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Publications (233)
Many seriously ill patients undergo surgical interventions. Palliative care clinicians may not be familiar with the nuances involved in perioperative care, however they can play a valuable role in enabling the delivery of patient-centered and goal-concordant perioperative care. The interval of time surrounding a surgical intervention is fraught wit...
Objective
To characterize the perceptions of surgeons, anesthesiologists, and geriatricians regarding perioperative CPR in surgical patients with frailty.
Summary Background Data
The population of patients undergoing surgery is growing older and more frail. Despite a growing focus on goal-concordant care, frailty assessment, and debate regarding t...
Importance:
Frailty is associated with mortality following surgery and cardiopulmonary resuscitation (CPR) for in-hospital cardiac arrest. Despite the growing focus on frailty as a basis for preoperative risk stratification and concern that CPR in patients with frailty may border on futility, the association between frailty and outcomes following...
Context:
Discussion of perioperative code status is an important element of preoperative care and a component of the American College of Surgeons' Geriatric Surgery Verification (GSV) Program. Evidence suggests code status discussions (CSDs) are not routinely performed and are inconsistently documented.
Objective:
Because preoperative decision m...
Context:
As part of the launch of the Geriatric Surgery Verification program in 2019, the American College of Surgeons issued care standards for older patients, including requirements for preoperative documentation of patients' goals. Hospital performance on these standards prior to the Geriatric Surgery Verification program is unknown.
Objective...
Objective
To assess the feasibility of administering the MoCA 5-minute test/Telephone (T-MoCA), an abbreviated version of the Montreal Cognitive Assessment to older adults perioperatively
Design
A feasibility study including patients aged ≥ 70 years scheduled for surgery from December 2020 to March 2021
Setting
Preoperative virtual clinic
Patien...
Study objective
This study aimed to assess the impact of data-driven didactic sessions on metrics including fund of knowledge, resident confidence in clinical topics, and stress in addition to American Board of Anesthesiology In-Training Examination (ITE) percentiles.
Design
Observational mixed-methods study.
Setting
Classroom, video-recorded e-l...
Introduction
Older adults account for an increasing proportion of emergency surgical procedures and have longer hospital lengths of stay than their elective counterparts. Identifying those at greatest risk of discharge to a postacute care facility would improve postoperative planning. We aimed to examine the role of preoperative cognitive and funct...
Objective:
Examine feasibility and construct validity of Pictorial fit frail scale (PFFS) for the first time in older surgical patients.
Background:
The PFFS uses visual images to measure health state in 14 domains and has been previously validated in outpatient geriatric clinics.
Methods:
Patients ≥65 year-old who were evaluated in a multidis...
Background:
Older adults may have new care needs and functional limitations after surgery. Many rely on informal caregivers (unpaid family or friends) after discharge but the extent of informal support is unknown. We sought to examine the role of informal postoperative caregiving on transitions of care for older adults undergoing routine surgical...
Purpose of review:
Millions of perioperative crises (e.g. anaphylaxis, cardiac arrest) may occur annually. Critical event debriefing can offer benefits to the individual, team, and system, yet only a fraction of perioperative critical events are debriefed in real-time. This publication aims to review evidence-based best practices for proximal crit...
American Society of Anesthesiologists guidelines recommend that anesthesiologists revisit do-not-resuscitate orders preoperatively and revise them if necessary based on patient preferences. In patients without do-not-resuscitate orders or other directives limiting treatment however, “full code” is the default option irrespective of clinical circums...
Objective
To characterize full cycle of care costs for managing an acute ureteral stone using time-driven activity-based costing.
Methods
We defined all phases of care for patients presenting with an acute ureteral stone and built an overarching process map. Maps for sub-processes were constructed through interviews with providers and direct obser...
A proof of concept study was conducted to implement an automated preoperative triage and preparation service with 2 components: (1) triage between preoperative visits and phone screens, and (2) delivery of preoperative instructions to patients. The study enrolled 2604 patients, of whom 75.7% completed the preoperative triage questionnaire and 47.6%...
Background:
Preoperative goals of care (GOC) and code status (CS) discussions are important in achieving an in-depth understanding of the patient's care goals in the setting of a serious illness, enabling the clinician to ensure patient autonomy and shared decision making. Past studies have shown that anesthesiologists are not formally trained in...
Objective:
To determine prevalence of documented preoperative code status discussions and post-operative outcomes (specifically mortality, readmission and discharge disposition) of patients with completed Medical Orders for Life-Sustaining Treatments (MOLST) forms before surgery.
