Cognitive status predicts preoperative instruction compliance.

The most common postoperative complication for older adults is perioperative neurocognitive disorder (PNCD). Its greatest risk factor is preoperative cognitive impairment. Cognitive impairment also predicts higher likelihood of postoperative complications. While the cause of disparity in outcomes is likely multifactorial, the ability to correctly follow perioperative instructions may be one modifiable component. The purpose of this study was to determine whether cognitive impairment led to reduced preoperative instruction compliance and if so, identify barriers and enact a tailored care-plan to close the gap. Our preoperative clinic implemented routine Mini-Cog screening to identify older (age ≥ 65) surgical patients at increased risk. All patients received the same instructions and, on day of surgery, were surveyed to determine correct execution of nil per os guidelines, chlorhexidine wipe use and medication management. Data was stratified by cognitive status to evaluate whether impairment predicted instruction execution. Feedback from patients and families were compiled. Of those who screened negative for impairment, 68% correctly followed instructions, while 84.2% of those impaired struggled with ≥1 instruction(s); impaired patients were more likely to incorrectly follow instructions (OR = 10.5, p-value = 0.001). Areas for change were identified and team-based solutions were enacted with additional support for those with impairment. We found a clear difference in correct execution with respect to cognitive status. By improving instructions as an institution and adding additional support for those with impairment, the compliance gap was significantly reduced. Targeting perioperative instructions and tailoring care in this population may be one modifiable component in the outcome disparity they face.

Nutrition Care for Poorly Nourished Outpatients Reduces Resource Use and Lowers Costs.

BACKGROUND AND OBJECTIVES: Over 25% of United States (US) community-dwelling, older adults are at nutritional risk. Health and cost burdens of poor nutrition can be lowered by nutrition programs for hospital inpatients, but few studies have looked at the impact on outpatients. The objective of our study was to assess outcomes of a nutrition focused quality improvement program (QIP) on healthcare resource use and costs in poorly nourished outpatients. METHODS: This pre-post QIP study was implemented at 3 US healthcare system clinics. Included patients (n = 600) were ≥45 years old, had ≥2 chronic conditions, and were enrolled over a 15-month interval. For comparison, historical (n = 600) and concurrent control (n = 600) groups were used. Assessment of poor nutritional status was performed during each patient's baseline visit. Healthcare resource use (hospitalizations, emergency department visits, and outpatient clinic visits), medication use, and costs were determined for a 90-day interval. RESULTS: QIP patients (mean age 61.6 years) were predominantly female (62.5%) and overweight/obese (81.7%). The proportion of QIP outpatients presenting for healthcare services was significantly reduced compared to both historical and concurrent controls-relative risk reduction (RRR) versus historical (11.6%, P < .001) and versus concurrent (8.9%, P = .003). Of those who presented, RRR for healthcare resource use by QIP was significant in comparison with historical (12.9%, P = .022) but not concurrent controls. No significant differences were observed for medication usage. Lower resource use among QIP patients yielded total cost savings of $290 923 or per-patient savings of $485. CONCLUSIONS: Nutrition QIPs in outpatient clinics are feasible and can reduce healthcare resource use and cut costs. Such findings underscore benefits of nutritional interventions for community-dwelling outpatients with poor nutritional status.

Classification of advanced and early stages of diabetic retinopathy from non-diabetic subjects by an ordinary least squares modeling method applied to OCTA images.

As the prevalence of diabetic retinopathy (DR) continues to rise, there is a need to develop computer-aided screening methods. The current study reports and validates an ordinary least squares (OLS) method to model optical coherence tomography angiography (OCTA) images and derive OLS parameters for classifying proliferative DR (PDR) and no/mild non-proliferative DR (NPDR) from non-diabetic subjects. OLS parameters were correlated with vessel metrics quantified from OCTA images and were used to determine predicted probabilities of PDR, no/mild NPDR, and non-diabetics. The classification rates of PDR and no/mild NPDR from non-diabetic subjects were 94% and 91%, respectively. The method had excellent predictive ability and was validated. With further development, the method may have potential clinical utility and contribute to image-based computer-aided screening and classification of stages of DR and other ocular and systemic diseases.

Beyond Cognitive Screening: Establishing an Interprofessional Perioperative Brain Health Initiative.

