We spend a significant amount of time with the patient and the family, and there is a pure human dimension in that experience that is sometimes lacking in modern health care,” says geriatrician Samir Tulebaev, MD, pictured above with a patient on Braunwald Tower 15.
The U.S. population is rapidly aging. As of the 2020 Census, one in six people in the United States were 65 and older. At the Brigham, the proportion is even greater: About 40 percent of surgical patients are over the age of 65.
The ranks of aging Americans are only growing. By 2029, every member of the Baby Boomer generation will be 65 or older. And they all have one thing in common: They will need health care, and, on average, they are more likely to have worse surgical outcomes than younger people.
None of these facts surprise Brigham surgeon Zara Cooper, MD, MSc, director of the Center for Geriatric Surgery and Kessler director of the Center for Surgery and Public Health, who has devoted her career to understanding and improving palliative and geriatric care for older surgical patients.
Rather, what surprises her is how little attention and resources the medical system at large gives to making surgery safer and better for older adults. Take, for example, medical education.
“Residents really don’t get any formal training in this area. There are some questions around geriatrics in the qualifying exams for general surgery, and there are some chapters in the standardized textbook, but it’s not enough,” Cooper said. “I think in some measure that’s because we’re a youth-oriented culture, and the people who are most immediately affected by this are not necessarily the people who are providing the care or making the decisions.”
Changing the Status Quo
For more than a decade, teams across the Brigham have been working to change the status quo and elevate the quality and safety of geriatric surgical care through innovative, interdisciplinary and evidence-based processes tailored to the needs of older adult patients.
On Nov. 1, the American College of Surgeons (ACS) validated these efforts by recognizing the Brigham as a national leader in geriatric care with Level 2 Verification-Focused Excellence status in its Geriatric Surgery Verification (GSV) Quality Improvement Program.
The Brigham is the first health care institution in New England and the first hospital of its size nationwide to achieve GSV designation, which requires hospitals to meet 32 quality standards for a percentage of surgical inpatients aged 75 and above.
“I cannot emphasize enough how impressed the American College of Surgeons’ reviewers were with our collaboration, cohesiveness, leadership and the exemplary care that we give to our older patients,” Cooper said. “They had trouble finding areas for improvement.”
The Brigham’s Center for Geriatric Surgery — which seeks to improve and standardize perioperative care of geriatric patients across the hospital — meets GSV requirements throughout the Trauma and Emergency General Surgery, Orthopaedics and Ortho Trauma, Colorectal and Neurosurgery Spine service lines, as well as a pilot currently underway in Vascular Surgery.
“One of the most compelling outcomes of our program is that our interventions have reduced postoperative delirium in older adults,” said geriatrician and palliative care physician Rachelle Bernacki, MD, MS, director of Care Transformation and Postoperative Pathways. “That means patients have their surgeries and are back home as fast as possible, getting to do the things they love. And if they need a little extra support while they are in the hospital, we are there to help them.”
A Big SSTEP Forward
Some of GSV’s quality standards include geriatric-friendly patient rooms, life-sustaining treatment discussion for patients with planned ICU admission, geriatric vulnerability screens, interdisciplinary care for high-risk patients, and geriatric education of surgeons, advanced practice providers and nurses.
“It’s been a huge effort on the part of so many individuals to take these verification standards and integrate them in a meaningful way that not only improves patient care but is also streamlined operationally for clinicians and staff,” said Lynne O’Mara, MPAS, PA-C, clinical program manager. “The information that we seek when screening a patient needs to flow into the electronic medical record in a way that clinicians can see and effectively use, and then translate into notes and documents and make it actionable.”
Among the many efforts to improve care for older adults are the Geriatric Inpatient Fracture Service (GIFTs) and Geriatric Co-Management for Orthopedic Patients programs. Led by Houman Javedan, MD, clinical director of the Division of Aging, these programs are designed to make orthopaedic surgery safer for patients aged 70 and up.
