Query: Geriatric length of stay neurosurgery

title: Geriatric comanagement reduces perioperative complications and shortens duration of hospital stay after lumbar spine surgery: a prospective single institution experience.
abstract: Geriatric patients undergoing lumbar spine surgery have unique needs due to the physiological changes of aging. They are at risk for adverse outcomes such as delirium, infection, and iatrogenic complications, and these complications, in turn, contribute to the risk of functional decline, nursing home admission, and death. Whether preoperative and perioperative comanagement by a geriatrician reduces the incidence of in hospital complications and length of in hospital stay after elective lumbar spine surgery remains unknown.  A unique model of comanagement for elderly patients undergoing lumbar fusion surgery was implemented at a major academic medical center. The Perioperative Optimization of Senior Health (POSH) program was launched with the aim of improving outcomes in elderly patients 65 years old) undergoing complex lumbar spine surgery. In this model, a geriatrician evaluates elderly patients preoperatively, in addition to performing routine preoperative anesthesia surgical screening, and comanages them daily throughout the course of their hospital stay to manage medical comorbid conditions and coordinate multidisciplinary rehabilitation along with the neurosurgical team. The first 100 cases were retrospectively reviewed after initiation of the POSH protocol and compared with the immediately preceding 25 cases to assess the incidence of perioperative complications and clinical outcomes.  One hundred twenty five patients undergoing lumbar decompression and fusion were enrolled in this pilot program. Baseline characteristics were similar between both cohorts. The mean length of in hospital stay was 30% shorter in the POSH cohort (6.13 vs 8.72 days; p 0.06) The mean duration of time between surgery and patient mobilization was significantly shorter in the POSH cohort compared with the non POSH cohort (1.57 days vs 2.77 days; p 0.02) and the number of steps ambulated on day of discharge was 2 fold higher in the POSH cohort (p 0.04) Compared with the non POSH cohort, the majority of patients in the POSH cohort were discharged to home (24% vs 54% p 0.01) CONCLUSIONS Geriatric comanagement reduces the incidence of postoperative complications, shortens the duration of in hospital stay, and contributes to improved perioperative functional status in elderly patients undergoing elective spinal surgery for the correction of adult degenerative scoliosis.

title: Traumatic vertebral artery injuries in the geriatric population: a retrospective cohort study.
abstract: Traumatic vertebral artery injuries (TVAIs) are a common finding in cervical spine trauma and can predispose patients to posterior circulation infarction. While extensive research has been conducted regarding the management and criteria for imaging in patients with suspected blunt vascular injury, little research has been conducted highlighting these injuries in the geriatric population.  The authors performed a retrospective review of all patients evaluated at a level 1 trauma center and found to have TVAIs between January 1, 2010, and January 1, 2018. Biometric, clinical, and imaging data were obtained from a trauma registry database. Patients were divided into 2 groups on the basis of age, a geriatric group (age 65 years) and an adult group (age 18 to 65 years) Variables evaluated included type of trauma, mortality, Injury Severity Score (ISS) and ICU length of stay. The Student t test was used for continuous variables, and Pearson's chi square test was used for categorical variables.  Of the 2698 of patients identified with traumatic cervical spine injuries, 103 patients demonstrated evidence of TVAI. Of these patients, 69 were 65 and 34 were 65 years old at the time of their trauma. There was no difference in the incidence of TVAIs between the 2 groups. The ICU length of stay (4.71 vs 4.32 days, p 0.05) hospital length of stay (10.71 vs 10.72 days, p 0.05) and the ISS (21.50 vs 21.32, p 0.05) did not differ significantly between the 2 groups. Mortality was significantly higher in the geriatric group, occurring in 9 of 34 patients (26.5% compared with only 3 of 69 patients (4.4% in the adult group (p 0.001) Ground level falls were the most common inciting event in the geriatric group (44% vs 14.5% p 0.001) whereas motor vehicle accidents were the most common etiology in the younger population (72.5% vs 38.2% p 0.001) Incidence of ischemic stroke did not vary significantly between the 2 groups (p 0.05) CONCLUSIONS TVAI in the older adult population is associated with a significantly greater risk of mortality than in the younger adult population, despite the 2 groups having similar ISSs. Additionally, low velocity mechanisms of injury, such as ground level falls, are a greater risk factor for acquired TVAI in older adults than in younger adults, in whom it is a significantly less common etiology.

