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Lodge ME, Dhesi J, Shipway DJ, Braude P, Meilak C, Partridge J, Andrew NE, Srikanth V, Ayton DR, Moran C. The implementation of a perioperative medicine for older people undergoing surgery service: a qualitative case study. BMC Health Serv Res 2024; 24:345. [PMID: 38491431 PMCID: PMC10943911 DOI: 10.1186/s12913-024-10844-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Accepted: 03/08/2024] [Indexed: 03/18/2024] Open
Abstract
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.
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Affiliation(s)
- Margot E Lodge
- National Centre for Healthy Ageing, Melbourne, Australia
- Peninsula Clinical School, Central Clinical School, Monash University, Melbourne, Australia
- Alfred Health, Melbourne, Australia
| | - Jugdeep Dhesi
- Guy's and St Thomas' NHS Foundation Trust, London, UK
- King's College London, London, UK
| | - David Jh Shipway
- CLARITY (Collaborative Ageing Research) group, North Bristol NHS Trust, Bristol, UK
- University of Bristol, Bristol, UK
| | - Philip Braude
- CLARITY (Collaborative Ageing Research) group, North Bristol NHS Trust, Bristol, UK
| | - Catherine Meilak
- East Kent Hospitals University NHS Foundation Trust, Canterbury, UK
| | - Judith Partridge
- Guy's and St Thomas' NHS Foundation Trust, London, UK
- King's College London, London, UK
| | - Nadine E Andrew
- National Centre for Healthy Ageing, Melbourne, Australia
- Peninsula Clinical School, Central Clinical School, Monash University, Melbourne, Australia
| | - Velandai Srikanth
- National Centre for Healthy Ageing, Melbourne, Australia
- Peninsula Clinical School, Central Clinical School, Monash University, Melbourne, Australia
- Peninsula Health, Frankston, Australia
| | - Darshini R Ayton
- National Centre for Healthy Ageing, Melbourne, Australia.
- Health and Social Care Unit, Monash University, Melbourne, Australia.
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.
| | - Chris Moran
- National Centre for Healthy Ageing, Melbourne, Australia
- Peninsula Clinical School, Central Clinical School, Monash University, Melbourne, Australia
- Alfred Health, Melbourne, Australia
- Peninsula Health, Frankston, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
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Law KY, Cross J, Dhesi J, Partridge J. Developing the workforce to deliver perioperative medicine for older people undergoing surgery: a transdisciplinary education programme. Future Healthc J 2023; 10:321-324. [PMID: 38162222 PMCID: PMC10753214 DOI: 10.7861/fhj.2022-0148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
Patients who are older, frail and medically complex are increasingly presenting for elective and emergency surgical interventions. Comprehensive Geriatric Assessment (CGA) and optimisation methodology improve morbidity and mortality in older surgical patients. However, there is a need to develop an extended and flexible workforce to provide patient-centred quality perioperative care and to simultaneously tackle the growing backlog of planned surgery following the Coronavirus 2019 (COVID-19) pandemic. At Guy's and St Thomas' NHS Foundation Trust, Perioperative Medicine for Older People (POPS) delivers a transdisciplinary education programme for foundation doctors, specialty registrars and advanced clinical practitioners to develop a blended team with shared capabilities and goals in perioperative care. This case study outlines the framework of how the education programme was developed and its evaluation, and the ongoing work of POPS to disseminate knowledge and promote national innovation and collaboration.