OBJECTIVE: Perioperative neurocognitive disorder (PND) is now recognized as the most common postoperative complication in older surgical patients. Current multidisciplinary guidelines recommend simple cognitive screening of older adults before surgery. Patients identified at risk should have input from an interprofessional team with expertise caring for older surgical patients. Data suggest these recommendations are infrequently met. We set out to test feasibility of routine cognitive screening in a busy preoperative assessment clinic and establish a perioperative pathway with multidisciplinary support for patients identified at risk. METHODS: We undertook a prospective quality improvement study. A cohort of 1,803 older surgical patients scheduled for preoperative evaluation was screened with the Mini-Cog© test. As the project developed, we began confirmatory neurocognitive testing by occupational therapists for those patients flagged at risk. Patients confirmed at risk were referred for further evaluation by a geriatrician and geriatric pharmacist. Alerts were developed to flag patients at risk through their in-patient journey, and a multidisciplinary team developed a comprehensive care pathway. RESULTS: We demonstrated that implementing routine cognitive screening can be done in a busy clinic, regardless of prior experience. The prevalence of preoperative cognitive impairment was 21% in our older patients undergoing inpatient surgery, rising to 36% in those older than 85 years. When the Mini-Cog results were not known to providers, they were unable to identify cognitive impairment in half of the patients, supporting the use of a validated screening test. We established an interprofessional team and pooled relevant recommendations into an age-friendly perioperative care pathway for patients at increased cognitive risk. CONCLUSION: Cognitive screening must be done to reliably identify older surgical patients at risk of PND. Demonstrating the prevalence of cognitive impairment in older surgical patients can provide impetus to develop a multidisciplinary team and care pathway with the aim of reducing the incidence of PNDs. J Am Geriatr Soc 68:2359-2364, 2020.

Occupational Therapy Student Learning on Interprofessional Teams in Geriatric Primary Care.

IMPORTANCE: Geriatric, interprofessional primary care training for occupational therapy students is needed. OBJECTIVE: To measure occupational therapy student-reported knowledge, attitudes, and skills after participation in interprofessional geriatric educational programs. DESIGN: Prospective, observational study with pre- and posttests for the three programs. PARTICIPANTS: Fifty-nine entry-level and postprofessional occupational therapy master's students. OUTCOMES AND MEASURES: Self-reported familiarity with other professionals' roles, perceptions of interprofessional training, capabilities to conduct assessments, and attitudes of older adults. RESULTS: Students of the three programs (Interprofessional Geriatrics Curriculum [IPGC], Student Senior Partnership Program [SSPP], and Geriatric Assessment Program [GAP]) reported different improvements in familiarity of roles, capabilities of assessment, and Geriatric Attitudes Scale (GAS) scores. For example, IPGC and SSPP students had changes in total GAS score (3.91-4.08, p = .002, and 3.84-3.99, p = .003, respectively), but no change was found for GAP students (3.85-3.91, p = .523). CONCLUSIONS AND RELEVANCE: More structured interprofessional education with older adults appeared to help prepare occupational therapy students to work on geriatric interprofessional teams in primary care. WHAT THIS ARTICLE ADDS: This article expands on growing evidence to support occupational therapy's role in primary care by addressing the need to train future generations to work on interprofessional geriatric primary care teams.

The Surgical Care Improvement project (SCIP) initiative to reduce infection in elective colorectal surgery: which performance measures affect outcome?

One component of the Surgical Care Improvement Project (SCIP) is the prevention of surgical site infections (SSIs) by: 1) timing the administration of prophylactic antibiotics (PAs) within 1 hour of incision; 2) using approved PA regimens; and 3) discontinuing PA within 24 hours. We sought to evaluate institutional compliance with SCIP recommendations in patients undergoing elective colorectal surgery and determine whether they affected the incidence of SSI. One hundred four elective colorectal cases were reviewed. In 58 patients (56%), PAs were administered within 1 hour of incision. In 71 cases (68%), the PA choice was considered compliant. There were a total of 12 SSIs (11.5%) overall. The incidence of SSI was significantly higher in cases in which PAs were not administered within 1 hour of incision (10 of 46 or 22% vs two of 58 or 3.5%, P = 0.005). There was no significant difference in the incidence of SSI in patients who received compliant versus noncompliant PA (12.7% vs 9.1%, P = 0.75). Timely PA administration significantly reduces the incidence of SSI in patients undergoing elective colorectal surgery. Efforts should focus on ensuring that PAs are given in a timely manner to reduce SSI in colorectal surgery.