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Background: Telehealth utilization rapidly increased following the pandemic. However, it is not widely used in the Veteran surgical population. We sought to evaluate postoperative telehealth in patients undergoing general surgery., Methods: Retrospective review of Veterans undergoing general surgery at a level 1A VA Medical Center from June 2019 to September 2021. Exclusions were concomitant procedure(s), discharge with drains or non-absorbable sutures/staples, complication prior to discharge or pathology positive for malignancy., Results: 1075 patients underwent qualifying procedures, 124 (12 ​%) were excluded and 162 (17 ​%) did not have follow-up. 443 (56 ​%) patients followed-up in-person (56 ​%) vs 346 (44 ​%) via telehealth. Telehealth patients had a lower rate of complications, 6 ​% vs 12 ​%, p ​= ​0.013. There were no significant differences in ED visits, 30-day readmission, postoperative procedures or missed adverse events., Conclusion: Telehealth follow-up after general surgical procedures is safe and effective. Postoperative telehealth care should be considered after low-risk general surgery procedures., Competing Interests: Declaration of competing interest Dr. Edward Jones is a consultant for Boston Scientific. Drs. Abbitt, Choy, Teresa Jones, Wikiel, Barnett, Moore and Robinson have no disclosures. Ms. Castle and Mr. Bollinger have no disclosures., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Surgical readmissions are clinically and financially problematic. Our purpose is to determine if a decrease in postoperative ambulation (steps/day) is associated with hospital readmission., Methods: In this prospective cohort study, patients undergoing elective operations wore an accelerometer activity tracker to measure steps/day for 28 consecutive postoperative days. The primary outcome was hospital readmission. The change in steps/day over two consecutive days prior to the day of the readmission were examined. Predetermined thresholds for decreases of consecutive daily ambulation levels were used to calculate sensitivity and specificity for the outcome of hospital readmission., Results: 215 patients (aged 63 ± 12 years) were included. Readmission occurred in 10% (n = 21). For each of the first 28-postoperative days, the entire cohort had an average daily step increase of 136 ± 146 steps/day (Spearman correlation rho = 0.990; p < 0.001). A decrease in steps for two consecutive days of >50% from the prior day had a 79% sensitivity and 90% specificity for hospital readmission., Conclusions: A decrease of >50% daily ambulation (steps/day) over two consecutive post-discharge days accurately forecasts hospital readmission. The implications of these findings are that monitoring daily ambulation could serve as a form of outpatient telemetry aiding to forecast post-surgical readmissions., (Published by Elsevier Inc.)

Background: We hypothesized that postoperative delirium is associated with diminished recovery toward baseline preoperative ambulation levels one-month postoperatively., Methods: Patients included were ≥60 years old undergoing inpatient operations. Ambulation was measured as steps/day using an accelerometer worn for ≥3-days preoperatively and ≥28-days postoperatively. Primary outcome was the percent recovery of preoperative steps., Results: 109 patients were included; 17 (16%) developed postoperative delirium. Recovery of ambulation toward preoperative baseline at postoperative day-28 was decreased in delirium group (34% vs. 69%; p < 0.01). Immediate postoperative ambulation was similar in the delirium vs. no-delirium groups (p = 0.79). Delirium occurred on average on postoperative 3 ± 4 days. Subsequently, ambulation was decreased in the delirium group compared to non-delirium group at postoperative week-1 (p = 0.01), week-2 (p = 0.02), week-3 (p < 0.01) and week-4 (p < 0.01)., Conclusion: Patients undergoing inpatient operations who develop delirium recover only one-third of their baseline steps one-month postoperatively. Postoperative delirium results in a decreased recovery towards baseline ambulation for at least 4-weeks following major operations in comparison to non-delirious patients. The decrease in ambulation in the delirium versus no-delirium groups occurred after the occurrence of postoperative delirium., Competing Interests: Declaration of competing interest The authors have no conflict of interest to report., (Published by Elsevier Inc.)