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Affiliation(s)
- Kar Yee Law
- Department of Ageing and Health, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Jason Cross
- Department of Ageing and Health, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Jugdeep Dhesi
- Department of Ageing and Health, Guy's and St Thomas' NHS Foundation Trust, London, UK; honorary professor, School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine, King's College London, UK; honorary associate professor, Division of Surgery and Interventional Science, University College London, UK
| | - Judith Partridge
- Department of Ageing and Health, Guy's and St Thomas' NHS Foundation Trust, London, UK; honorary senior lecturer, School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine, King's College London, UK
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Perioperative medicine for Older People undergoing Surgery (POPS): Comprehensive Geriatric Assessment (CGA) and optimization in the perioperative setting. Int Anesthesiol Clin 2023; 61:62-69. [PMID: 36892984 DOI: 10.1097/aia.0000000000000396] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/10/2023]
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Viswanath M, Clinch D, Ceresoli M, Dhesi J, D’Oria M, De Simone B, Podda M, Di Saverio S, Coccolini F, Sartelli M, Catena F, Moore E, Rangar D, Biffl WL, Damaskos D. Perceptions and practices surrounding the perioperative management of frail emergency surgery patients: a WSES-endorsed cross-sectional qualitative survey. World J Emerg Surg 2023; 18:7. [PMID: 36653865 PMCID: PMC9850554 DOI: 10.1186/s13017-022-00471-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 12/25/2022] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Frailty is associated with poor post-operative outcomes in emergency surgical patients. Shared multidisciplinary models have been developed to provide a holistic, reactive model of care to improve outcomes for older people living with frailty. We aimed to describe current perioperative practices, and surgeons' awareness and perception of perioperative frailty management, and barriers to its implementation. METHODS A qualitative cross-sectional survey was sent via the World Society of Emergency Surgery e-letter to their members. Responses were analysed using descriptive statistics and reported by themes: risk scoring systems, frailty awareness and assessment and barriers to implementation. RESULT Of 168/1000 respondents, 38% were aware of the terms "Perioperative medicine for older people undergoing surgery" (POPS) and Comprehensive Geriatric Assessment (CGA). 66.6% of respondents assessed perioperative risk, with 45.2% using the American Society of Anaesthesiologists Physical Status Classification System (ASA-PS). 77.8% of respondents mostly agreed or agreed with the statement that they routinely conducted medical comorbidity management, and pain and falls risk assessment during emergency surgical admissions. Although 98.2% of respondents agreed that frailty was important, only 2.4% performed CGA and 1.2% used a specific frailty screening tool. Clinical frailty score was the most commonly used tool by those who did. Screening was usually conducted by surgical trainees. Key barriers included a lack of knowledge about frailty assessment, a lack of clarity on who should be responsible for frailty screening, and a lack of trained staff. CONCLUSIONS Our study highlights the ubiquitous lack of awareness regarding frailty assessment and the POPS model of care. More training and clear guidelines on frailty scoring, alongside support by multidisciplinary teams, may reduce the burden on surgical trainees, potentially improving rates of appropriate frailty assessment and management of the frailty syndrome in emergency surgical patients.
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Affiliation(s)
| | - Darja Clinch
- Registrar in General Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Marco Ceresoli
- General and Emergency Surgery, School of Medicine and Surgery, Milano-Bicocca University, Monza, Italy
| | - Jugdeep Dhesi
- Department of Ageing and Health, Guy’s and St Thomas NHS Foundation Trust, London, UK
| | - Mario D’Oria
- Division of Vascular and Endovascular Surgery, Cardiovascular Departments, University Hospital of Trieste, ASUGI, Trieste, Italy
| | - Belinda De Simone
- Unit of Digestive and Bariatric Surgery, Clinique Saint Louis, Poissy, Île-de-France France
| | - Mauro Podda
- Emergency Surgery Unit, Department of Surgical Science, University of Cagliari, Cagliari, Italy
| | - Salomone Di Saverio
- Hospital of San Benedetto del Tronto, AV5 ASUR Marche, San Benedetto del Tronto, Italy
| | - Federico Coccolini
- Emergency and Trauma Surgery Department, Pisa University Hospital, Pisa, Italy
| | | | - Fausto Catena
- General and Emergency Surgery Dept, Bufalini Hospital, Cesena, Italy
| | - Ernest Moore
- Denver Health System-Denver Health Medical Center, Denver, USA
| | - Deepa Rangar
- Medicine of the Elderly, Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | - Dimitrios Damaskos
- Department of General Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
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Shahab R, Lochrie N, Moppett IK, Dasgupta P, Partridge JSL, Dhesi JK. A Description of Interventions Prompted by Preoperative Comprehensive Geriatric Assessment and Optimization in Older Elective Noncardiac Surgical Patients. J Am Med Dir Assoc 2022; 23:1948-1954.e4. [PMID: 36137559 DOI: 10.1016/j.jamda.2022.08.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 08/12/2022] [Accepted: 08/14/2022] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- Rihan Shahab
- Perioperative Medicine for Older People undergoing Surgery (POPS), Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Nicola Lochrie
- Perioperative Medicine for Older People undergoing Surgery (POPS), Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Ian K Moppett
- Department of Anesthesia, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom; Anesthesia and Critical Care Section, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom
| | - Prokar Dasgupta
- Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom; Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - Judith S L Partridge
- Perioperative Medicine for Older People undergoing Surgery (POPS), Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom; School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - Jugdeep K Dhesi
- Perioperative Medicine for Older People undergoing Surgery (POPS), Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom; School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom; Division of Surgery and Interventional Science, Research Department of Targeted Intervention, University College London, London, United Kingdom.
