Perioperative care for surgical patients

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.

This service evaluation reviewed the impact of the Perioperative Care of Older People Clinic (POPS) on Anticholinergic Burden (ACB) in older surgical patients and identified areas for improvement. The study assessed 75 patients aged ≥65 years, revealing widespread anticholinergic use. Among patients on anticholinergics, 34% experienced a reduction in ACB post-POPS review. However, maintaining these changes at ≥6 months was challenging, with 50% of patients experiencing a change in their ACB score due to new prescriptions or the re-initiation of old medications. The study identified communication gaps at the POPS-primary care interface affecting de-prescribing efforts, underscoring the need for improved discharge letters, systems to flag high ACB patients and a universal ACB tool.

Introduction

The UK's ageing population is increasingly undergoing surgery, and older adults are at higher surgical risk partly due to anticholinergic use. POPS is a relatively new initiative aimed at reducing ACB in this demographic, but the sustainability of these reductions is not well understood. This service evaluation aims to fill this gap and suggest solutions for maintaining reduced ACB levels.

Methods

Retrospective data from 75 patients from 2022-2023 who met the criteria for ACB evaluation pre- and post-POPS review, with follow-up at ≥6 months, were included. Results Post-POPS, ACB was reduced in 34% of patients, with a median decrease of -2. However, ACB increased again in 50% of patients at ≥6 months, with re-initiation of amitriptyline and furosemide contributing to the rise in 67% of these cases.

Conclusions

CGA effectively reduces ACB in older surgical patients, but sustaining these reductions poses significant challenges. Communication difficulties at the POPS-primary care interface likely contribute to the re-initiation of medications, indicating a need for standardised discharge summaries and a universal system for evaluating and flagging high ACB patients to maintain improvements.

Introduction

• Preoperative systemic inflammation has been shown to worsen postoperative outcome in emergency surgical patients.
• C-reactive protein (mg/L)/Albumin (g/L) ratio is a well validated inflammation marker.
• Studies have shown an inverse relationship between 25-hydroxyvitamin D level and markers of inflammation. Vitamin D deficiency has been previously shown to be associated with inflammation.

Aims and Objectives

• To determine the relationship between 25-hydroxyvitamin D level and CRP/Albumin ratio in older acute hip fracture patients.
• To explore the impact of gender on this relationship.

Methods

• A retrospective review of electronic notes from the hip fracture database was carried out on hip fracture patients attending a single trauma centre from January to December 2022.
• Anonymised data were extracted from the database. Patients aged 60 years and older who sustained an acute hip fracture were included. Patients with incomplete data were excluded. The IBM SPSS 29 software was used for statistical analysis.
• Descriptive statistics was used for baseline characteristics. Linear regression was used to determine correlation.

Results

• A total of 293 patients were analysed: 82 males and 211 females with a mean age of 81.6(SD 8.28) and 83.2(SD 7.85) years respectively.
• Mean 25-hydroxyvitamin D levels were 39.1 (SD 25.0) and 49.7 (SD 29.01) nmols/L respectively.
• Mean CRP/Albumin ratio was 0.94 (SD 1.51) and 0.71 (SD 1.34).
• There was a negative, statistically significant correlation between 25-hydroxyvitaminD and CRP/Albumin ratio in male patients but not in the females (r = -.274; p = .013 & r = - .035; p = .61) respectively.

Conclusion

• In this study, 25-hydroxyvitamin D levels are inversely correlated with markers of inflammation (CRP/Albumin ratio) in older male hip fracture patients but not older female hip fracture patients. More studies are needed to clarify whether vit D lowers inflammation or inflammation lowers 25-hydroxyvitamin D concentrations and to investigate the gender difference.

Introduction: Delirium is a common and serious complication in frail older patients undergoing emergency hip fracture surgery, often resulting in prolonged hospital stays, increased morbidity, and a greater risk of long-term cognitive decline. Recognizing and managing delirium effectively is critical in improving patient outcomes. However, initial assessments indicated variability in the confidence and capability of surgical postgraduate doctors to assess and manage delirium appropriately. A baseline survey revealed that 50% of staff were not familiar with hospital delirium guidelines, and 62% rated their confidence in managing delirium as 3 out of 5. Additionally, over one-third of staff inappropriately used the AMT10 as a delirium screening tool, and many lacked confidence in interpreting the 4AT score.

