Care of Older People in Surgery for general surgery: a single centre experience

Development of a minimum clinical dataset for preoperative comprehensive geriatric assessment using a modified Delphi technique

OBJECTIVE

To construct a standardised, consensus-guided minimum clinical dataset (MCDS) for preoperative comprehensive geriatric assessment and optimisation (CGA) in Australia and Aotearoa New Zealand.

METHODS

We conducted a review of the international perioperative literature to identify CGA domains and tools for potential inclusion in the MCDS. We invited members of the Australian and New Zealand Society for Geriatric Medicine to participate in a Delphi study to obtain consensus on MCDS tools. Participants were asked to rate proposed tools using Likert scales (when >2 tools) or make a binary choice between two proposed tools. Consensus was considered to be achieved when there was at least 75% concordance between the two rounds amongst the participants, and at least one variable attaining over 50% of participants' votes. Domains that did not achieve consensus in Round 1 were carried over to Round 2.

RESULTS

There were 73 participants in Round 1 of the Delphi study and 47 participants in Round 2. Consensus was achieved on tool/s recommended for every MCDS domain: Clinical Frailty Scale (frailty); sMMSE, RUDAS, MoCA (cognition); 4AT (delirium); timed-up-and-go (physical function); GDS-15 (mood); Barthel Index (functional status); and MUST (malnutrition).

CONCLUSIONS

We recommend clinicians delivering preoperative CGA consider the use of the MCDS we have constructed when assessing older people contemplating surgery, as part of a multicomponent and multidisciplinary approach to optimising perioperative outcomes.

Emergency laparotomy in older adults with geriatric medicine input: implications of demographics, frailty and comorbidities on outcomes

BACKGROUND

We (1) describe West Australian (WA) older adults undergoing emergency laparotomy (EL) in a tertiary-centre Acute Surgical Unit (ASU) with proactive geriatrician input and (2) explore the impact of Clinical Frailty Scale (CFS) and Charlson's Comorbidity Index (CCI) on patient outcomes.

METHODS

We performed a prospective cohort-study of older adults undergoing EL, between April 2021 and April 2022, in a tertiary ASU, with dedicated geriatrician-led perioperative care via the Older Adult Surgical Inpatient Service (OASIS).

RESULTS

Of 114 patients, average age was 76.7 ± 7.61 years-old (range 65-96), with 35.1% (n = 40) frail (CFS 5-7), 18.4% (n = 21) vulnerable (CFS 4) and 46.5% (n = 74) not frail (CFS 1-3). 61.4% (n = 70) were severely comorbid (CCI ≥5), 34.2% (n = 39) moderately comorbid (CCI 3-4), and 4.4% (n = 5) mildly comorbid (CCI 1-2). 95.9% (n = 109) EL patients were reviewed by OASIS. Inpatient mortality was 7.9% (n = 9) and 1-year mortality 16.7% (n = 19). Majority, 64.9% (n = 74), were discharged directly home with 17.5% (n = 20) discharged with in-home rehabilitation. Each increment in CCI was associated with increased in-hospital (HR 1.38, p = 0.034) and 1-year (HR 1.39, p = 0.006) mortality, and each increment in CFS with 1-year mortality (HR 1.62, p = 0.016). Higher CFS but not CCI was associated with increased level of care at discharge. Age was not statistically significant with any outcomes.

CONCLUSION

We describe demographics, frailty and comorbidity of 114 older adults undergoing EL in ASU. We suggest CFS and CCI as independent risk-stratification tools, and proactive management of both comorbidity, and frailty, should be incorporated into preoperative optimisation.

Implementation of a geriatric in-reach service improves acute surgical unit outcomes; a retrospective before-and-after study

BACKGROUND

Australia's ageing population is challenging for surgical units and there is a paucity of evidence for geriatric co-management in acute general surgery. We aimed to assess if initiating a Geriatric Medicine in-reach service improved outcomes for older adults in our Acute Surgical Unit (ASU).