Background: Post-operative delirium is associated with increased short term morbidity and mortality. Limited data exists on long term outcomes for older adults with postoperative delirium. We hypothesize that postoperative delirium is associated with increased 5-year mortality., Methods: Patients ≥50 years undergoing elective operations with planned intensive care unit (ICU) admissions were prospectively enrolled. The Confusion Assessment Method ICU (CAM-ICU) was used to diagnose delirium. The primary outcome variable was 5-year mortality., Results: 172 patients were enrolled with an average age of 64 years. The overall incidence of delirium was 44% (75/172). At 5-years post-operatively, mortality was higher (59%, 41/70) in patients with delirium compared to patients without delirium (13%, 12/94, p < 0.001). These results remained true after multivariable risk adjustment, showing the odds of five year mortality following delirium were 7.35 fold greater (95% CI: 1.49-36.18)., Conclusions: Postoperative delirium is associated with increased long term mortality., (Published by Elsevier Inc.)

Background: Surgical energy-based devices emit energy, which can interfere with other electronic devices (eg, implanted cardiac pacemakers and/or defibrillators). The purpose of this study was to quantify the amount of unintentional energy (electromagnetic interference [EMI]) transferred to an implanted cardiac defibrillator by common surgical energy-based devices., Methods: A transvenous cardiac defibrillator was implanted in an anesthetized pig. The primary outcome measure was the average maximum EMI occurring on the implanted cardiac device during activations of multiple different surgical energy-based devices., Results: The EMI transferred to the implanted cardiac device is as follows: traditional bipolar 30 W .01 ± .004 mV, advanced bipolar .004 ± .003 mV, ultrasonic shears .01 ± .004 mV, monopolar Bovie 30 W coagulation .50 ± .20 mV, monopolar Bovie 30 W blend .92 ± .63 mV, monopolar instrument without dispersive electrode .21 ± .07 mV, plasma energy 3.48 ± .78 mV, and argon beam coagulator 2.58 ± .34 mV., Conclusion: Surgeons can minimize EMI on implanted cardiac defibrillators by preferentially utilizing bipolar and ultrasonic devices., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: Our purpose was to determine the relationship between preoperative frailty and the occurrence of postoperative complications after colorectal and cardiac operations., Methods: Patients 65 years or older undergoing elective colorectal or cardiac surgery were enrolled. Seven baseline frailty traits were measured preoperatively: Katz score less than or equal to 5, Timed Up and Go test greater than or equal to 15 seconds, Charlson Index greater than or equal to 3, anemia less than 35%, Mini-Cog score less than or equal to 3, albumin less than 3.4 g/dL, and 1 or more falls within 6 months. Patients were categorized by the number of positive traits as follows: nonfrail: 0 to 1 traits, prefrail: 2 to 3 traits, and frail: 4 or more traits., Results: Two hundred one subjects (age 74 ± 6 years) were studied. Preoperative frailty was associated with increased postoperative complications after colorectal (nonfrail: 21%, prefrail: 40%, frail: 58%; P = .016) and cardiac operations (nonfrail: 17%, prefrail: 28%, frail: 56%; P < .001). This finding in both groups was independent of advancing age. Frail individuals in both groups had longer hospital stays and higher 30-day readmission rates. Receiver operating characteristic curves examining frailty's ability to forecast complications were colorectal (.702, P = .004) and cardiac (.711, P < .001)., Conclusions: A simple preoperative frailty score defines older adults at higher risk for postoperative complications across surgical specialties., (Published by Elsevier Inc.)

Background: The purpose of this study was to determine the relationship of frailty and 6-month postoperative costs., Methods: Subjects aged ≥ 65 years undergoing elective colorectal operations were enrolled in a prospective observational study. Frailty was assessed by a validated measure of function, cognition, nutrition, comorbidity burden, and geriatric syndromes. Frailty was quantified by summing the number of positive characteristics in each subject., Results: Sixty subjects (mean age, 75 ± 8 years) were studied. Inpatient mortality was 2% (n = 1). Overall, 40% of subjects (n = 24) were considered nonfrail, 22% (n = 13) were prefrail, and 38% (n = 22) were frail. With advancing frailty, hospital costs increased (P < .001) and costs from discharge to 6-months increased (P < .001). Higher degrees of frailty were related to increased rates of discharge institutionalization (P < .001) and 30-day readmission (P = .044)., Conclusions: A simple, brief preoperative frailty assessment accurately forecasts increased surgical hospital costs and postdischarge to 6-month healthcare costs after colorectal operations in older adults., (Published by Elsevier Inc.)