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Partridge JSL, Ryan J, Dhesi JK, Barker C, Bates L, Bell R, Bryden D, Carter S, Clegg A, Conroy S, Cowley A, Curtis A, Diedo B, Eardley W, Evley R, Hare S, Hopper A, Humphry N, Kanga K, Kilvington B, Lees NP, McDonald D, McGarrity L, McNally S, Meilak C, Mudford L, Nolan C, Pearce L, Price A, Proffitt A, Romano V, Rose S, Selwyn D, Shackles D, Syddall E, Taylor D, Tinsley S, Vardy E, Youde J. New guidelines for the perioperative care of people living with frailty undergoing elective and emergency surgery-a commentary. Age Ageing 2022; 51:6847803. [PMID: 36436009 DOI: 10.1093/ageing/afac237] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 08/02/2022] [Indexed: 11/28/2022] Open
Abstract
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.
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Affiliation(s)
- Judith S L Partridge
- Department of Ageing and Health, Guy's and St Thomas' NHS Foundation Trust, London, UK.,School of Life Course and Population Sciences, King's College London London, UK
| | - Jack Ryan
- Department of Ageing and Health, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Jugdeep K Dhesi
- Department of Ageing and Health, Guy's and St Thomas' NHS Foundation Trust, London, UK.,School of Life Course and Population Sciences, King's College London London, UK
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Partridge JSL, Moonesinghe SR, Lees N, Dhesi JK. Perioperative care for older people. Age Ageing 2022; 51:6678855. [PMID: 36040439 DOI: 10.1093/ageing/afac194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Indexed: 01/25/2023] Open
Abstract
Increasing numbers of older people are undergoing surgery with benefits including symptom relief and extended longevity. Despite these benefits, older people are more likely than younger patients to experience postoperative complications, which are predominantly medical as opposed to surgical. Comprehensive Geriatric Assessment and optimisation offers a systematic approach to risk assessment and risk modification in the perioperative period. Clinical evidence shows that Comprehensive Geriatric Assessment and optimisation reduces postoperative medical complications and is cost effective in the perioperative setting. These benefits have been observed in patients undergoing elective and emergency surgery. Challenges in the implementation of perioperative Comprehensive Geriatric Assessment and optimisation services are acknowledged. These include the necessary involvement of a wide stakeholder group, limited available geriatric medicine workforce and ensuring fidelity to Comprehensive Geriatric Assessment methodology with adaptation to the local context. Addressing these challenges needs a cross-specialty, interdisciplinary approach underpinned by evidence-based medicine and implementation science with upskilling to facilitate innovative use of the extended workforce. Future delivery of quality patient-centred perioperative care requires proactive engagement with national audit, collaborative guidelines and establishment of networks to share best practice.