Also at the heart of this work is the Superior Surgical Treatment for sEniors Pathway (SSTEP), an order set that encompasses pain management, mobility, sleep and nutrition for older adults and is now available for use across the hospital. SSTEP is focused heavily on ensuring providers put in the correct orders so nursing can provide the appropriate care to older adult patients. This was shown to improve outcomes, decrease delirium and lessen readmissions.
To date, approximately 600 surgical residents, fellows and physician assistants (PAs) have been trained in the utilization of the SSTEP order set. O’Mara, who helped launch SSTEP, has been providing training and geriatric education to all Brigham trainees and PA staff in Surgery and ICUs for the past eight years using SSTEP, in addition to orienting all new PA hires.
Nursing staff implement interventions as part of SSTEP, including geriatric nursing best practices, with an emphasis on early mobility and delirium prevention. Interprofessional care teams — including nurse care coordinators, social workers, pharmacists, physical therapists, occupational therapists and dietitians — optimize the patient’s care and discharge planning.
“In order to build a comprehensive geriatric surgery program that provides optimal, patient- and family-centered care in a meaningful way, it is critical to include diverse professional roles and disciplines, perspectives and levels of experience,” said Amy Bulger, MPH, RN, GERO-BC, CPHQ, director of Geriatrics Operations and co-chair of the Geriatrics Care Improvement Committee. “Our geriatric education, committees and pathways highlight the vital role each team member plays in the patient’s care. Throughout my career, I have advocated for the crucial role the interprofessional team plays, with the clear understanding that both the patient and the team members will benefit.”
Partnering with Patients and Families
Some older patients require more specialized care, and the Center for Geriatric Surgery has championed protocols that lead to better care for more vulnerable older patients.
“Older adults are not all the same. Some 75 year olds are still running marathons, and others may need a walker,” Bernacki said. “The treatment plans may need to be different, and we adjust our care plans accordingly.”
In the Brigham’s 21 outpatient surgery clinics and the Emergency Department, residents and medical assistants screen patients 75 and older for frailty using the FRAIL scale, a five-question assessment of fatigue, resistance, aerobic capacity, illnesses and loss of weight. If a patient scores a 3 or higher, they are considered frail. To determine whether a patient should have a consultation with a geriatrician, the patient must be deemed frail, have cognitive impairment or have dementia.
“We work tirelessly to match the resources we have with the patients who need their services the most and ensure that the system is set up to support the remainder of the geriatric patients,” O’Mara said.
Geriatricians conduct a comprehensive assessment of a patient’s health that does not just include the medical problem that prompted them to seek care. Goals of care are also discussed before surgery or before any significant intervention. Geriatricians speak with the patient and their family about what they expect from the treatment and what is important to them.
“More than half of what we do is preparing the family for what could happen to the patient in the hospital so that families are not alarmed or blindsided when the patient has delirium or another complication,” Cooper said. “It’s hard to see the people you love go through that.”
Prior to surgery, perioperative staff and surgeons conduct necessary screenings and ensure the patient’s plan of care is aligned with recommendations provided by Geriatrics and Anesthesiology through the Weiner Center for Preoperative Evaluation. After the procedure, PAs and residents place the patient on SSTEP and, depending on the patient’s frailty assessment, consult the Geriatrics team to follow the patient.
Teams continue to work closely to develop a safe discharge plan that aligns with the patient’s goals and provides guidance for caregivers to manage common geriatric vulnerabilities, such as falls and delirium.
“We spend a significant amount of time with the patient and the family, and there is a pure human dimension in that experience that is sometimes lacking in modern health care,” said geriatrician Samir Tulebaev, MD, of the Division of Aging. “Some portion of humanity is lost in trying to be too efficient, especially for older adults who cannot react very quickly. We spend time with patients, not only to seek out what problems they have or discuss goals of care, but to just talk to them and sit with them.”