Background: Hospital falls are an important cause of morbidity in older surgical patients. The objectives of this study were to describe the characteristics, risk factors, and outcomes for postoperative falls., Methods: A retrospective study was performed on patients who were admitted to the hospital for more than 23 hours after surgery. Patients who fell within 30 days of their surgery were considered to have experienced a postoperative fall., Results: Over 5 years and 9,625 inpatient surgical procedures, 154 patients experienced 190 falls. Injuries resulting from postoperative falls included major injury (hip fracture), less than 1%; injury requiring intervention, 2%; injury not requiring intervention, 27%; and no injury, 70%. Variables associated with postoperative falls included older age, functional dependence, lower albumin level, and higher American Society of Anesthesia score., Conclusions: One or more postoperative falls occurred in 1.6% of surgical inpatients and can lead to significant morbidity. Recognition of fall risk factors will help design postoperative fall prevention programs by identifying patients at highest risk for postoperative falls., (Published by Elsevier Inc.)

Background: This study aimed to describe the natural history of delirium after major injury, to identify risk factors that predict the development of postinjury delirium, and to compare outcome measures in subjects with and without delirium., Methods: A prospective study was performed on patients with an injury severity score of 8 or higher admitted to the trauma intensive care unit (ICU) of a level I trauma center. Patients underwent daily assessments for delirium with the Confusion Assessment Method-ICU., Results: Sixty-nine patients (53 male) were enrolled. Delirium occurred in 41 (59%) subjects. Logistic regression found lower arrival Glasgow Coma Score (12 +/- 1.0 vs 15 +/- .1; P < .01), increased blood transfusions (2.8 +/- .7 vs .5 +/- .3; P < .01), and higher multiple organ failure score (1.2 +/- .2 vs .1 +/- .1; P < .01) to be the strongest predictors for developing delirium. Outcome measures revealed subjects with delirium had longer hospital stays, longer ICU stays, and were more likely require postdischarge institutionalization., Conclusions: Delirium is common in the trauma ICU. Higher multiple organ failure score was the strongest predictor of postinjury delirium.

Background: Postoperative delirium is a common complication in geriatric patients. Tryptophan is an amino acid precursor to the mood-stabilizing neurotransmitters serotonin and melatonin. We hypothesized that tryptophan levels are lower in elderly subjects who develop postoperative delirium., Methods: A prospective observational study was performed. Subjects older than 50 years undergoing surgery with an anticipated postoperative intensive care unit admission were recruited. Postoperative delirium assessment occurred daily using the Confusion Assessment Method-intensive care unit. Peripheral serum tryptophan levels were measured 2 days after surgery., Results: Forty-nine subjects (46 men) were enrolled, with an average age of 64 +/- 7 years. The incidence of delirium was 43% (21 of 49). The average duration of delirium was 2.9 +/- 3.0 days. Tryptophan levels were lower in the subjects who developed delirium (29.9 +/- 13.3 vs 48.5 +/- 19.8 microg/mL; P = .001)., Conclusions: Lower levels of tryptophan postoperatively were associated with the development of delirium in the elderly.

Background: Outpatient laparoscopic cholecystectomy (LC) is safe and feasible, but factors related to the failure of outpatient surgery are poorly defined. We hypothesized that patients in whom same day discharge (SDD) is unlikely may be identified preoperatively., Methods: Three hundred eighty-seven consecutive patients scheduled for elective LC were prospectively enrolled in an outpatient clinical pathway., Results: In all, 269 (70%) patients successfully underwent outpatient LC. Factors related to failure of SDD were age, American Society of Anesthesiology (ASA) class, surgery start time, and duration of surgery. Body mass index, liver function tests, and ultrasound findings did not predict failure of SDD. Three factors were able to predict more than 50% failure of SDD: age more than 50 years, ASA class 3 or more, and surgery start time later than 1:00 PM., Conclusions: Outpatient LC is feasible in a large county hospital. These data may be used in scheduling cases and counseling patients.