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Affiliation(s)
- Judith S L Partridge
- Consultant Geriatrician, Perioperative Medicine for Older People undergoing Surgery (POPS), Department of Ageing and Health, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Honorary Senior Lecturer, School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - S Ramani Moonesinghe
- Professor of Perioperative Medicine, University College London (UCL), London, UK
- Consultant in Anaesthesia, Department of Critical and Perioperative Care, University College Hospitals, London, UK
| | - Nicholas Lees
- Consultant General & Colorectal Surgeon, Salford Royal, Northern Care Alliance NHS Foundation Trust, UK
| | - Jugdeep K Dhesi
- Consultant Geriatrician, Perioperative Medicine for Older People undergoing Surgery (POPS), Department of Ageing and Health, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Honorary Professor, School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- Honorary Associate Professor, Division of Surgery and Interventional Science, University College London, London, UK
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Prasad R, Edwards J, Newton P, Gerbasi Rodrigues T, Curl C. Impact of a geriatric assessment and optimisation-based preoperative clinic on the management of older patients receiving dental treatment under general anaesthetic or conscious sedation: A service evaluation. Gerodontology 2022; 40:192-199. [PMID: 35460087 DOI: 10.1111/ger.12632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 03/22/2022] [Accepted: 03/28/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The main objectives of the study were to review patient characteristics, recommendations made and treatment outcomes of frail/older patients referred to a specialist multidisciplinary geriatric assessment and optimisation-based preoperative clinic (PROKARE), prior to patients receiving dental treatment under general anaesthesia (GA) or conscious sedation (CS). BACKGROUND Although the use of preoperative comprehensive geriatric assessment to improve pre/peri and postoperative mortality has been reported for many surgical domains, its use prior to dental surgery has not been reported previously. METHODS The data were collected retrospectively from the dental notes of 52 patients referred from the Special Care Dental (SCD) Department to the PROKARE service for optimisation prior to dental treatment under GA/CS using a case note study approach. The data extracted included patient demographic characteristics, medical history, clinical management and the treatment outcomes for each patient. The data extracted was analysed with descriptive statistics. RESULTS Key reasons for referral were caries management, retained roots and poor co-operation. Multiple co-morbidities were noted among the patients referred, with 14 (27%) having four or more co-morbidities. The PROKARE assessment identified issues such as treatment could be carried out under CS instead of GA; consent; and the need for medication change and/or further medical investigations. As per recommendations from PROKARE, 39 patients (75%) received dental treatment while five (10%) did not receive treatment, and a further eight (15%) died prior to treatment. CONCLUSION Geriatric assessment and optimisation-based preoperative clinics in the dental management of frail, elderly patients having treatment under GA or CS techniques is valuable, but further research and assessment of current service provision are needed to increase the evidence base.
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Affiliation(s)
- Ria Prasad
- Department of Special Care Dentistry, King's College Hospital NHS Foundation Trust, London, UK
| | - Julie Edwards
- Department of Special Care Dentistry, King's College Hospital NHS Foundation Trust, London, UK
| | - Paul Newton
- Faculty of Education and Human Sciences, School of Health Sciences, University of Greenwich, London, UK
| | - Taianny Gerbasi Rodrigues
- Faculty of Education and Human Sciences, School of Health Sciences, University of Greenwich, London, UK
| | - Charlotte Curl
- Department of Special Care Dentistry, King's College Hospital NHS Foundation Trust, London, UK
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Thillainadesan J, Hilmer SN, Fleury AM, Naganathan V. New horizons in the perioperative care of older adults. Age Ageing 2022; 51:6520523. [PMID: 35134849 DOI: 10.1093/ageing/afab245] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Indexed: 12/18/2022] Open
Abstract
Older adults undergoing surgery have high perioperative morbidity and mortality. Age-related physiological changes and prevalence of geriatric syndromes such as frailty increase the risk of adverse postoperative outcomes. Geriatricians utilise comprehensive geriatric assessment (CGA) and management to identify and manage geriatric syndromes, and deliver patient-centred perioperative care. Perioperative models of CGA are established for older patients undergoing hip fracture surgery. Recent trials support the benefits of perioperative models of CGA for non-orthopaedic surgery, and have influenced current care recommendations for older surgical patients. Areas for further action include addressing the implementation gap between recommended evidence-based perioperative care and routine perioperative care, evaluating the clinical and cost-effectiveness of perioperative models of CGA for patients living with frailty, and embedding routine use of patient-reported outcome measures to inform quality improvement.