Summary of background data:
A MOLST form documents patient care pr...
Background:
Anemia is common in cardiac surgery affecting 25-40% of patients and associated with increased blood transfusions, morbidity, mortality, and higher hospital costs. Higher rates of stroke, acute renal injury, and total number of adverse postoperative outcomes have also been reported to be associated with preoperative anemia. This system...
Purpose of review:
The landscape of medical education continues to evolve. Educators and learners must stay informed on current medical literature, in addition to focusing efforts on current educational trends and evidence-based methods. The present review summarizes recent advancements in anesthesiology education, specifically highlighting trends...
Background/objectives:
Identifying surgical patients at risk for discharge to a post-acute facility has the potential to reduce hospital length of stay, improve postoperative planning, and increase patient satisfaction. We sought to examine the association between a positive response to a preoperative patient-reported frailty screen and non-home d...
Context
Optimal surgical care for older adults with life-threatening conditions, with high risk of poor perioperative outcomes and morality in the months after surgery, should incorporate an understanding of the patient's treatment goals and preferences. However, little research has explored the patient perspective of decision making and advanced c...
Background:
Frailty and cognitive impairment are associated with postoperative delirium, but are rarely assessed preoperatively. The study was designed to test the hypothesis that preoperative screening for frailty or cognitive impairment identifies patients at risk for postoperative delirium (primary outcome).
Methods:
In this prospective cohor...
To prepare for the increasing numbers of older adults undergoing surgery, the American College of Surgeons (ACS) has recently launched the Geriatric Surgery Verification Program with the goal of encouraging the creation of centers of geriatric surgery. Meanwhile, the Society for Perioperative Assessment and Quality Improvement (SPAQI) has published...
There are few cognitive screening tools appropriate for fast-paced settings with limited staffing, and particularly in preoperative evaluation clinics. The Society for Perioperative Assessment and Quality Improvement (SPAQI) convened experts in neuropsychology, geriatric medicine, and anesthesiology to conduct a review of the literature and compile...
Shared decision making (SDM) is an essential element of providing patient-centered perioperative care. Newer value-based health care models, defined as patient-centered outcomes versus the cost required to achieve these outcomes, will necessitate the use of metrics that reflect alignment of treatment decisions with patient preferences and goals. Th...
There are few cognitive screening tools appropriate for fast-paced settings with limited staffing, and particularly in preoperative evaluation clinics. The Society for Perioperative Assessment and Quality Improvement (SPAQI) convened experts in neuropsychology, geriatric medicine, and anesthesiology to conduct a review of the literature and compile...
Background:
High-quality shared decision-making for patients undergoing elective surgical procedures includes eliciting patient goals and treatment preferences. This is particularly important, should complications occur and life-sustaining therapies be considered. Our objective was to determine the preoperative care preferences of older higher-ris...
A shift in healthcare payment models from volume toward value-based incentives will require deliberate input into systems development from both perioperative clinicians and administrators to ensure appropriate recognition of the value of all services provided-particularly ones that are not reimbursable in current fee-for-service payment models. Tim...
Background:
Earlier studies have demonstrated poor concordance between patients' advance care preferences and those endorsed by their surrogate health care decision makers in a medical setting. This study aimed to determine concordance in the perioperative setting among high-risk patients and to identify areas for improvement.
Methods:
This was...
Study objective:
Total hip arthroplasty (THA) is a common surgical procedure in the elderly. Varying degrees of cognitive impairment (CI) are frequently seen in this patient population. To date, there has been no systematic review of the literature specifically examining the impact of CI on outcomes after elective THA. The aim of this systematic r...
p>Background: Postoperative hypotension and hypertension are frequent events associated with increased risk of adverse outcomes. However, proper assessment and management is often poorly understood. As a part of the PeriOperative Quality Improvement (POQI) 3 workgroup meeting, we developed a consensus document addressing this topic. The target popu...
p>Background: A multidisciplinary international working subgroup of the third Perioperative Quality Initiative consensus meeting appraised the evidence on the influence of preoperative arterial blood pressure and community cardiovascular medications on perioperative risk.
Methods: A modified Delphi technique was used, evaluating papers published...
Directed discussion about advanced care planning in the preoperative setting is often lacking. We implemented an educational intervention pilot to increase the number of high-risk patients who have health care proxy and advanced directives documents completed. We developed a novel short video describing the advanced care planning process and the in...
Background
Perioperative arterial blood pressure management is a physiologically complex challenge influenced by multiple factors.
