Perioperative care for surgical patients

Introduction: Total Laparoscopic Hysterectomies (TLHs) are one of the most common gynaecological surgical interventions in the ageing population. Whilst co-morbidities have huge influence on the perceived patient suitability for surgery, patient factors like age ought to be considered in the pre-operative stage. Clinicians must counsel patients on individualised risks to enable informed decisions.This audit looked to identify the impact of age on the likelihood of operative complications in TLHs, guiding specific counselling for older patients considering this procedure.

Methods: Extensive data was collected retrospectively using electronic care records and operative notes regarding patients undergoing TLH by a single surgeon at a UK cancer centre between 2008-2020 (N=593). Complications were intra-operative (bladder injury, bowel injury and bleeding >500ml) or post-operative (bleeding, infection, readmission, return to theatre and GAU attendance). Patients were grouped according to their age. Complication rates (intra-operatively and post-operatively) were compared between groups and differences tested for statistical significance (p<.05).

Results: intra-operatively complication rates increased with age. significant differences were found between most age groups (>50yrs p=0.001, >60yrs p=0.021, >70yrs p=0.04). A significant difference in post-operative complication rates was found >50yrs (p=0.011).

Conclusions: With significant differences in TLH complication rates between different age groups, pre-operative assessment of patient factors becomes increasingly important. Not only for patient education purposes, but also for their suitability for surgery. Whilst co-morbidities are more pertinent in the ageing population which could account for this significant difference, age alone is a factor that should not be overlooked. It is a simple measure that is easily conceptualised to patients to stratify risk in the decision making progress.

Introduction - The POPS service (SOPAS) in Morriston Hospital receives over 300 referrals a year. However, many of these referrals did not meet service criteria. Inefficient direction of referrals has a negative impact on service efficiency and can result in poor patient experience and outcomes. This is a quality improvement initiative to increase the quality and suitability of referrals made to the service.

Aim - To implement a referral system able to offer safe, rapid assessment for surgical patients who would benefit from geriatrician-led intervention.

Method - We developed a list of criteria for referral to the service and included 47 referrals over a two-month-span for analysis. Two PDSA improvement cycles were then performed. The first cycle involved implementation of an automatic email response to referrals as they came in addressing the main safety concerns highlighted in the analysis. The second cycle involved setting up a new referral process via an online form to provide structure and prompts for key information to improve the content of referrals along with collecting service data prospectively.

Results - Prior to invention, many referrals missed key information. Almost a quarter of referrals were from specialties that POPS does not accept and some requested emergency reviews not appropriate for this service. The first improvement cycle effectively decreased the number of inappropriate or unsafe referrals according to clinician feedback. With the second cycle we hope to improve the quality and content of referrals as we introduce our referral form.

Conclusion - The new system improved the suitability and quality of referrals to POPS. By reducing inappropriate referrals to POPS, eligible patients could be seen by the right service in a timely manner, improving outcomes. We saw that a proforma is an effective way to improve referral content, and that an online form is useful in making an accessible referral process.

Introduction: In 2021, there were 38,839 adults >65 years living in Brighton and Hove, 13% of the local population, compared to 18% in England. However, 56% of emergency laparotomy procedures in the UK are in the > 65s. At the Royal Sussex County Hospital, a consultant geriatrician was appointed to lead a Frailty Liaison Service to respond to the needs of frail older patients undergoing general surgery (GS). No process was in place for the early identification of these patients, so intervention decisions were being made without GS Frailty Liaison input, potentially leading to unnecessary procedures and adverse outcomes such as deconditioning, which could potentially be reduced by timely clinical frailty scoring (CFS) and comprehensive geriatric assessment. This quality improvement project sought to identify all appropriate frail older patients over 70 within 1 week of admission to be seen by the Frailty Liaison Team on the general surgical ward.

Methods: We used the Model for Improvement and diagnostic tools (fishbone; stakeholder mapping; driver diagrams) and PDSA cycles to test the impact of junior doctor education on CFS scoring and awareness raising primarily through a newsletter; measured by the number of frailty scores given to patients pre-intervention, remeasured at 3 months after the initial data set. We captured feedback following the education sessions to assess usefulness.