Method: To address these gaps, we implemented a multipronged educational program to improve staff knowledge and confidence in delirium assessment and management. This approach included formal teaching sessions, the display of delirium infographics in ward areas, and the dissemination of key information via email and WhatsApp. The program emphasized the appropriate use of the 4AT for screening and highlighted common delirium triggers and their management.

Results: Post-intervention analysis showed an improvement in both the confidence and accuracy of delirium assessment among staff. All staff were able to use the 4AT correctly, and everyone reported increased confidence in assessing delirium. Management practices revealed that pain, infection, constipation, and electrolyte abnormalities were generally well-addressed in patients. However, there remained a lower frequency of medication reviews, along with insufficient attention to nutrition and hypoxia as potential contributors to delirium.

Conclusion: Our educational intervention significantly enhanced staff confidence and competence in detecting and managing delirium in the trauma and orthopaedic ward setting. Following these improvements, the next phase of our project is to introduce a standardized delirium care bundle in the surgical setting. This care bundle aims to establish a structured approach to delirium management, thereby minimizing delirium-related complications and improving overall patient care.

Introduction 

Prompted by observation and directed by The Centre for Perioperative Care (CPOC) guidelines, two quality improvement cycles were carried out during 2021-2023 seeking to improve the identification and care of frail patients admitted emergently to the general surgery department at Peterborough City Hospital (PCH), a busy district general hospital with over 40 general surgical beds. 

Method 

Two Plan-Do-Study-Act cycles were undertaken. The medical records of patients 65+ years were interrogated for documentation of frailty assessment, evidence of escalation planning and geriatrician review. Results were presented at departmental clinical governance meetings where the barriers that are limiting progress in this area of clinical practice were debated. In view of finite resources and funding, realistic measures, such as highlighting frailty scores during handover, were introduced during both cycles. 

Results 

Both cycles demonstrated that current practice within the general surgery department at PCH does not meet CPOC standards and no significant improvement was made by simple interventions. Frailty scores are not routinely assessed or utilised by clinicians, only some patients are given opportunity to undertake shared decision-making including escalation planning and a small number of patients receive a geriatrician review. Departmental discussions revealed barriers including lack of knowledge of frailty, insufficient communication within the department, and insufficient resources for specialist geriatric input. 

Conclusion 

This project has demonstrated the challenges of changing clinical practice on the front line. Although our results demonstrated no significant improvement in care of frail surgical patients, change has occurred in terms of engagement of general surgeons. Gold standard practice seems elusive, but small, realistic steps are being taken. Whilst there is no immediate prospect of the resources to deliver specialist geriatric input for all frail surgical patients, there is hope that progress can be made towards this so we will continue to build a case for future investment. 

Introduction Surgical interventions for older adults are increasing as the population ages. This demographic has a higher perioperative risk. Perioperative care through virtual wards (VWs) is a new service, allowing patients to remain at home. We compared operational and clinical metrics between two age groups (65+ and <65 years) receiving surgical inpatient care through a VW service to evaluate safety and efficacy.

Methods The VW service at Wrightington Wigan and Leigh (WWL) NHS Foundation Trust cared for patients at home using the Current Health (CH) platform for medical and surgical inpatients. Patients wore a device that transmitted vital signs, allowing VW staff to monitor real-time data. Patients in this service would have otherwise been hospitalized; bed days saved were estimated based on clinical judgment. De-identified and aggregated data from January 14, 2022, to January 31, 2024, were analysed to evaluate differences between older (65+ years) and younger (<65 years) patients. Fisher’s exact, t-tests and Mann-Whitney tests compared outcomes.

Results There were 75 younger patient admissions (mean age 47.5 ± 11.1 years, 57% female) and 30 older patient admissions (mean age 72.7 ± 6.0, 53% female). Both groups had a similar VW length of stay (mean 9.3, SD 5.4 days), bed days saved (median 7, IQR 5-7 days), and adherence (median 92%, IQR 87-96%). Median alarms per patient-day were 2.9 (IQR 1.4-5.4). In total, seven patients (6.7% of admissions) returned to the hospital. Of those, four patients presented to A&E out of hours from the VW (2 per group). There were no escalations to community services or adverse events.