METHODS

The Older Adult Surgical Inpatient Service (OASIS) was integrated into ASU in 2021. We retrospectively reviewed all patients over age 65 admitted to ASU over a 12-month period before and after service integration with a length of stay (LOS) greater than 24 h. There was no subsequent truncation or selection. Primary outcomes were 30-day mortality, LOS, and 28-day readmissions. Secondary outcomes were discharge disposition, in-hospital mortality, and hospital-acquired complications (HACs).

RESULTS

1339 consecutive patients were included in each group, with no differences in baseline characteristics. There was a significant decrease in 28-day readmissions from 20.2% to 16.0% (P < 0.05), greatest in patients undergoing non-EL operative procedures (21.9% pre-OASIS vs. 12.6% post-OASIS; P < 0.05). Trends towards reduced 30-day mortality (7.17% vs. 5.90%; P = 0.211), in-hospital mortality (3.88% vs. 2.91%; P = 0.201), permanent care placement (7.77% vs. 7.09%; P = 0.843) and HACs (8.14% vs. 7.62%; P = 0.667) were seen, although statistical significance was not demonstrated. LOS remained unchanged at 4 days (P = 0.653).

CONCLUSION

The addition of a geriatric in-reach service to a tertiary ASU led to a significant reduction in 28-day readmissions. Downtrends were seen in mortality, permanent care placement, and HAC rates, while LOS remained unchanged.

The implementation of a perioperative medicine for older people undergoing surgery service: a qualitative case study

BACKGROUND

The international scale and spread of evidence-based perioperative medicine for older people undergoing surgery (POPS) services has not yet been fully realised. Implementation science provides a structured approach to understanding factors that act as barriers and facilitators to the implementation of POPS services. In this study, we aimed to identify factors that influence the implementation of POPS services in the UK.

METHODS

A qualitative case study at three UK health services was undertaken. The health services differed across contextual factors (population, workforce, size) and stages of POPS service implementation maturity. Semi-structured interviews with purposively sampled clinicians (perioperative medical, nursing, allied health, and pharmacy) and managers (n = 56) were conducted. Data were inductively coded, then thematically analysed using the Consolidated Framework for Implementation Research (CFIR).

RESULTS

Fourteen factors across all five CFIR domains were relevant to the implementation of POPS services. Key shared facilitators included stakeholders understanding the rationale of the POPS service, with support from their networks, POPS champions, and POPS clinical leads. We found substantial variation and flexibility in the way that health services responded to these shared facilitators and this was relevant to the implementation of POPS services.

CONCLUSIONS

Health services planning to implement a POPS service should use health service-specific strategies to respond flexibly to local factors that are acting as barriers or facilitators to implementation. To support implementation of a POPS service, we recommend health services prioritise understanding local networks, identifying POPS champions, and ensuring that stakeholders understand the rationale for the POPS service. Our study also provides a structure for future research to understand the factors associated with 'unsuccessful' implementation of a POPS service, which can inform ongoing efforts to implement evidence-based perioperative models of care for older people.

Study protocol for a national observational cohort investigating frailty, delirium and multimorbidity in older surgical patients: the third Sprint National Anaesthesia Project (SNAP 3)

INTRODUCTION

Older surgical patients are more likely to be living with frailty and multimorbidity and experience postoperative complications. The management of these conditions in the perioperative pathway is evolving. In order to support objective decision-making for patients, services and national guidance, accurate, contemporary data are needed to describe the impact and associations between frailty, multimorbidity and healthcare processes with patient and service-level outcomes.

METHODS AND ANALYSIS

The study is comprised of an observational cohort study of approximately 7500 patients; an organisational survey of perioperative services and a clinician survey of the unplanned, medical workload generated from older surgical patients. The cohort will consist of patients who are 60 years and older, undergoing a surgical procedure during a 5-day recruitment period in participating UK hospitals. Participants will be assessed for baseline frailty and multimorbidity; postoperative morbidity including delirium; and quality of life. Data linkage will provide additional details about individuals, their admission and mortality.The study's primary outcome is length of stay, other outcome measures include incidence of postoperative morbidity and delirium; readmission, mortality and quality of life. The cohort's incidence of frailty, multimorbidity and delirium will be estimated using 95% CIs. Their relationships with outcome measures will be examined using unadjusted and adjusted multilevel regression analyses. Choice of covariates in the adjusted models will be prespecified, based on directed acyclic graphs.A parallel study is planned to take place in Australia in 2022.