Results and conclusion: Results showed 100% of participants felt more confident in identifying frailty in GS patients. The average number of days from admission to identification and first review decreased from 8.29 to 6.36, possibly reducing adverse outcomes. The proportion of appropriate referrals increased, releasing time to care for those who needed it most. Moving forward, we plan to promote the use of a CFS column on the handover list and continue our education sessions, incorporating real patient cases as requested in feedback.

Introduction

Sarcopenia is common in patients with hip fracture, but few studies have examined whether assessment of sarcopenia improves prediction of adverse post-operative outcomes. We examined whether sarcopenia, diagnosed using handgrip strength (HGS), could predict outcomes after hip fracture.

Methods

Routinely collected data from the National Hip Fracture Database were combined with locally collected HGS data from a high-volume orthopaedic trauma unit. Patients aged ≥65years with surgically managed, non-pathological hip fracture with grip strength measured on admission were included. The European Working Group on Sarcopenia in Older People (EWGSOP2) thresholds were used to identify patients with or without sarcopenia; those unable to complete grip strength testing were also included in analyses. Outcomes examined were 30-day and 120-day mortality, residential status and mobility, prolonged length of stay (>15 days) and post-operative delirium. Binary logistic regression models were used to examine prognostic value of HGS, and discriminant ability for the Nottingham Hip Fracture Score (NHFS) alone and on adding sarcopenia status were compared using c-statistics.

Results

We analysed data from 282 individuals; mean age 83.2 (SD 9.2) years; 200 (70.9%) were female. 99 (35.1%) patients had sarcopenia and 109 (38.7%) were unable to complete testing. Sarcopenia predicted higher 120-day mortality (OR 13.0, 95%CI 1.7-101.1, p=0.014), but not 30-day mortality (OR 1.5, 95%CI 0.1-16.9, p=0.74). Patients unable to complete HGS testing had higher 30-day mortality (OR 13.5, 95%CI 1.8-103.8, p=0.012) and 120-day mortality (OR 34.5, 95%CI 4.6-258.7, p<0.001). Sarcopenia status did not significantly improve discrimination for mobility but improved prediction of 120-day residential status (c-statistic 0.89 [95%CI 0.85-0.94] for NHFS+sarcopenia vs 0.82 [95%CI 0.76-0.87] for NHFS alone) and post-operative delirium (c-statistic 0.91 [95%CI 0.87-0.94] vs 0.78 [95%CI 0.73-0.84]).

Conclusion

Sarcopenia assessment via HGS testing may provide additional prognostic information to existing risk scores in older patients with hip fracture.

Introduction

With recent advances in surgical techniques and immunosuppressive therapy, solid organ transplantation (SOT) is increasingly accessible to older and more complex patients. Multiple previous studies have shown quality of life improvements in SOT patients post-transplant across age group and despite significant pre-transplant frailty. As such, we are investigating if SOT is associated with a reduction in frailty status post-tranplant.

Methods

Studies across five databases between 2000 and 2023 were included if an objective frailty status measurement was used, SOT was performed during the study, and no rehabilitation took place pre- or post-transplant. Included studies were graded for risk of bias using the Newcastle Ottawa Scale. Data extracted from the studies was pooled in a random-effects meta-analysis using the Mantel-Haenszel method.

Results

Across the 12 studies included in the review (6 kidney transplant, 2 liver transplant, 3 lung transplant and 1 heart transplant), there was a total of 3065 transplant recipients (62% male 38% female) with a mean age of 51.35 years old. There is an worsening of frailty status in transplant patient immediately post-transplant. Thereafter, there is a reduction in frailty status 3 months post-transplant sustained 6 – 12 months post-transplant. However, frailty status plateaus after this period up to 36 months, based on the 3 studies that did track frailty status beyond 12 months. Five studies were included in the meta-analysis which demonstrated an odds ratio = 0.27 (95% CI, 0.12, 0.59, P = .001, I^2= 82%), When the single paper deemed to be of poor quality was removed the remaining four studies demonstrated a reduced odds ratio of being frail at 6-12 months posttransplant (OR 0.45 (95% CI, 0.32, 0.65, P = .001, I^2= 13%).

