Perioperative care for surgical patients

Introduction: Prevalence of aortic stenosis and comorbidity burden correlates with advancing age. The Charlson Comorbidity Index (CCI) is a widely validated tool that predicts outcomes in a range of conditions and settings.

Methods: We analysed 38 eligible patients referred for CT TAVI at our institution between August 21 - December 22 and calculated their CCI score to study its impact on symptoms, procedural complications and mortality at 30-days, 6-months and 1-year post TAVI. Evidence of frailty screening was determined using retrospective case note review.

Results: Thirty-eight patients were referred for TAVI with mean age 77.9 and mean CCI 4.5. Twenty-seven (71%) underwent TAVI with mean age 77.5 and mean CCI 5.2. The commonest comorbidities were myocardial infarction (47%), congestive heart failure (21%) and COPD (34%). At 30-days, 41% of patients (mean CCI 4.3) had objective improvement in exercise tolerance, 33% (mean CCI 5) reported subjective improvement and 7% (mean CCI 7) experienced no change in symptoms. Complications occurred in 2 (mean CCI 4.5). The benefit persisted in 15 out of 18 at 6 months. At 1-year, 3 out of 6 reported sustained benefit (mean CCI 4.6) and 3 reported worsening symptoms (mean CCI 5.6) due to progression of mitral valve disease (1), new diagnosis of possible cancer (1) and worsening ankle swelling (1). Frailty screening was not routinely done.

Conclusion: The CCI tool is reliable in predicting TAVI outcomes. Good 30-day outcomes were seen with CCI ≤5 but benefit decreased at 6-months and 1-year when CCI >5.6, reflecting European Society of Cardiology guidance of CCI >5 conferring poorer prognosis. Futility was predicted by CCI >7 in our group. The Rockwood Clinical Frailty scale identifies mild-moderate frailty (CFS 5/6), in whom comprehensive geriatric assessment can help. These rapid web-based tools can be performed in clinic to identify potential barriers to recovery.

Introduction 

Shared decision making (SDM) is a vital element in ensuring a more personalised approach to care.  The Peri-operative Care of Older People in Surgery (POPS) Team adopts enhanced SDM in frail patients referred for elective urological or colorectal surgery using the BRAN (benefits, risks, alternatives, nothing) approach. In frail populations, there is a complex balance between providing appropriate access to surgery and minimising exposure to potentially harmful procedures. SDM can help to negotiate this balance. This study aimed to evaluate the patient perception of the SDM process.  

Method 

Patients and/or their family proxy attending the POPS clinic between December 2023 – March 2024 were invited to participate in a follow-up telephone interview. The content of the interview was based on the CollaboRATE tool, a quick 3-question, validated questionnaire used for evaluating SDM from the patient’s perspective.  

Results 

Overall, 22 out of 29 (76%) consenting patients and/or their proxy were contactable and well enough to participate in the CollaboRATE evaluation.  

All (n=22, 100%) reported that the POPS team had made ‘a lot’ or ’every’ effort in helping them understand their health issues and listening to what mattered most to them. 86% (n=19) thought they had made ‘a lot’ or ‘every’ effort to include what mattered most to them in deciding what to do next. Patients/proxies were also able to add unstructured comments which were also positive: 

 ‘the staff were excellent - my husband transformed in front of my eyes, he was so happy with the decision.’ 

Conclusion 

The SDM process within the POPS clinic is highly rated and valued by the patients.  Considering that SDM also reduced the number who opted for surgery by 30% (April – July 2023; 9 out of 30 chose not to have surgery), it can offer added value to the individual and the wider system. 

There is unequivocal evidence to support Perioperative care for the Older Person Undergoing Surgery (POPS) services. However, POPS services are not available in all Trusts offering surgery, including Royal Surrey Foundation Trust (RSFT). The necessity for POPS services will continue to grow with increasing numbers of older people undergoing elective and emergency surgery due to: changing demographics, surgical and anaesthetic advancements, shifts in culture and patients’ expectation of healthcare (1). A RSFT POPS steering group was convened to explore the current orthopaedic elective pathway, the what-why-how of implementing a POPS service and ultimately write a business case to submit to the board to request funding for a formal POPS service. Unfortunately, ahead of submitting we were informed a business case would unlikely secure funding due to the current financial climate. To continue to evidence the need for this service, over the course of a year, Geriatricians used their Supporting Professional Activities (SPA) time to provide informal POPS Comprehensive Geriatric Assessment (CGA) reviews to patients aged ≥65 with a CFS ≥5 on the elective waiting list for knee/hip operations. The average age of patients seen was 82 years (range 67-92). The average Clinical Frailty Score calculated was 7 (range 4-7) with the average number of frailty markers identified being 4 (range 1-7). Following CGA, 75% of patients decided not to proceed with operative management. 88% either initiated or completed a Recommended Summary Plan for Emergency Care and Treatment (ReSPECT). We now have both local and national data to support the need for a POPS service at RSFT. When financial support is not available to invest in and develop new services, alternate methods such as staff re-distribution can be considered with the aim of both providing a service as well as collating invaluable evidence to support a business case and secure funding.

