Palliative Care in Emergency General Surgery Patients: Reduced Inpatient Mortality And Increased Discharge to Hospice

The 2023 WSES guidelines on the management of trauma in elderly and frail patients

BACKGROUND

The trauma mortality rate is higher in the elderly compared with younger patients. Ageing is associated with physiological changes in multiple systems and correlated with frailty. Frailty is a risk factor for mortality in elderly trauma patients. We aim to provide evidence-based guidelines for the management of geriatric trauma patients to improve it and reduce futile procedures.

METHODS

Six working groups of expert acute care and trauma surgeons reviewed extensively the literature according to the topic and the PICO question assigned. Statements and recommendations were assessed according to the GRADE methodology and approved by a consensus of experts in the field at the 10th international congress of the WSES in 2023.

RESULTS

The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage, including drug history, frailty assessment, nutritional status, and early activation of trauma protocol to improve outcomes. Acute trauma pain in the elderly has to be managed in a multimodal analgesic approach, to avoid side effects of opioid use. Antibiotic prophylaxis is recommended in penetrating (abdominal, thoracic) trauma, in severely burned and in open fractures elderly patients to decrease septic complications. Antibiotics are not recommended in blunt trauma in the absence of signs of sepsis and septic shock. Venous thromboembolism prophylaxis with LMWH or UFH should be administrated as soon as possible in high and moderate-risk elderly trauma patients according to the renal function, weight of the patient and bleeding risk. A palliative care team should be involved as soon as possible to discuss the end of life in a multidisciplinary approach considering the patient's directives, family feelings and representatives' desires, and all decisions should be shared.

CONCLUSIONS

The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage based on assessing frailty and early activation of trauma protocol to improve outcomes. Geriatric Intensive Care Units are needed to care for elderly and frail trauma patients in a multidisciplinary approach to decrease mortality and improve outcomes.

Incidence and outcomes of emergency department patients requiring emergency general surgery: a 5-year retrospective cohort study

AIMS

Patients undergoing emergency general surgery are at high risk of complications and death. Our objectives were to estimate the incidence of emergency general surgery in a Swiss University Hospital, to describe the characteristics and outcomes of patients undergoing such procedures, and to study the impact of age on clinical outcomes.

METHODS

This was a retrospective cohort study of adult patients who visited the emergency department (ED) of Geneva University Hospitals between January 2015 and December 2019. Routinely collected data were extracted from electronic medical records. The primary outcome was the incidence of emergency general surgery among patients visiting the emergency department, defined as general surgery within three days of emergency department admission. We also assessed demographic characteristics, mortality, intensive care unit admission and patient disposition. Multivariable log-binomial regression was used to study the associations of age with intensive care unit (ICU) admission, one-year mortality and dependence at discharge. Age was modelled as a continuous variable using restricted cubic splines and we compared older patients (75th percentile) with younger patients (25th percentile).

RESULTS

Between January 2015 and December 2019, a total of 310,914 emergency department visits met our inclusion criteria. Among them, 3592 patients underwent emergency general surgery within 3 days of emergency department admission, yielding an annual incidence of 116 events per 10,000 emergency department visits (95% CI: 112-119), with a higher incidence in females and young patients. Overall, 5.3% of patients were admitted to ICU, 7.8% were dependent on rehabilitation or assisted living at discharge and 4.8% were dead after one year. Older patients had a higher risk of ICU admission (adjusted risk ratio (aRR) 2.9 [1.5-5.4]), dependence at discharge (aRR 15.3 [5.5-42.4]) and one-year mortality (aRR 5.4 [2.2-13.4]).

CONCLUSION

Emergency department visits resulting in emergency general surgery are frequent, but their incidence decreases with patient age. Mortality, ICU admission and dependence at discharge following emergency general surgery are more frequent in older patients. Taking into account the increased risk for older patients, a shared process is appropriate for making more informed decisions about their options for care.

Optimization of Care for the Elderly Surgical Emergency Patient

Geriatric patients undergoing emergency surgery are at significantly higher risk for complications and death when compared with younger patients. Optimizing care for these patients requires a multidisciplinary team, special attention to physiologic changes and medication use, as well as targeted intervention to mitigate complications such as delirium, which can worsen overall outcomes. Frailty can be assessed preoperatively to identify patients at the highest risk for complications. Shared decision-making with both the family and patient during the consent process is integral to defining patient's goals of care in these high-risk situations.

What If We Do Not Operate? Outcomes of Nonoperatively Managed Emergency General Surgery Patients

INTRODUCTION

Although two-thirds of patients with emergency general surgery (EGS) conditions are managed nonoperatively, their long-term outcomes are not well described. We describe outcomes of nonoperative management in a cohort of older EGS patients and estimate the projected risk of operative management using the NSQIP Surgical Risk Calculator (SRC).