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Affiliation(s)
- Janani Thillainadesan
- Department of Geriatric Medicine, Concord Hospital, Sydney, Australia
- Faculty of Medicine and Health, Concord Clinical School, University of Sydney, Sydney, Australia
- Centre for Education and Research on Ageing, and Ageing and Alzheimers Institute, Sydney, Australia
| | - Sarah N Hilmer
- Department of Aged Care, Kolling Institute of Medical Research, Sydney Medical School, University of Sydney and Royal North Shore Hospital, Sydney, Australia
| | - Aisling M Fleury
- Perioperative Medicine Unit, Division of Surgery, Logan Hospital, Logan, Queensland, Australia
| | - Vasi Naganathan
- Department of Geriatric Medicine, Concord Hospital, Sydney, Australia
- Faculty of Medicine and Health, Concord Clinical School, University of Sydney, Sydney, Australia
- Centre for Education and Research on Ageing, and Ageing and Alzheimers Institute, Sydney, Australia
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de Las Casas R, Meilak C, Whittle A, Partridge J, Adamek J, Sadler E, Sevdalis N, Dhesi J. Establishing a perioperative medicine for older people undergoing surgery service for general surgical patients at a district general hospital. Clin Med (Lond) 2021; 21:e608-e614. [PMID: 34862220 DOI: 10.7861/clinmed.2021-0356] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION There is growing recognition of the need for perioperative medicine services for older surgical patients. Comprehensive geriatric assessment and optimisation methodology has been successfully used to improve perioperative outcomes at tertiary centres. This paper describes translation of an established model of geriatrician-led perioperative care to a district general hospital (DGH) setting. METHODS A mixed methods quality improvement programme was used and included stakeholder co-design, identification of core components, definition of mechanisms for change, and measurement of impact through qualitative and quantitative approaches. RESULTS Within 18 months, a substantive perioperative service for older people was established at a DGH, funded by the surgical directorate. Key outcomes included reduction in length of stay and 30-day readmission and positive staff and patient experience. DISCUSSION This study is in keeping with improvement science literature demonstrating the importance of a mixed-methods approach in translating an evidenced-based intervention into another setting, maintaining fidelity and replicating results.
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Affiliation(s)
| | | | | | - Judith Partridge
- Guy's and St Thomas' NHS Foundation Trust, London and honorary senior lecturer, King's College London, London, UK
| | | | - Euan Sadler
- School of Health Sciences, University of Southampton, Southampton, UK
| | - Nick Sevdalis
- Centre for Implementation Science, King's College London, London, UK
| | - Jugdeep Dhesi
- Guy's and St Thomas' NHS Foundation Trust, London, UK, honorary reader, King's College London, London, UK, and honorary associate professor, University College London, London, UK
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Thillainadesan J, Aitken SJ, Monaro SR, Cullen JS, Kerdic R, Hilmer SN, Naganathan V. Geriatric Comanagement of Older Vascular Surgery Inpatients Reduces Hospital-Acquired Geriatric Syndromes. J Am Med Dir Assoc 2021; 23:589-595.e6. [PMID: 34756839 DOI: 10.1016/j.jamda.2021.09.037] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 09/27/2021] [Accepted: 09/28/2021] [Indexed: 02/08/2023]
Abstract
OBJECTIVE This study evaluates the impact of a novel model of care called Geriatric Comanagement of Older Vascular surgery inpatients on clinical outcomes. DESIGN, SETTING, AND PARTICIPANTS A pre-post study of geriatric comanagement, comparing prospectively recruited preintervention (February-October 2019) and prospectively recruited postintervention (January-December 2020) cohorts. Consecutively admitted vascular surgery patients age ≥65 years at a tertiary academic hospital in Concord and with an expected length of stay (LOS) greater than 2 days were recruited. INTERVENTION A comanagement model where a geriatrician was embedded within the vascular surgery team and delivered proactive comprehensive geriatric assessment based interventions. METHODS Primary outcomes of incidence of hospital-acquired geriatric syndromes, delirium, and LOS were compared between groups using univariable and multivariable logistic regression analyses. Prespecified subgroup analysis was performed by frailty status. RESULTS There were 150 patients in the preintervention group and 152 patients in the postintervention group. The postintervention group were more frail [66 (43.4%) vs 45 (30.0%)], urgently admitted [72 (47.4%) vs 56 (37.3%)], and nonoperatively managed [52 (34.2%) vs 33 (22.0%)]. These differences were attributed to the coronavirus disease 2019 pandemic during the postintervention phase. The postintervention group had fewer hospital-acquired geriatric syndromes [74 (48.7%) vs 97 (64.7%); P = .005] and reduced incident delirium [5 (3.3%) vs 15 (10.0%); P = .02], in unadjusted and adjusted analyses. Cardiac [8 (5.3%) vs 30 (20.0%); P < .001] and infective complications [4 (2.6%) vs 12 (8.0%); P = .04] were also fewer. LOS was unchanged. Frail patients in the postintervention group experienced significantly fewer geriatric syndromes including delirium. CONCLUSIONS AND IMPLICATIONS This is the first prospective study of inpatient geriatric comanagement for older vascular surgery patients. Reductions in hospital-acquired geriatric syndromes including delirium, and cardiac and infective complications were observed after implementing geriatric comanagement. These benefits were also demonstrated in the frail subgroup.