Conclusions

Transplant is associated with a reversal in frailty status 6 to 12 months post-transplant, although heterogeneity was demonstrated across studies.

Introduction: The incidence of dementia among patients in perioperative settings is on the rise, presenting significant challenges for healthcare professionals in delivering adequate and appropriate care to this patient population. In order to gain a deeper understanding of the perioperative care needs of patients with dementia, thirty healthcare professionals were interviewed. The focus was on their experiences and perspectives regarding the fulfilment of these needs. Key factors influencing perioperative care were identified and categorized into three main themes: patient-related factors, healthcare professional-related factors, and healthcare environment-related factors. Methods: Thirty interviews were conducted with a diverse group of healthcare professionals, including anaesthetists, surgeons, nurses, and other perioperative staff. Thematic analysis was employed to process and interpret the data, identifying recurring themes and sub-themes that reflect the complexities of perioperative care for patients with dementia. Results: The analysis revealed three primary themes: 1) Factors related to the patient with dementia: Cognitive impairment and comorbidities uniquely challenge perioperative care. The unfamiliar hospital environment often exacerbates cognitive symptoms, and adherence to postoperative protocols can be problematic. Family involvement is crucial in supporting these patients. 2) Healthcare Professional Factors: Perceptions of dementia, communication issues, pain assessment, and the need for personalized care were highlighted. Training and education deficits among healthcare professionals were evident, impacting the quality of care. 3) Institutional Factors: Organisational policies and resource allocation significantly affect the provision of dementia care. Support for healthcare professionals through ongoing education and the development of dementia-specific guidelines were identified as essential needs. Conclusion: Effective perioperative care for patients with dementia requires addressing multifaceted challenges. Improving communication, enhancing education and training for healthcare professionals, involving family members, and ensuring institutional support are critical steps. A comprehensive, empathetic approach can lead to better outcomes and experiences for patients with dementia in the perioperative setting.

INTRODUCTION: Post-traumatic stress disorder (PTSD) is an anxiety disorder caused by frightening or traumatic events. Delirium is a state of acute confusion associated with acute illness, surgery, and hospitalisation. Delirium is known to be associated with a risk of PTSD in patients in the Intensive Care (ICU) setting. However, there is limited information on the prevalence of delirium in older adults outside of Intensive Care. Therefore we undertook a systematic review to ascertain the prevalence of PTSD in elderly patients after an episode of delirium on a general ward.

METHODS: The systematic review was conducted using MEDLINE (1946-10/01/2024), Embase (1974- 10/01/2024), and PsycINFO (1806- 10/01/2024) to identify studies. Studies were eligible if they included adults aged ≥ 65 years, admitted to an acute hospital, diagnosed with delirium using a validated screening tool, (e.g. 4AT, CAM-ICU) and subsequently screened for PTSD at any point following discharge with a validated screening tool (e.g. the PTSS-14). The exclusion criteria excluded ICU cohorts and terminal illness with < 3 months life expectancy. Two researchers (SM, NM) independently reviewed all studies with any disparities resolved though a 3rd researcher (AM)

RESULTS: After removal of duplicates, the search identified 1042 titles from which only 3 eligible studies were identified. All 3 studies were in older patients after surgical procedures (n=132 participants in total). Two of the studies reported no association between delirium and the subsequent risk of PTSD. However, the largest study (n=77) reported a significant independent association between delirium and the 3-month risk of PTSD.

CONCLUSION: The current body of research on the prevalence of PTSD following episodes of in-patient delirium in older adults is limited. The findings of this review highlight the need for further research. A prospective cohort study on Geriatric Medicine wards is being planned.

