• A Clinical Practice Guideline for Postoperative Cognitive Impairment: Anesthetic Interventions

      Taylor, Natalie L.; Pellegrini, Joseph (2020-05)
      Problem & Purpose: Postoperative delirium and postoperative cognitive dysfunction, collectively referred to as postoperative cognitive impairment (PCI), are two neurocognitive risks that accompany anesthesia. The incidence of developing PCI can be as high as 50% and is heightened after the age of 65. Currently, the anesthesia department at a mid-sized community hospital in Baltimore City does not have a structured process for the perioperative management of these patients. A Clinical Practice Guideline (CPG) was written recommending a strategy to preoperatively assess and identify high-risk surgical patients, and includes evidence-based anesthetic interventions recommended for this population. The purpose of this scholarly project was to identify the anesthetic interventions included within this CPG: a guide which outlines the perioperative anesthetic management of patients >65 in order to decrease the incidence of PCI. Methods: CPG content was derived from a literature search identifying evidence published within the past 10 years and included five systematic reviews, two randomized control trials, and the current recommendations of the American Geriatrics Society and American College of Surgeons. The CPG was designed, analyzed by key stakeholders, and revised according to criteria found within the AGREE II tool. The CPG was presented to anesthesia staff and analyzed for applicability and acceptance using the Practitioner Feedback Questionnaire (PFQ). Results: AGREE II results by key stakeholders provided >88% positive feedback showing CPG quality in scope, content, and development. PFQ results demonstrated an overall average positive feedback and agreement of 70% (SD=19.1) among anesthesia providers (n=13). Feedback regarding the overall Quality of the CPG was both positive (88%) and neutral (12%). Applicability of Recommendations received the least encouraging feedback: 35% positive, 38% neutral, and 27% negative. Conclusion: Analysis demonstrates that the CPG’s content was regarded by anesthesia staff as high quality and that the majority of providers believe the CPG to be an improvement compared to what is currently practiced. While the majority of the polled anesthesia providers felt favorably towards the interventions, there remains reluctance towards its applicability into practice. Even so, 70% of anesthesia staff answered positively when asked if the CPG should become a guideline. Further staff education is recommended to enhance user buy-in.
    • Implementation of an Anesthesia Practice Change to Impact Postoperative Cognitive Dysfunction

      Greenberg, Rachel A.; Franquiz, Renee (2022-05)
      Problem: Approximately 25-40% of patients over the age of 60 who undergo anesthesia experience postoperative cognitive dysfunction (POCD) at hospital discharge, and 10% continue to suffer from this complication 3 months postoperatively. Devastating physical and financial outcomes occur including prolonged hospital stays, higher rates of readmission, financial stress and dependence, as well as increased mortality. Intraoperative administration of dexamethasone and dexmedetomidine are evidence-based effective strategies to reduce the incidence of POCD. Purpose: The purpose of this Quality Improvement (QI) project is to implement an anesthesia practice change to impact the incidence of POCD. The overall goal is to increase adherence to the administration of intraoperative dexamethasone and dexmedetomidine for patients who are identified preoperatively as high-risk for POCD through screening. Methods: Through collaboration with anesthesia leadership and other key stakeholders, a site-specific intraoperative checklist was developed to illustrate the anesthesia practice change. Anesthesia providers were prompted to evaluate results of the preoperative screening; patients with a positive screening result, indicating a higher risk of developing POCD, should be administered at least one of the evidence-based interventions listed on the intraoperative checklist. Administration of these interventions were documented on a paper checklist and collected for data analysis. Results: Preimplementation rates of dexamethasone and/or dexmedetomidine administration to patients aged 60 or older was compared to post-implementation rates of administration to high-risk individuals. Post-implementation findings demonstrate an overall adherence of 93.8% to the anesthesia practice change. Conclusions: Intraoperative administration of dexamethasone and/or dexmedetomidine is a safe, effective, and feasible strategy to reduce the risk of POCD in highrisk surgical patients.
    • Reducing Post-Operative Delirium and Cognitive Dysfunction: Intraoperative Anesthesia Interventions Guideline

      Crisostomo, Ryan P.; Franquiz, Renee (2021-05)
      Problem: Post-operative delirium, a common complication in the elderly after surgery, is associated with poor outcomes such as post-operative cognitive dysfunction which is a reduction in cognitive performance following surgery that lasts months after surgery or longer. Implementation of anesthetic interventions can reduce the development of cognitive dysfunction, estimated 40 percent of post-operative delirium cases are preventable using these interventions. Purpose: The purpose of this quality improvement project was to implement and evaluate tailored anesthesia interventions for surgical patients who screened preoperatively as high risk of developing post-operative delirium/post-operative cognitive dysfunction. Methods: The project involved patients ≥ 65 years old undergoing surgery at a suburban hospital that screen as high-risk for cognitive dysfunction. Anesthesia providers were educated and demonstrated understanding of the intraoperative anesthesia interventions guideline. Anesthesia providers considered, and when clinically appropriate, provided the interventions in accordance with the guidelines and documented as customary in the patient record. Data regarding the provider’s adherence to the guidelines were collected weekly by retrospective chart review. Results: Of the eligible 345 patients, 217 underwent a cognition screening pre-operatively and 50 screened positive. Anesthesia providers gave consideration to the intraoperative guidelines an average of 96 percent during the project with a range of 50 to 100. On average, the intraoperative guidelines were adhered to 85 percent of the time with a range of 43 to 100. Conclusions: While the recommended intraoperative care was evidence based and often received consideration, execution of those cares occurred less often. This may have been an oversight on anesthesia providers or due to the contextual nature of intraoperative anesthesia care wherein the recommended guidelines were appropriate in one clinical situation but not another.