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Affiliation(s)
- Janani Thillainadesan
- Department of Geriatric Medicine, Concord Hospital, Concord, Sydney, Australia; Concord Clinical School, Faculty of Medicine and Health, The University of Sydney, Concord, Sydney, Australia; Center for Education and Research on Aging, and Aging and Alzheimers Institute, Concord, Sydney, Australia.
| | - Sarah J Aitken
- Concord Clinical School, Faculty of Medicine and Health, The University of Sydney, Concord, Sydney, Australia; Concord Institute of Academic Surgery, Vascular Surgery Department, Concord Hospital, Concord, Sydney, Australia; Department of Vascular Surgery, Concord Hospital, Concord, Sydney, Australia
| | - Sue R Monaro
- Department of Vascular Surgery, Concord Hospital, Concord, Sydney, Australia; Susan Wakil School of Nursing, The University of Sydney, Sydney, Australia
| | - John S Cullen
- Department of Geriatric Medicine, Concord Hospital, Concord, Sydney, Australia; Concord Clinical School, Faculty of Medicine and Health, The University of Sydney, Concord, Sydney, Australia; Center for Education and Research on Aging, and Aging and Alzheimers Institute, Concord, Sydney, Australia
| | - Richard Kerdic
- Department of Vascular Surgery, Concord Hospital, Concord, Sydney, Australia
| | - Sarah N Hilmer
- Kolling Institute of Medical Research, Sydney Medical School, University of Sydney and Royal North Shore Hospital, St Leonards, Sydney, Australia
| | - Vasi Naganathan
- Department of Geriatric Medicine, Concord Hospital, Concord, Sydney, Australia; Concord Clinical School, Faculty of Medicine and Health, The University of Sydney, Concord, Sydney, Australia; Center for Education and Research on Aging, and Aging and Alzheimers Institute, Concord, Sydney, Australia
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Aitken R, Harun NS, Maier AB. Which preoperative screening tool should be applied to older patients undergoing elective surgery to predict short-term postoperative outcomes? Lessons from systematic reviews, meta-analyses and guidelines. Intern Emerg Med 2021; 16:37-48. [PMID: 32613471 PMCID: PMC7843484 DOI: 10.1007/s11739-020-02415-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 06/20/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Older surgical patients have a higher risk of postoperative mortality and morbidity compared to younger patients. Timely identification of high-risk patients facilitates comprehensive preoperative evaluation, optimization, and resource allocation to help reduce this risk. This review aims to identify a preoperative screening tool for older patients undergoing elective surgery predictive of poor short-term postoperative outcomes. METHODS A scoping review was conducted. An Ovid MEDLINE search was used to identify systematic reviews or meta-analyses comprising older elective patients in at least two different surgical settings. International guidelines were reviewed for recommendations regarding preoperative tools in this population. RESULTS Over 50 screening tools were identified. The majority showed a positive association with short-term postoperative mortality and morbidity in older patients. The most commonly described tools were the American Society of Anesthesiologists Physical Status (ASA-PS), frailty tools and domain-specific tools administered as part of comprehensive geriatric assessment (CGA). Due to heterogeneity in outcome measures and statistical methodology the predictive capacity between tools could not be compared. International guidelines described a comprehensive preoperative approach incorporating domain-specific tools rather than recommending a screening tool. CONCLUSION Multiple tools were associated with poor short-term postoperative outcomes in older elective surgical patients. No single superior tool could be identified. Frailty, cognitive and/or functional tools were most frequently utilized.
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Affiliation(s)
- Rachel Aitken
- Department of Medicine and Aged Care, The University of Melbourne, The Royal Melbourne Hospital, @AgeMelbourne, Parkville, VIC, Australia
| | - Nur-Shirin Harun
- Department of Medicine, The Royal Melbourne Hospital, Melbourne, Australia
| | - Andrea Britta Maier
- Department of Medicine and Aged Care, The University of Melbourne, The Royal Melbourne Hospital, @AgeMelbourne, Parkville, VIC, Australia.
- Department of Human Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, @AgeAmsterdam, Amsterdam, The Netherlands.
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