RE: Delayed discharge after major surgical procedures in Ontario, Canada: a population‑based cohort study.
References
Angela Jerath, Jason Sutherland, Peter C. Austin, et al. Delayed discharge after major surgical procedures in Ontario, Canada: a population-based cohort study. CMAJ 2020;192:E1440-E1452.
Cunha AIL, Veronese N, de Melo Borges S, Ricci NA. Frailty as a predictor of adverse outcomes in hospitalized older adults: A systematic review and meta-analysis. Ageing Res Rev 2019;56:100960. doi: 10.1016/j.arr.2019.100960.
Oh ES, Fong TG, Hshieh TT, Inouye SK. Delirium in Older Persons: Advances in Diagnosis and Treatment. JAMA 2017 Sep 26;318(12):1161-1174. doi: 10.1001/jama.2017.12067.
Patel JN, Klein DS, Sreekumar S, Liporace FA, Yoon RS. Outcomes in Multidisciplinary Team-based Approach in Geriatric Hip Fracture Care: A Systematic Review. J Am Acad Orthop Surg. 2020 Feb 1;28(3):128-133. doi: 10.5435/JAAOS-D-18-00425.
Costa AP, Hirdes JP. Clinical Characteristics and Service Needs of Alternate-Level-of-Care Patients Waiting for Long-Term Care in Ontario Hospitals. Healthc Policy. 2010 Aug;6(1):32-46.
We commend the authors of the article “Delayed discharge after major surgical procedures in Ontario, Canada: a population‑based cohort study” for their robust methodology, but were disappointed that they did not address the concepts of frailty, iatrogenic delirium, and functional decline (1).
The lack of adequate data on the concepts of frailty and geriatric syndromes in our acute care national data repositories highlights the existence of major gaps in Canada’s health information infrastructure. First, the lack of meaningful data on frailty, delirium and functional decline, reduces these key concepts to “nonmedical reasons” for delayed discharge. Clearly, they are not. Frailty, irrespective of how it is operationalized, has repeatedly been shown to be a more robust predictor of major adverse postoperative outcomes than chronological age (2). Delirium and functional decline are often iatrogenic and thus preventable, including in surgical patients, and delayed discharge can be avoided (3,4). Second, the lack of meaningful data on frailty, and delirium and functional decline leads to the interpretation that “downstream” interventions and resources are required to improve the “flow of patients”, though senior-friendly practices to prevent iatrogenic complications in the first place would be far more efficient. The principles of management rest on systematic screening and assessment of at-risk patients, followed by multidisciplinary non-pharmacological interventions (3,4).
It is possible to include concepts of frailty, delirium, and functional decline in our acute care national data repositories. Standardized information on these syndromes is available in the databases for home care and long-term care curated by the Canadian Institute of Health Information, which have been shown to be highly useful at characterizing hospital patients awaiting institutionalization (5). It is high time for standardized information systems compatible with those in home care and long-term care to be implemented in Canadian acute care hospitals.