Duke’s POSH Initiative Is Rapidly Expanding

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A geriatric perioperative screening initiative called the Perioperative Optimization of Senior Health (POSH) developed by Duke is reducing hospital stays and readmissions while increasing discharges to self-care at home following surgery.

A team of Duke geriatricians and senior care providers launched the POSH initiative in June 2011 as a practical solution to bring together surgical, anesthesia, and hospital care teams to help patients and families prepare for surgery and plan for recovery. The early success of the initiative has prompted an expansion that has continued 5 years later.

An analysis of POSH outcomes among older adults with a higher disease burden following elective abdominal surgery indicated a 1.95-day reduction in length of hospital stay, a 7.08% decrease in hospital readmissions at 7 days, and a 10.53% hospital readmission decrease at 30 days. The percentage of patients returning to self-care at home was 11.25% higher, a difference that was statistically significant. POSH results were compared with historical controls. Duke’s Division of Geriatrics and Department of Surgery collaborated on the findings.

“The number of patients who need this planning is dramatically high,” says Shelley R. McDonald, DO, PhD, a geriatric care specialist who works with patients and families in the POSH program. “Increasingly, we get POSH referrals because a surgeon sees a patient and recognizes the challenges the individual will face after surgery.”

The program was designed as an evaluation and planning initiative to screen and advise patients aged older than 80 years who require medically necessary surgery—typically abdominal or colorectal procedures—and it quickly expanded. POSH also receives referrals from patients older than 65 years of age who are choosing elective surgery and present with cognitive concerns, significant weight loss, multimorbidities, polypharmacy, or sensory impairment. From an initial patient group of approximately 70, POSH has now worked with more than 750 older patients.

“One of the most important aspects of POSH is meeting with each patient and family and communicating what to expect before, during, and after surgery,” McDonald says.

Postoperative delirium is a common concern of physicians and health care teams, but patients also receive counseling regarding nutrition and pain management. Personal needs are considered: patients are advised to bring glasses and hearing aids, for example, and family engagement is encouraged.

“When a senior patient experiences a big change in environment—waking up in a hospital recovery room, for example—all normal actions can change dramatically and present many more challenges,” says Christy M. Cassas, MSN, RN, FNP-C, who works with patients in the POSH program.

Because loss of sensorium often hampers surgical recovery and can precipitate delirium, POSH teams make glasses and hearing aids readily available for older patients immediately following surgery. They also attempt to quickly move them to inpatient rooms offering natural light.

"Even seemingly small interventions can have a huge impact on preventing delirium after surgery,” says Cassas. Working with Duke Arts and Health and the related Confusion Avoidance Led by Music initiative, patients may benefit from personalized music players or a visit by a hospital musician. Family members are encouraged to stay overnight in the patient's room.

McDonald and other POSH team members say a key factor in good outcomes is establishing a relationship with the patient. “We want to be sure we are hearing their personal goals,” she says. “They may want to take their grandchildren to the beach again. They may want to cook a meal at home. Everything we do in POSH is framed by their goals.”