title: Evaluation of Postoperative Delirium: Validity and Reliability of the Nursing Delirium Screening Scale in the Turkish Language
abstract: Postoperative delirium is the most well known form of postoperative cognitive impairment in all patient groups, especially in the elderly. Delirium is a syndrome that causes serious consequences, increasing mortality and morbidity rates and extending the length of hospital stay. The aim of this study was to evaluate the validity and reliability of the Turkish version of the Nursing Delirium Screening Scale (Nu DESC)  One hundred twelve patients who were hospitalized for a surgical operation in the orthopedics, neurosurgery, and general surgery clinic of a state hospital for 3 months were evaluated concurrently (and independently for delirium) Patients were observed by clinical nurses 3 times over a 24 h period. The presence of delirium was diagnosed by 2 neurologists according to DSM IV criteria. Student's t test, the kh2 test, and the Mann Whitney U test were used, and construct validity, intrascale factor analysis, interrater reliability, and specificity and sensitivity (ROC) analyses were performed for descriptive analysis. SPSS 25.0 and MedCalc18.6 were used for statistical analysis.  Delirium was detected in 28 patients according to the Nu DESC. The ICC (intraclass correlation) is 0.97 in the 95% confidence interval from 0.96 to 0.98 for agreement between nurses and neurologists for the total Nu DESC score. Weighted k rates were between 0.78 and 0.92. In the ROC analysis of the Nu DESC scale, the optimum cutoff value calculated for the 1,344 observations and 112 patients was determined as >1 according to the maximum sensitivity and the specific situation. Sensitivity at the cut off point was 92.27; specificity was determined as 92.72. The Youden index was found to be J 0.845 (0 J 0.845 1)  We believe that Turkish translation of Nu DESC is valid and reliable for clinicians, nurses, and researchers and will contribute to delirium studies.

title: Outcomes of Subdural Hematoma in the Elderly with a History of Minor or No Previous Trauma.
abstract: Subdural hematoma (SDH) in the elderly is an increasingly common entity because of increased use of antithrombotic medications, an aging population, and increasing frequency of geriatric trauma. The present study describes the functional outcomes and mortality of SDH in an elderly population and to identify potential prognostic factors.  Patients >65 years of age with SDH who were treated at our institution from 2005 to 2015 were identified. Patients with a history of preceding high velocity trauma were excluded. Electronic medical records were retrospectively reviewed. The outcomes of interest were mortality, length of stay, and discharge Glasgow Outcome Score.  A total of 671 patients were included in final statistical analyses. For patients with acute SDH, survival was 74.9% 72.3% and 69.8% at 30, 60, and 100 days, respectively. With respect to chronic SDH, survival was 87.0% 83.7% and 80.3% at 30, 60, and 100 days, respectively. On multivariate analysis, admission Glasgow Coma Scale (GCS) score was significantly predictive of mortality in both the acute and chronic populations. In the acute cohort, admission GCS score was a significant predictor of increased length of stay, whereas age >80 years, admission GCS score, contusion volume >10 cm3, SDH volume >50 cm3, and antiplatelet use were significant predictors of discharge functional status.  SDH in the elderly carries high morbidity and mortality and several prognostic factors were identified. These results can be used to guide discussions with family regarding prognosis and perhaps aid in treatment decisions.