The elderly population ( cut off 65 and over, for this audit) are being increasingly prescribed direct oral anticoagulants(DOAC) for prevention of stroke in atrial fibrillation/ prevention and treatment of DVT/PE.This poses significant difficulties when stopping/ restarting these medications in the peri-operative period , due to the ever changing clinical circumstances in this period. Therefore , we performed an audit( in Glangwili Hospital, Jan-July 2024)  , using the Welsh Frailty Fracture Network guidelines as our standard and found out(during the first cycle) that around 40 percent of patients did not have their DOAC restarted on time post surgery and that poor documentation regarding the circumstances causing delay was prevalent. We intervened by providing teaching , putting up posters and trying to include the guidelines in the trust intranet. In the second cycle, there was significant improvement in the documentation of the circumstance causing delay of restart and higher number of patients with DOACs stopped in correct time in keeping with their renal functions.

Background

Perioperative management of diabetes is a strong predictor of post-operative outcomes for patients undergoing major elective surgery. The national confidential enquiry into patient outcome and death (NCEPOD) has specific recommendations for diabetes care in the perioperative phase. We aimed to audit current practice in East Sussex Healthcare Trust (ESHT) against these recommendations prior to the introduction of a recognised programme designed to improve the perioperative pathway for patients with diabetes (IP3D).

Methods

A retrospective audit of 30 patients with diabetes who underwent major orthopaedic or colorectal surgery. Data was collected on basic demographics, quality of initial referral, preoperative assessment, intraoperative diabetes management and postoperative recovery.

Results

Mean patient age was 73 (57-91), with the majority having type-2 diabetes (93%, n=28). Initial referral letters mentioned diabetes in 77% (n=23) of cases; 7% (n=2) included the latest HbA1c. 97% (n=29) had a pre-operative HbA1c; mean was 50.9mmol/mol (39-74). 43% (n=13) of patients were scheduled in the first third of the operating list. Blood glucose was measured preoperatively in 93% (n=28), intraoperatively in 40% (n=12) and postoperatively in 77% (n=23). Postoperatively, three patients had hypoglycaemic events and five had hyperglycaemic events. One patient had deficient wound healing due to poorly controlled diabetes.

Conclusions

Perioperative management of patients with diabetes at ESHT does not currently meet the NCEPOD standards. This shortfall will be addressed by the implementation of the IP3D programme and supported by a perioperative diabetes specialist nurse. The programme will focus on educating and supporting patients perioperatively whilst improving diabetes knowledge amongst surgical staff.

Introduction

Orthopaedic surgery is an important treatment for musculoskeletal (MSK) conditions. In the NHS, 25% of all surgical interventions are for MSK conditions and account for 16.1% of the total cost of surgery. Complications following joint surgery include venous thromboembolism, infection, stroke, myocardial infarction, falls and delirium. Remote ischaemic conditioning (RIC) is a technique which induces intermittent ischaemia of a limb, through inflating a tourniquet above systolic blood pressure for intervals that avoid physical injury but trigger several intrinsic protective mechanisms.

Method

A systematic literature search was performed in Pubmed, Medline and Embase for studies investigating RIC in fracture, trauma or orthopaedic surgery, published between 1966 and November 2023. Pre-clinical trials and clinical randomised controlled trials (RCTs) were included. There was insufficient data to conduct meta-analyses, so a narrative review was undertaken. PEDro risk of bias scale was performed on RCTs.

Results

Three pre-clinical trials studied RIC in animal models. Results showed a reduction in markers of oxidative stress and up-regulation of genes involved in osteoblast expression, causing improved fracture healing. 20 clinical RCT manuscripts considered the used of RIC in elective and emergency orthopaedic surgery. In total, 1276 participants were studied, and protocols used one dose of RIC prior to surgery. 17 studies demonstrated statistically significant positive outcomes in RIC compared to control, including known mechanisms of RIC such as oxidative stress, inflammation and oxygenation. Additionally, when measured, post-operative pain was improved and there were fewer cardiovascular complications in at-risk individuals.

Conclusions

There is evidence that RIC has a positive effect in orthopaedic surgery, however the populations and outcomes measured were varied. Repeated use of RIC, including post-operative doses, may result in more profound beneficial effects. There is a need for designed RCTs to test whether this intervention can improve the clinical outcomes in wider populations.