Methods
A multidisciplinary, international working subgroup of the Third Perioperative Quality Initiative (POQI) consensus meeting reviewed the (patho)physiology and measurement of arterial pressure as applied to perio...
Background
The role of anesthesiologists has expanded from operating rooms to preoperative evaluation clinics. This role involves performing preoperative cardiovascular evaluation and optimization of patients before elective surgery, which can include ordering cardiac stress tests. We aimed to study the ordering patterns by anesthesiologists for pr...
Background:
Code status discussions, goals of care discussions, and shared decision-making in the perioperative setting are of great importance. As perioperative physicians, anesthesiologists are uniquely poised to handle these discussions. Yet formal training for anesthesiology residents in how to approach these scenarios is currently lacking.
M...
Introduction
To evaluate the body of evidence on the predictive value of preoperative cognitive impairment on in-hospital, short-term, and midterm postoperative outcomes for elderly patients undergoing total knee arthroplasty (TKA).
Significance
With an aging population, an increasing percentage of the U.S. patient population will be living with c...
To assess the predictive value of preoperative cognitive impairment on postoperative in-hospital, short-term, and mid-term outcomes among patients undergoing surgical or transcatheter aortic valve replacement. The review was conducted according to PRISMA guidelines. Articles were identified in EMBASE, Medline, and PubMed. Eligible articles compared...
Traditional systems of anesthesia evaluation do not routinely incorporate cognitive screening into preoperative assessments of vital organ systems. Increasing recognition of the importance of preoperative cognitive assessment of the elderly surgical patient has resulted in a "call to action" from experts in this area. A paradigm shift will be neces...
Background
Preoperative anesthetic evaluations of patients before surgery traditionally involves assessment of a patient's functional capacity to estimate perioperative risk of cardiovascular complications and need for further workup. This is typically done by inquiring about the patient's physical activity, with the goal of providing an estimate o...
Despite the aligned histories, development, and contemporary practices, today, pediatric anesthesiologists are largely absent from pediatric intensive care units. Contributing to this divide are deficits in exposure to pediatric intensive care at all levels of training in anesthesia and significant credentialing barriers. These observations have le...
Background
Time-driven activity-based costing (TDABC) is a methodology that calculates the costs of healthcare resources consumed as a patient moves along a care process. Limited data exist on the application of TDABC from the perspective of an anesthesia provider. We describe the use of TDABC, a bottom-up costing strategy and financial outcomes fo...
Purpose of Review
Defining and ensuring the quality of surgical decision making is extremely complex. This manuscript will provide a review of current state in this evolving area and a conceptual framework to help clinicians understand how to approach this issue.
Recent Findings
Recent reports support the hypothesis of the existence of significant...
Purpose
Preoperative clinics are an increasingly common mechanism for preoperative evaluation. Factors predicting prolonged visit times are poorly understood. Our objective was to identify patient factors that would allow non-medically trained staff to determine appropriate scheduling needs.
Methods
At the preoperative assessment center of a terti...
Background:
Periprocedural providers are encountering more patients with code status limitations (CSLs) regarding their preferences for resuscitation and life-sustaining treatment who choose to undergo palliative procedures. Surgical and anesthesia guidelines for preprocedural reconsideration of CSLs have been available for several years, but it i...
AIM
To determine morbidity and mortality in hip fracture patients and also to assess for any independent associations between Do-Not-Resuscitate (DNR) status and increased post-operative morbidity and mortality in patients undergoing surgical repair of hip fractures.
METHODS
We conducted a propensity score matched retrospective analysis using de-i...
Defining and ensuring the quality of decision making around surgery and other procedures is extremely complex. There are a number of factors that contribute to this complexity: lack of adequate metrics to define decisional quality, lack of training in this area for clinical providers, and lack of compensation for the additional time it might take t...
Background:
The American College of Surgeons and the American Geriatrics Society have suggested that preoperative cognitive screening should be performed in older surgical patients. We hypothesized that unrecognized cognitive impairment in patients without a history of dementia is a risk factor for development of postoperative complications.
Meth...
Objective:
Despite caring for patients near the end-of-life (EOL), surgeons and anesthesiologists report low confidence in their ability to facilitate EOL conversations. This discrepancy exists despite competency requirements and professional medical society recommendations. The objective of this systematic review is to identify articles describin...
Crisis checklists and emergency manuals are cognitive aids that help team performance and adherence to evidence-based practices during operating room crises. Resources to enable local implementation and training (key for effective use) are linked at http://www.emergencymanuals.org.