title: Preoperative pulmonary assessment of the older adult.
abstract: Postoperative pulmonary complications in the elderly are common and are a significant source of morbidity, mortality, and prolonged length of stay. Risk factors differ from the well known risk factors for cardiac complications and can be divided into patient and procedure related factors. Patient related factors include COPD, recent cigarette use, poor general health status as defined by Goldman or ASA class, dependent functional status, and laboratory parameters including abnormal chest radiograph, renal insufficiency, and low serum albumin. Age is a minor risk factor when adjusted for comorbidities and confers approximately a two fold increase in risk. Elderly patients who are otherwise acceptable surgical candidates should not be denied surgery based solely on age and concern for postoperative pulmonary complications. The surgical site is the single most important predictor of pulmonary complications. High risk surgeries include thoracic, upper abdominal, aortic, neurosurgery, and peripheral vascular. Other procedure related risk factors include surgery lasting longer than 3 hours, the use of general anesthesia, pancuronium use, and emergency surgery. Clinicians should not recommend routine preoperative spirometry before high risk surgery because it is no more accurate in predicting risk than clinical evaluation. Patients who might benefit from preoperative spirometry include those who have unexplained dyspnea or exercise intolerance and those who have COPD or asthma in whom uncertainty exists as to the status of airflow obstruction when compared with baseline. After identifying patients at risk for postoperative pulmonary complications, clinicians can recommend strategies to reduce risk throughout the operative period. In addition to minimizing or avoiding the above risk factors, optimization of COPD or asthma, deep breathing exercises, incentive spirometry, and epidural local anesthetics reduce the risk of postoperative pulmonary complications in elderly surgical patients.

title: [Neurosurgery in the elderly patient: Geriatric neurosurgery]
abstract: Between 2000 and 2050, the proportion of the world's population over 60 years will double, and the number of people aged 80 and older will quadruple. Health professional training does not include instructions about specific care for older people. The World Health Organization maintains that all health providers should be trained on ageing issues. Thus, it is proposed to analyse the effect of ageing on Neurosurgery in our country.  A retrospective historical cohort study was performed on individuals age 70 years or older admitted to the Neurosurgery or the Intensive Care Unit of our hospital, with neurosurgical disease, between two periods: 1999 2000 and 2010 2011. An analysis was made on variables such as: age, pathology, length of stay, comorbidity, performance status, re admissions and mortality.  Similar numbers of patients were admitted during the two periods: 409 and 413. However, there was an increase of 77.5% in patients older than 70 years: 80 versus 142. Statistically significant differences were observed in the Charlson Comorbidity Index, the admission Glasgow Coma Scale (GCS) score, length of stay, and re admissions. Comorbidity and admission GCS score were particularly worse in the second period. Nevertheless, the mean length of stay was lower in that period, but showing more hospital re admissions. After multivariate analysis, it was observed that re admissions were associated with comorbidity, but not with early hospital discharge. No differences were found in performance status or mortality.  A very considerable increase in percentage of patients older than 70 years old was found. There were no differences in performance status or mortality, which was probably due to the multidisciplinary management of these patients. The results of this study support the development of an interdisciplinary work group dedicated to Geriatric Neurosurgery.

title: P50 The role of care of the elderly in neurosurgery
abstract: Assess the volume of frailty in a neurosurgical centre and role of geriatric liaison.   We reviewed patient notes to assess frailty score using the Clinical Frailty Scale (Dalhousie University) and differences with emergency vs elective admissions and length of stay (LoS) Results More than 50% of patients admitted to the unit were above 65 years old. 30% of all admissions met the criteria for mild to moderate frailty moreover 34% were classed as severely frail. These findings are comparable to acute medical wards. Two third of patients had an average LoS above 10 days, of these 50% were severely frail. Emergency admissions demonstrated a greater burden of frailty and expectedly LoS in severely frail patients was significantly higher 15 vs 40 days in elective and emergency admissions.  Neurosurgery units would benefit from a geriatric liaison service given the burden of frailty is equivalent to medical wards in order to improve patient care, experience, turnover and LoS.