MATERIALS AND METHODS

We studied single-center inpatients aged 65 y and more with an EGS consult who did not undergo an operation (January 2019-December 2020). For each patient, we recorded the surgeon's recommendation as either an operation was "Not Needed" (medical management preferred) or "Not Recommended" (risk outweighed benefits). Our main outcome of interest was mortality at 30 d and 1 y. Our secondary outcome of interest was SRC-projected 30-day postoperative mortality risk (median % [interquartile range]), calculated using hypothetical low-risk and high-risk operations.

RESULTS

We included 204 patients (60% female, median age 75 y), for whom an operation was "Not Needed" in 81% and "Not Recommended" in 19%. In this cohort, 11% died at 30 d and 23% died at 1 y. Mortality was higher for the "Not Recommended" cohort (37% versus 5% at 30 d and 53% versus 16% at 1 y, P < 0.05). The SRC-projected 30-day postoperative mortality risk was 3.7% (1.3-8.7) for low-risk and 5.8% (2-11.8) for high-risk operations.

CONCLUSIONS

Nonoperative management in older EGS patients is associated with very high risk of short-term and long-term mortality, particularly if a surgeon advised that risks of surgery outweighed benefits. The SRC may underestimate risk in the highest-risk patients.

Variation in hospice use among trauma centers may impact analysis of geriatric trauma outcomes: An analysis of 1,961,228 Centers for Medicare and Medicaid Services hospitalizations from 2,317 facilities

BACKGROUND

Defining discharges to hospice as "deaths" is vital for properly assessing trauma center outcomes. This is critical with older patients as a higher proportion is discharged to hospice. The goals of this study were to measure rates of hospice use, evaluate hospice discharge rates by trauma center level, and identify variables affecting hospice use in geriatric trauma.

METHODS

Patients from the Centers for Medicare and Medicaid Services Inpatient Standard Analytical Files for 2017 to 2019, 65 years or older, with ≥1 injury International Classification of Diseases, Tenth Revision , code, at hospitals with ≥50 trauma patients per year were selected. Total deaths was defined as inpatient deaths plus hospice discharges. Dominance analysis identified the most important contributors to a model of hospice use.

RESULTS

A total of 1.96 million hospitalizations from 2,317 hospitals (Level I, 10%; II, 14%; III, 18%; IV, 7%; none, 51%) were included. Level I's had significantly lower raw hospice discharge values compared with Levels II and III (I, 0.030; II, 0.035; III, 0.035; p < 0.05) but not Level IV (0.032) or nontrauma centers (0.030) ( p > 0.05). Adjusted Level I hospice discharge rates were lower than all other facility types (Level I, 0.026; II, 0.031; III, 0.034; IV, 0.033; nontrauma, 0.030; p < 0.05). Hospice discharges as a proportion of total deaths varied by level and were lowest (0.38) at Level I centers. Dominance analysis showed that proportion of patients with Injury Severity Score of >15 contributed most to explaining hospice utilization rates (3.2%) followed by trauma center level (2.3%), proportion White (1.9%), proportion female (1.5%), and urban/rural setting (1.4%).

CONCLUSION

In this near population-based geriatric trauma analysis, Level I centers had the lowest hospice discharge rate, but hospice discharge rates varied significantly by trauma level and should be included in mortality assessments of hospital outcomes. As the population ages, accurate assessment of geriatric trauma outcomes becomes more critical. Further studies are needed to evaluate the optimal utilization of hospice in end-of-life decision making for geriatric trauma.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level II.

Palliative Care in the Trauma and Surgical Critical Care Settings: A Narrative Review

BACKGROUND

We aimed to conduct a narrative review of available literature to understand the use of palliative care in the trauma and surgical critical care setting.

METHODS

PubMed, EMBASE, and Google Scholar databases were searched for studies investigating the use of palliative care in the trauma and surgical critical care setting. The search included all studies published through January 9th, 2022. The risk of bias of included studies was assessed using the Joanna Briggs Institute Critical Appraisal Checklist tools. Outcomes were summarized in tables and synthesized qualitatively.

RESULTS

A total of 22 studies were included in this review. Key elements of successful palliative care include communication, shared decision-making, family involvement, pain control, establishing a patient's prognosis, and end-of-life management. Approaches to implementation based upon these key elements include best-case/worst-case scenarios, consultation trigger systems, and integrated institutional palliative care programs. Palliative care may reduce hospital length of stay, improve symptom management, and increase patient satisfaction, but the impact on mortality is unclear.

CONCLUSION

The core elements of palliative care have been identified and palliative care has been shown to improve outcomes in trauma and surgical critical care. However, the approaches for implementation still require development. The underutilization of palliative care for trauma patients reveals the need for refining criteria for use of palliative care and improvement in the education of surgical critical care teams to provide primary palliative care services.