ETHICS AND DISSEMINATION

The study has received approval from the Scotland A Research Ethics Committee and Wales Research Ethics Committee 7.This work hopes to influence the development of services and guidelines. We will publish our findings in peer-reviewed journals and provide summary documents to our participants, sites, healthcare policy-makers and the public.

TRIAL REGISTRATION NUMBER

ISRCTN67043129.

A Description of Interventions Prompted by Preoperative Comprehensive Geriatric Assessment and Optimization in Older Elective Noncardiac Surgical Patients

OBJECTIVES

Comprehensive Geriatric Assessment (CGA), a multicomponent, complex intervention, can be used to improve perioperative outcomes. This study aimed to describe the actions and interventions prompted by preoperative CGA and optimization in elective noncardiac, older, surgical patients.

DESIGN

Retrospective observational study.

SETTING AND PARTICIPANTS

Five hundred consecutive patients aged over 65 years attending a preoperative CGA and optimization clinic in a single academic center.

METHODS

A retrospective review of electronic clinical records was undertaken. CGA prompted actions and interventions were categorized a priori and examined according to the perioperative pathway and frailty status.

RESULTS

Patients received a median of nine interventions (IQR 6‒12, range 0‒28). Long-term condition medication changes were made in 375 (75.0%) patients, lifestyle advice provided in 269 (53.8%), therapy interventions delivered in 117 (23.4%), shared decision making documented in 495 (99.0%) with individualized admission plans documented in 410/426 (96.2%). Following CGA, 74/500 (14.8%) patients did not undergo surgery and were more likely to have benign pathology (69% vs 53%, P = .01), higher frailty scores (Edmonton Frail Scale 8 (IQR 5‒10) vs 4 (IQR 2-6), P < .001), lower functional status (Nottingham Extended Activities of Daily Living 33 (IQR 16‒47) vs 57 (IQR 45‒64), P < .001) or cognitive scores (Montreal Cognitive Assessment 19 (IQR 14‒24) vs 24 (IQR 20‒26), P < .001).

CONCLUSIONS AND IMPLICATIONS

This study provides a description of actions and interventions prompted by preoperative CGA at one center. Such a detailed exploration of the CGA process and the clinical skills necessary to deliver it, should be used to inform future multicenter studies and the development and implementation of perioperative services for older patients.

New guidelines for the perioperative care of people living with frailty undergoing elective and emergency surgery-a commentary

Frailty is common in the older population and is a predictor of adverse outcomes following emergency and elective surgery. Identification of frailty is key to enable targeted intervention throughout the perioperative pathway from contemplation of surgery to recovery. Despite evidence on how to identify and modify frailty, such interventions are not yet routine perioperative care. To address this implementation gap, a guideline was published in 2021 by the Centre for Perioperative Care and the British Geriatrics Society, working with patient representatives and all stakeholders involved in the perioperative care of patients with frailty undergoing surgery. The guideline covers all aspects of perioperative care relevant to adults living with frailty undergoing elective and emergency surgery. It is written for healthcare professionals, as well as for patients and their carers, managers and commissioners. Implementation of the guideline will require collaboration between all stakeholders, underpinned by an implementation strategy, workforce development with supporting education and training resources, and evaluation through national audit and research. The guideline is an important step in improving perioperative outcomes for people living with frailty and quality of healthcare services. This commentary provides a summary and discussion of the evidence informing the standards and recommendations in the published guideline.

Perioperative Risk Stratification and Modification

This article discusses the important topic of perioperative risk stratification and the interventions that can be used in the perioperative period for risk modification. It begins with a brief overview of the commonly used scoring systems, risk-prediction models, and assessments of functional capacity and discusses some of the evidence behind each. It then moves on to examine how perioperative risk can be modified through the use of shared decision making, management of multimorbidity, and prehabilitation programs, before considering what the future of risk stratification and modification may hold.