Supplemental Digital Content is available in the text.
Objective:
The aim of this study was to evaluate whether preoperative diabetes management can improve glycemic control and clinical outcomes after elective surgery.
Background:
There is lack of data on the importance of diabetes treatment before elective surgery. Diabetes is often ignored before surgery and aggressively treated afterwards.
Meth...
Background:
Impaired capacity of patients necessitates the use of surrogates to make decisions on behalf of patients. Little is known about surrogate decision-making in the surgical intensive care unit, where the decline to critical illness is often unexpected. We sought to explore surrogate experiences with decision-making in the surgical intensi...
Background:
Do-not-resuscitate (DNR) orders instruct medical personnel to forego cardiopulmonary resuscitation in the event of cardiopulmonary arrest, but they do not preclude surgical management. Several studies have reported that DNR status is an independent predictor of 30-day mortality; however, the etiology of increased mortality remains uncl...
Objective:
To compare survival, readmissions, and end-of-life care after palliative procedures compared with medical management for malignancy-associated bowel obstruction (MBO).
Background:
MBO is a late complication of intra-abdominal malignancy for which surgeons are frequently consulted. Decisions about palliative treatments, which include m...
Fragmented and variable perioperative care exposes patients to unnecessary risks and handoff errors. The perioperative surgical home aims to optimize quality, value-based care. We performed a retrospective evaluation of how a preoperative assessment center could coordinate care through e-mails sent to a patient's healthcare team that initiate discu...
Study objective:
Acute postoperative pain may transition to persistent/chronic pain in up to 50% or more of patients after certain surgeries. Despite this concern, it is unclear that patients' preprocedure understanding and expectations are aligned with these potential outcomes. This study was designed to evaluate the extent of this alignment and...
Background:
Patient involvement in surgical decisions is formalized in the informed consent process, which should reflect that the patient understands their diagnosis, planned procedure, and the associated risks and benefits before consenting to treatment. If high-quality shared decision making has occurred, the treatment chosen should best match...
Code status discussions (CSDs) clarify patient preferences for cardiopulmonary resuscitation in the event of cardiac or respiratory arrest. CSDs are a key component of perioperative care, particularly at the end of life, and must be both patient-centered and shared. Physicians at all levels of training are insufficiently trained in and inappropriat...
The decision to pursue surgery is often complicated in older adults. A multidisciplinary, shared approach to decision-making may improve communication between patients and their providers and facilitate complex risk assessment. We describe a case of an older adult presenting for complex surgery in which the preoperative anesthesia clinic visit was...
Background
Despite efforts for improvement, cerebrospinal fluid (CSF) shunt failure rates remain high. Recent studies have shown promising reductions in failure rates and infection rates with the routine use of perioperative checklists. This study was conducted to pilot test the feasibility and efficacy of integrating specific CSF shunt surgery qua...
Background
Previous literature from the study site identified the impact of the preoperative visit in meeting established guidelines and managing clinical issues and preventing cancellations. The authors sought to quantify the value added from the preoperative visit to the patient surgical experience.
Method
Over a three-month period, using an ele...
Purpose:
This study evaluated the effect of nurse practitioner (NP) mediated interventions on diabetes control before elective surgery.
Data sources:
A program was initiated to improve preoperative diabetes control in patients with HbA1c > 8%. The intervention was initially mediated by a physician alone and subsequently changed to involve NPs. T...
Background:
Preexisting cognitive impairment is emerging as a predictor of poor postoperative outcomes in seniors. We hypothesized that preoperative cognitive screening can be performed in a busy preadmission evaluation center and that cognitive impairment is prevalent in elective geriatric surgical patients.
Methods:
We approached 311 patients...
Previous literature on preoperative evaluation focuses on the impact on the day of surgery cancellations and delays; however, the framework of cancellations and delays at the time of the elective outpatient preoperative anesthesia visit has not been categorized. We describe the current model in the preoperative clinic at Brigham and Women's Hospita...
As the population of the world is rapidly ageing, the amount of surgery being performed in older patients is also increasing.
Special attention is required for the anaesthetic and perioperative management of these patients. The clinical and non-clinical
issues specific to older surgical patients are reviewed, with a special emphasis on areas of deb...
Objective
Our study describes improvement in patient adherence to guidelines for peri-procedural management of antithrombotic therapy following development of protocols and implementation of a standardized process to deliver instructions to patients who are scheduled to undergo procedures in the community hospital setting.
Methods
Baseline data re...