title: How safe are elective craniotomies in elderly patients in neurosurgery today? A prospective cohort study of 1452 consecutive cases.
abstract: With global aging, elective craniotomies are increasingly being performed in elderly patients. There is a paucity of prospective studies evaluating the impact of these procedures on the geriatric population. The goal of this study was to assess the safety of elective craniotomies for elderly patients in modern neurosurgery.  For this cohort study, adult patients, who underwent elective craniotomies between November 1, 2011, and October 31, 2018, were allocated to 3 age groups (group 1, 65 years [n 1008] group 2, 65 to 75 [n 315] and group 3, 75 [n 129] Primary outcome was the 30 day mortality after craniotomy. Secondary outcomes included rate of delayed extubation 1 hour) need for emergency head CT scan and reoperation within 48 hours after surgery, length of postoperative intensive or intermediate care unit stay, hospital length of stay (LOS) and rate of discharge to home. Adjustment for American Society of Anesthesiologists Physical Status (ASA PS) class, estimated blood loss, and duration of surgery were analyzed as a comparison using multiple logistic regression. For significant differences a post hoc analysis was performed.  In total, 1452 patients (mean age 55.4 14.7 years) were included. The overall mortality rate was 0.55% (n 8) with no significant differences between groups (group 1: 0.5% [95% binominal CI 0.2% 1.2% group 2: 0.3% [95% binominal CI 0.0% 1.7% group 3: 1.6% [95% binominal CI 0.2% 5.5% Deceased patients had a significantly higher ASA PS class (2.88 0.35 vs 2.42 0.62; difference 0.46 [95% CI 0.03, 0.89] p 0.036) and increased estimated blood loss (1444 1973 ml vs 436 545 ml [95% CI 618, 1398] p <0.001) Significant differences were found in the rate of postoperative head CT scans (group 1: 6.65% [n 67] group 2: 7.30% [n 23] group 3: 15.50% [n 20] p 0.006) LOS (group 1: median 5 days [IQR 4; 7 days] group 2: 5 days [IQR 4; 7 days] and group 3: 7 days [5; 9 days] p 0.001) and rate of discharge to home (group 1: 79.0% [n 796] group 2: 72.0% [n 227] and group 3: 44.2% [n 57] p 0.001) CONCLUSIONS Mortality following elective craniotomy was low in all age groups. Today, elective craniotomy for well selected patients is safe, and for elderly patients, too. Elderly patients are more dependent on discharge to other hospitals and postacute care facilities after elective craniotomy.

title: A predictive model for increased hospital length of stay following geriatric hip fracture.
abstract: The purpose of this study was to identify the risk factors that are significantly associated with hospital length of stay (LOS) following geriatric hip fracture and to use these significant variables to develop a LOS calculator.  This was a retrospective study examining 614 patients treated for geriatric hip fracture between January 2000 and December 2009 at an urban, Level 1 trauma center. A negative binomial regression analysis was used to identify perioperative variables associated with hospital LOS.  patients met the inclusion criteria, presenting with a mean age of 78 10) years. The most common pre operative comorbidity was hypertension, followed by diabetes and COPD. After controlling for all collected comorbidities as well as demographics and operative variables, hypertension (IRR: 1.10, p 0.029) and disseminated cancer (IRR: 1.24, p 0.007) were found to be significantly associated with LOS. In addition, two demographic/presenting variables, admission to the medicine service (IRR: 1.48, p 0.001) and male sex (IRR: 1.09, p 0.034) were shown to be independent risk factors for prolonged LOS. These variables were synthesized into a LOS formula, which estimated LOS to within 3 days of the true length of stay for 0.758 of the series (95% confidence interval: 0.661 to 0.855)  This study identified several comorbidity and perioperative variables that were significantly associated with LOS following geriatric hip fracture surgery. The resulting LOS model may have utility in the risk stratification of orthopaedic trauma patients presenting with hip fracture.

title: Predictive Modeling for Geriatric Hip Fracture Patients: Early Surgery and Delirium Have the Largest Influence on Length of Stay
abstract: Averaging length of stay (LOS) ignores patient complexity and is a poor metric for quality control in geriatric hip fracture programs. We developed a predictive model of LOS that compares patient complexity to the logistic effects of our institution's hip fracture care pathway.  A retrospective analysis was performed on patients enrolled into a hip fracture co management pathway at an academic level I trauma center from 2014 to 2015. Patient complexity was approximated using the Charlson Comorbidity Index and ASA score. A predictive model of LOS was developed from patient specific and system specific variables using a multivariate linear regression analysis; it was tested against a sample of patients from 2016.  LOS averaged 5.95 days. Avoidance of delirium and reduced time to surgery were found to be notable predictors of reduced LOS. The Charlson Comorbidity Index was not a strong predictor of LOS, but the ASA score was. Our predictive LOS model worked well for 63% of patients from the 2016 group; for those it did not work well for, 80% had postoperative complications.  Predictive LOS modeling accounting for patient complexity was effective for identifying (1) reasons for outliers to the expected LOS and (2) effective measures to target for improving our hip fracture program.