Peri-operative Care for Older Patients Undergoing Surgery

Executive summary

Increasing numbers of older people are undergoing elective and emergency surgery

Older people have much to gain from surgery, and there is a growing evidence base for clinical interventions and processes of care that lead to better outcome.  However, this population remains at increased risk of adverse postoperative outcome

The needs of the older surgical patient are often substantially different from those of younger patients. In particular, the impact of reduced physiological reserve, multi-morbidity and geriatric syndromes at all stages of the surgical pathway must be appreciated.

Models of service provision vary, but the key principles, outlined in this Guide, should underpin any service dealing with older surgical patients. 

With the increasing focus on both quality and cost-effectiveness in the NHS, there is a need to further define best practice with regard to surgical care of older people. 

The role of geriatricians and other professionals who specialise in care of older people is crucial in implementing best practice in terms of leadership, clinical services, education and training and research.

There is a need to standardise geriatric medicine input into the care of older surgical patients throughout the NHS 

Introduction 

The rate of older people undergoing surgical procedures is increasing faster than the rate of population ageing . This is due to advances in surgical technique and anaesthetic management coupled with changes in patient and professional expectations and behaviours. Despite this progress, older surgical patients remain at increased risk of adverse postoperative outcome in comparison to younger patients. This is both in terms of morbidity and mortality. Factors contributing to this increased risk include an age related reduction in physiological reserve, an increase in multi-morbidity and the ‘geriatric syndromes’.  Clinicians with experience in assessment and management of these issues should play a central role in the surgical pathway. However, this is not routine in either emergency or elective surgery. There have been significant improvements in the care of the older hip fracture patient, resulting from joint working between geriatricians, orthopaedic surgeons and anaesthetists. This has allowed the development of a clinical evidence base, national audit and financial incentives. The gains which have been made in this field now need to be translated across other emergency and elective surgical populations. We need to rise to the challenge of reorganising and providing an evidence-based multi-disciplinary model of care which has the older surgical patient at its centre. 

National reports and drivers

This section provides a summary of the relevant national reports and guidance

1. Extremes of age. National Confidential Enquiry into Patient Outcome and Death (NCEPOD, 1999). Reviewed surgical care in the very young and the very old. Raised concerns regarding prolonged waits for theatre, inadequate intensive care facilities, insufficient senior clinician input, poor team working.
2. Department of Health. National Service Framework for Older People. DH, London, 2001. Laid out 8 standards, 5 of which are relevant to surgery in older people: rooting out age discrimination, person-centred care, intermediate care, general hospital care and the promotion of health and active life in older age. 
3. Philp I. A recipe for care – not a single ingredient. Clinical case for change: report by Professor Ian Philp, national clinical director for older people. Department of Health, London, 2007. Highlighted that many existing health services are not designed with older people in mind, and that there is evidence that early intervention and assessment, easy access to specialists and equal access to specialist in-patient care when needed can improve outcomes and utilisation of resources.
4. Department of Health. High Quality Care for All. NHS Next Stage Review Final Report. DH, London, 2008. Outlines the future focus for the NHS – locally led, patient centred and clinically driven; responsive to changes in healthcare and society including an ageing population; and a focus on quality and quality improvement methods.
5. NHS Institute for Innovation and Improvement. Focus on: frail older people. London, 2009. www.institute.nhs.uk. Part of the ‘delivering quality and value’ series, this resource document outlines a number of key characteristics of organisations that provide high quality care and value for money with a specific focus on care of frail older people
6. ‘An Age Old Problem’ (NCEPOD, 2010). Focussed on patients aged over 80 years who had died within 30 days of elective and emergency surgery. Primary finding that less than one third of patients received good care, consequent to poor recognition of risk factors specific to the older population, poor decision making, and inadequate and untimely escalation of care.  Recommended increased input from elderly medicine physicians and for an emphasis on the geriatric syndromes of frailty and delirium. 
7. ‘Knowing the risk’ (NCEPOD, 2011) described poor identification of the high risk patient resulting in underuse of appropriate intraoperative monitoring techniques and underutilisation of level 2 and 3 care. It recommended the use of risk assessment tools to stratify care. 
8. ‘The high risk general surgical patient’ (Royal College of Surgeons and Department of Health, 2011).  Summarises high morbidity and mortality related to emergency general surgery. Provides care pathways and escalation strategies for surgical complications in particular sepsis. However it has not addressed the need for improved medical care for older surgical patients. 
9. Enhanced recovery programmes (NHS Institute for Innovation and Improvement).  An approach which emphasises the need for a patient centred pathway focusing on the provision of the best possible pre-, intra-, and post-operative care. However, scant data in the frail older surgical population.
10. ‘Access all Ages’ (Royal College Surgeons and Age UK, 2012). Showed a decline in the rate of elective surgical procedures for those aged over 65 years despite the fact that the incidence of underlying conditions requiring surgery increases with age. Recommended improved communication with patients, development  of evidence base, guidelines, models of care  and methods of monitoring services for the older population  and high quality commissioning.