Conclusion The VW service has successfully managed surgical inpatients from their homes, demonstrating good adherence, bed days saved, minimal hospital returns, and no adverse outcomes in both older and younger patients. There were no statistical differences in operational or clinical outcomes between groups.

Introduction:

The prevalence of older patients with Colorectal Cancer (CRC) is increasing. While surgery can offer benefits, older patients living with frailty undergoing Colorectal Surgery are more at risk of postoperative mortality and complications. The literature suggests comprehensive geriatric assessment (CGA) pre-operatively enhances shared decision making (SDM), equity of access to surgery, length of stay (LOS) and mortality. Our aim is to evaluate how a joint Geriatrician/Anaesthetic pre-assessment clinic would impact outcomes for elective colorectal surgery in older patients.

Method:

Patients aged >= 65 years had a CGA as part of the pre-operative assessment when undergoing Colorectal Surgery between September 2021 to December 2023. Data including Clinical Frailty Score (CFS), LOS, P-POSSUM Score, medication reconciliation, A&E Re-admissions and 30-day and 90-day mortality was analysed.

Results:

197 patients were seen over 28 months. 147 (75%) of patients underwent surgery and 50 (25%) declined after SDM. 30-day and 90-day mortality was 0% and 0.5% respectively. The average age was 80 (65-94), compared to 74 (65-88) prior to clinic inception. The median CFS was 4. LOS with CFS <=4 averaged 7.7 days and CFS >=5 averaged 16.5 days (t-test -4.88, p 9.91e-06). 12 new diagnoses (5%) were made. Common diagnoses included Dementia and Atrial Fibrillation. 123 referrals were made, accounting for 49% of the cohort. 22% of the cohort’s medication were altered (16% of which were deprescriptions). A&E Reattendance was 18%, compared to 29% in other studies. 0 patients required ICU admission.

Conclusion:

Perioperative Frailty Involvement for patients undergoing CRC Surgery greatly improves outcomes and reduces postoperative mortality following Colorectal Surgery. CFS, LOS and P-POSSUM Score are major predictors of poor postoperative outcome in this population. There has been a reduction in A+E admissions and onward referrals. Further work needs to be completed on the financial implications and impact on other surgical specialties.

Introduction:

Chronic limb-threatening ischemia (CLTI) is defined by presence of peripheral artery disease, rest pain, and/or gangrene or ulceration.1 Management of CLTI often involves a major amputation which has a 30-day in-hospital mortality of 6.6%. Despite improvements in secondary risk management, 5-year mortality remains high.1 Understanding how comorbidity affects amputation survival may help support patient optimisation and shared decision-making.

Methods:

This audit assessed the outcomes of patients who were reviewed by the POPS team using a comprehensive geriatric assessment (CGA) before undergoing a major lower limb amputation. We retrospectively analysed electronic records from 60 patients with CLTI who were admitted in an emergency setting, reviewed by the POPS team, and underwent a major lower limb amputation during 2022. The primary outcome measure was death following surgery. Data was collected from the patient records and analysed using the Chi square test.

Results:

In this group of 60 patients the 30-day mortality was 5% (3 patients) and 1-year mortality 43% (26 patients), with the average age at time of death being 77 years. Age (p=0.022) and co-morbidity (p = 0.021) were the strongest prognostic factors for mortality. Other factors like clinical frailty score (CFS), albumin concentration and length of hospital stay showed non-significant correlations with mortality in patients who underwent lower limb amputation.

Conclusion:

This study highlighted prognostic factors that could enable doctors to identify high-risk patients who may benefit from optimisation and detailed shared decision-making prior to undergoing a major lower limb amputation. As mortality is not necessarily modifiable, even in the context of a CGA in this group, it also highlights the need for advanced care planning before discharge.

References 1. Waton S, Johal A, Birmpili P, et al. National Vascular Registry: 2022 Annual Report. London: The Royal College of Surgeons of England.