patients who are at risk for postoperative delirium (e.g., those identified as moderate‐to‐high risk based on previous risk stratification models such as the National Institute for Health and Care Excellence (NICE) guidelines, Delirium: Diagnosis, Prevention and Management. Clinical Guideline 103; London (UK): 2010 July 29). For management of delirium, the goals of this guideline are to decrease delirium severity and duration, ensure patient safety and improve outcomes.

Hospital-level Variation in Secondary Complications After Surgery.

Objectives:To assess whether hospital rates of secondary complications could serve as a performance benchmark and examine associations with mortality. Background:Failure to rescue (death after postoperative complication) is a challenging target for quality improvement. Secondary complications (complications after a first or “index” complication) are intermediate outcomes in the rescue process that may provide specific improvement targets and give us insight into how rescue fails. Methods:We used American College of Surgeons’ National Surgical Quality Improvement Program data (2008–2012) to define hospital rates of secondary complications after 5 common index complications: pneumonia, surgical site infection (SSI), urinary tract infection, transfusion/bleed events, and acute myocardial infarction (MI). Hospitals were divided into quintiles on the basis of risk- and reliability-adjusted rates of secondary complications, and these rates were compared along with mortality. Results:A total of 524,860 patients were identified undergoing one of the 62 elective, inpatient operations. After index pneumonia, secondary complication rates varied from 57.99% in the highest quintile to 22.93% in the lowest [adjusted odds ratio (OR), 4.64; confidence interval (CI), 3.95–5.45). Wide variation was seen after index SSI (58.98% vs 14.81%; OR, 8.53; CI, 7.41–9.83), urinary tract infection (38.41% vs 8.60%; OR, 7.81; CI, 6.48–9.40), transfusion/bleeding events (27.14% vs 12.88%; OR, 2.54; CI, 2.31–2.81), and acute MI (64.45% vs 23.86%, OR, 6.87; CI, 5.20–9.07). Hospitals in the highest quintile had significantly greater mortality after index pneumonia (10.41% vs 6.20%; OR, 2.17; CI, 1.6–2.94), index MI (18.25% vs 9.65%; OR, 2.67; CI, 1.80–3.94), and index SSI (2.75% vs 0.82%; OR, 3.93; CI, 2.26–6.81). Conclusions:Hospital-level rates of secondary complications (failure to arrest complications) vary widely, are associated with mortality, and may be useful for quality improvement and benchmarking.