Models of care

Different models of care have evolved for the assessment and optimisation of the older and/or high risk surgical patient. This has been influenced by local resources, local populations, the specific needs of certain centres and the available expertise. 

Geriatrician led services – Preoperative comprehensive geriatric assessment provided by a consultant geriatrician led multidisciplinary team (MDT) involves multi-domain assessment and optimisation of the high risk or older surgical patient. The MDT can support the surgical teams with postoperative medical care, focussing on functional optimisation and discharge planning for both emergency and elective patients.  Examples of this model include the  Proactive care of Older People undergoing Surgery (POPS) service at Guy’s and St Thomas’ NHS Foundation  Trust and the Systematic Care Older Patients undergoing Elective Surgery (SCOPES) at Nottingham University Hospitals NHS Trust

Anaesthetist led services – Patients are triaged (based on perioperative risk of mortality) with the higher risk patients attending an anaesthetist led clinic. The clinician employs various methods of clinical assessment and physiological testing (e.g. cardiopulmonary exercise testing)  to provide an objective assessment of the risks and benefits of surgery. The clinic is supported by a range of health-care professionals to provide expert advice and support (organ specialists, therapists, and allied health-care professionals).  An example of this model is the Torbay Preoperative Preparation Clinic, South Devon Healthcare NHS Foundation Trust .

Enhanced Recovery Programme (ERP) This national programme combines organisation of care and clinical management throughout the surgical patient pathway with the aim of improving postoperative outcomes. ERP has now been adopted as part of standard care by many surgical specialities. Components of ERP include a focus on preoperative consent, planning and nutrition, intraoperative management including close fluid balance, maintenance of normothermia and use of minimally invasive approaches where possible and postoperative initiatives such as early mobilisation, prompt resumption of normal diet, innovative analgesic techniques and proactive discharge planning. 

Standards of care

Achieving the following standards will require collaboration between all those involved in the perioperative pathway. This includes geriatricians, anaesthetists, surgeons, pre-assessment and ward nursing staff, therapists and allied health care professionals, as well as local managers and commissioning groups. The collaboration should extend to improving clinical standards, governance, education, and the development of a research agenda. In this section the essential components are considered.

Clinical standards

Preoperative risk assessment and optimisation

Use systematic methodology (CGA) to: 

• Identify multi-domain issues (medical, functional , psychological and social) 
• Assess risk of perioperative mortality (using an accepted tool e.g. PPOSSUM, ASA)
• Assess risk of postoperative morbidity (e.g. delirium, AKI, ACS, respiratory decompensation, functional decline)
• Undertake optimisation across all domains in order to modify perioperative risk 
• Provide specialist advice on issues related to consent and ethics of surgery 
• Ensure patient is well informed, promote wellbeing and health promotion

Postoperative management

Joint ward rounds led by a consultant geriatrician and surgeon to:

• Promote shared clinical working and decision making
• Provide proactive recognition of postoperative medical complications and functional decline
• Promote standardised management of medical complications
• Set appropriate ceilings for escalation of care
• Promote good communication between patient, carers and health care professionals
• Weekly geriatrician led ward based multidisciplinary team meeting
• Lead setting of realistic patient-centred goals
• Promote timely discharge planning 

Governance

• Joint geriatric and surgical clinical governance
• Development of integrated  guidelines, pathways and patient safety initiatives
• Scheduled joint audit meetings (e.g. morbidity and mortality meetings) 
• Establish routine national data collection to facilitate robust audit and quality improvement initiatives (e.g. the NHFD)

Education and training 

• Development of local training in perioperative medicine for older surgical patients across disciplines
• Development of national curricula for perioperative medicine across anaesthetics, surgery and medicine, engaging with the Royal Colleges and local education and training boards.
• Develop a training programme aligned with the national curricula and delivered across specialties
• Joint sessions at national and international conferences

Research

• Ensure older people are included in research studies
• Identify the priorities in clinical research and in health services research
• Promote the use of appropriate methodology including newer approaches including quality improvement 
• Use multi-site, cross-speciality research to  address gaps in the literature pertinent to older surgical patients