POSH program takes team-based approach for care of older patients who need surgery

Thursday, August 3, 2017

By Mary-Russell Roberson

Bill Chism, 77, recently sailed through a serious surgery. “I had eight or nine hours of surgery,” Chism says. “Considering that, my recovery was very good. I did not lose my memory. I had no pain, (just some) discomfort.”

Chism participated in a Duke program designed to identify and proactively address issues in older adults that might lead to surgical complications.

That program is POSH—the Perioperative Optimization of Senior Health. POSH is a team-based approach in which surgeons, geriatricians, advanced practice providers from anesthesia, and patients work together to head off potential problems before surgery. Older adults are at risk for complications because they are more likely to have more than one medical condition, multiple prescriptions, and decreased strength, vision, hearing, and/or cognition.

“Surgeons are seeing older and older patients,” says Shelley McDonald, DO, PhD, assistant professor of medicine (Geriatrics). “We’ve learned that by working together, these patients can get through surgery with fewer complications.”

Research bears this out. A study at Duke showed that POSH patients undergoing elective abdominal surgeries were able to leave the hospital two days earlier on average than non-POSH patients, and were much less likely to be readmitted afterward.

Chism, who is from Lumberton, had a complex surgery known as the Whipple procedure to remove a malignant tumor in a bile duct.

His surgeon recommended the POSH program, so several weeks before the surgery, he and his wife, Bobbie Britt, came to Duke for an appointment in the POSH clinic. A nurse took Chism’s vital signs and assessed his vision, cognition, mood, and gait speed, among other things.

Next, a nurse practitioner from the preoperative screening clinic carried out the necessary medical screening that all patients, regardless of age, must go through before surgery.

After that, Chism and Britt met with McDonald. “With every patient, we talk about the surgery in the context of goals for health,” McDonald says. “We talk about how to minimize risks of delirium or loss of independence. We send them off with information to get ready for surgery. We also get people to start thinking about what they need when they go home.”

In Chism’s case, McDonald prescribed pre-surgery respiratory exercises to help him avoid lung problems while hospitalized. Chism was already a regular walker, but she suggested he add some core strengthening exercises. She also stressed the importance of getting up and walking with assistance in the hospital as soon as he was cleared by his surgeons to do so.

To avoid delirium in the hospital, she adjusted some of his prescriptions and advised him to wear his hearing aids and glasses as much as possible so that he could stay engaged. Episodes of delirium, which are common among older patients, are deeply distressing to patients and family and can lead to falls and other medical problems.

Laura Previll, MD, and Bill Chism talk during a recent visit.

She suggested he ward off anxiety and stress in the hospital by engaging in pleasurable activities, such as reading, playing cards, speaking with a chaplain, and listening to music.

Multiple studies have shown that listening to music can reduce perceptions of anxiety and pain in the hospital. Neema Sharda, MD, medical instructor in medicine (Geriatrics), works with the POSH team to provide patients with iPod Shuffles preloaded with their favorite music. She met with Chism before surgery to ask about the kind of music he enjoyed and to encourage him to listen at least twice a day in the hospital.

“They gave me earphones with some music that I wanted to hear—Willie Nelson and Elvis Presley—and I listened to that,” Chism says. “It helped pass the time.”

Another comfort for Chism and Britt, who find great solace in their faith, was receiving visits in the hospital from their pastor and Sunday school teacher.

Despite his risk factors, Chism had no episodes of delirium during the eight days he was in the hospital. In addition, he was not bothered by pain. He says he had a few instances of pain after he got home, but they were easily managed with acetaminophen.

“I’m very grateful to the thoughtful input that the geriatricians provide addressing and anticipating issues that we as surgeons might not be as likely to think of." Oluwadamilola “Lola” Fayanju, MD, MA, MPHS, assistant professor of surgery 

Looking back on the experience, Chism and Britt say the Duke doctors did a good job of keeping them informed and involving them in Chism’s care. “It was a team thing,” Britt says. “I felt pretty good about that and Bill did too.”

What might not be as obvious to patients is the collaboration that takes place between the geriatricians and the surgical team as they pool their knowledge of the patient’s medical history and geriatric assessment to minimize risk. For Durham resident Mary Ann Szczech, that teamwork was especially important. In her late 70s, Szczech went through two serious surgeries with the help of POSH and had a good recovery each time.

Her daughter, Lynda Szczech, MD, explains: “My mother was a very complicated individual medically. The real benefit of POSH was coordinating the team medically behind the scenes. As a doctor, I appreciated that. That made me feel very good about the situation.” She says a member of the POSH team visited her mother in the hospital after surgery to check in and answer questions.  Mary Ann passed away in late April due to recurring illness.

POSH got its start in 2011, when surgeon Sandhya Lagoo-Deenadayalan MD, PhD, associate professor of surgery (Advanced Oncologic and Gastrointestinal Surgery), approached the Geriatric Division asking for help determining what support older patients might need to get through surgery, or even whether surgery was a good option for some patients.

Starting with that conversation, Lagoo began collaborating with McDonald and Mitchell Heflin, MD, MHS, associate professor of medicine (Geriatrics) to create a multi-disciplinary program to improve surgical outcomes for older patients. Six years in, POSH has expanded to the Durham VA Medical Center, and the team has received a grant from the Duke Institute for Health Innovation (DIHI) to harness machine learning and electronic health records to identify those older patients who have the most to gain from participating in POSH.

After starting small, the POSH team is reaching out to more surgeons to encourage them to participate.

Oluwadamilola “Lola” Fayanju, MD, MA, MPHS, assistant professor of surgery (Advanced Oncologic and Gastrointestinal Surgery), has referred several patients to POSH and says she would absolutely recommend it to other surgeons. As a breast surgeon, most of her surgeries are relatively low risk, but in older patients that might not be the case.

“I’m very grateful to the thoughtful input that the geriatricians provide addressing and anticipating issues that we as surgeons might not be as likely to think of,” she says. One example: “They have great recommendations for pain control to minimize delirium.”

The first patient Fayanju referred to POSH was a 90-year-old woman who needed breast surgery, but also had multiple other health problems. “She did great,” Fayanju says.