Introduction

It is predicted that over 4,000,000 patients will be on an elective waiting list in England by 2030 (1) with increased demand, age and frailty following COVID (2). The importance of early assessment of frailty and geriatrician input to allow optimisation and shared decision making is key. A Geriatrician led perioperative clinic was established in Swansea Bay for patients on elective general surgical waiting lists in September 2023.

Method

Using an electronic Power Business Intelligence frailty flag, we highlighted patients and screened either electronically or via telephone using a combination of CFS and CRANE questionnaire. Covering a number of areas including continence, falls and cognition. The outcomes are reviewed by a geriatrician and directed to appropriate avenues such as face-to-face perioperative clinic, continence services or virtual wards. All patients who decide to continue on their journey to surgery are given advice r.e. operative risk, diet and fitness along with optimisation of medications and tests such as echo to minimize delays going forward.

Results

Over 250 patients >65 have been screened to date-either Digitally/Paper/Telephone. Digital responders have an average CFS of 4.48. Over 20 patients have been seen per month since initiating the service with a variety of outcomes. Over 50 (~20%) have decided against surgery following shared decision making demonstrating cost savings of approx. £200,000. There are a number of new diagnoses including dementia and incontinence. Over 20 patients have accepted referral to continence services.

Conclusion

Formalising a perioperative clinic has allowed improvements in patient care and cost savings. We have now completed an initial screen on all general surgical patients who have been on the waiting list over 1 year and have initiated ongoing screening to detect changes in frailty going forward. The next step is initiation of frailty screening at point of referral on WCCG referral.

Introduction

Patients living with dementia are more likely to experience delirium and adverse outcomes when admitted to hospital (Dementia UK, 2022). The General Surgery directorate at Cardiff and Vale University Health Board secured funding for a Memory Link Worker (MLW) in the emergency stream. The aim of the MLW is to improve the hospital experience for patients living with cognitive impairment or anyone experiencing delirium. The MLW should also increase awareness and completion rates of “Read About Me” (RAM).

Method

Eligible patients are identified by ward staff or the Perioperative care of Older People undergoing Surgery (POPS) team and referred. The MLW reviews patients, offers activities, contacts families/ carers and completes the RAM. We used dementia care mapping (DCM), an observational tool to objectively measure the impact of interventions on patient wellbeing and improve care for people living with dementia. Patient, relative and staff feedback was collected via a short survey.

Results

During the first 2 years the MLW has seen 107 and 141 patients respectively. DCM demonstrated a positive impact on patient well-being, mood and engagement. Very few patients were able to self-entertain in the absence of the MLW and those that did were using tools supplied by the MLW. A small survey of patients and relatives (n=9) found MLW support to be ‘extremely helpful’ and if readmitted would want MLW support again. A larger staff survey (n=52) showed most felt their ward had benefitted from MLW input, and felt that other wards with cognitively impaired patients would benefit from similar, as well as showing good awareness of the role.

Conclusion

The DCM process aligned with survey findings of a positive impact of the MLW role on patient experiences in secondary care setting.

Introduction:

Polypharmacy is commonly defined as the concomitant use of five or more medications. This is a common problem in frail elderly patients and more so on the surgical inpatients where it is not regularly reviewed by the surgical team.

Methods:

We reviewed retrospectively the data on vascular inpatients from 2015-2016 and after the set-up of the perioperative services in 2022-23. Patients above 65 years of age with a clinical frailty score of 4 or more or with two or more co-morbidities were selected from both groups. In total 130 patients were selected from each group and their notes were reviewed in terms of polypharmacy review, before and after the introduction of the perioperative service in the trust.

Results:

Average age of the patients in both groups combined was 75 years. Average polypharmacy number per patient before and after the perioperative service were 6.8 and 10.7, respectively. In 2022-23, all the 130 patients had a polypharmacy review by a Consultant Geriatrician. In 2015-16, polypharmacy was reviewed only if there was an adverse effect to the drug, for example bradycardia caused by beta blockers. There was no routine review of polypharmacy. 0.06 Medications were stopped per patient in 2015-16, in contrast to 1.7 per patient in 2022-23. Most common causes of discontinuation of medications were falls, confusion, postural hypotension, drowsiness, electrolyte imbalance or medication no longer needed.

Conclusions:

Polypharmacy optimisation should routinely be practised in frail vascular surgical patients as it leads to avoidance of undesirable side-effects, improves patient compliance to medications, and has a huge financial benefit from deprescribing.

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 Centre for Perioperative Care recommends the assessment and documentation of delirium using a validated tool such as the 4-AT in older people undergoing surgery.

Aim: This quality improvement project (QIP) aimed to improve the assessment and documentation of delirium in patients aged 65 and above following vascular surgery in a tertiary centre.

Methods: Patients aged ≥65 years who had undergone vascular surgery were identified and data was collected with access to the electronic patient record system. Analysis was carried out using Microsoft Excel and SPSS. Following baseline measurements taken in August 2023, 1 plan-do-study-act (PDSA) cycle was completed between September 2023-January 2024.

Baseline measures: Baseline data collected between August 1-31st 2023 identified 51 patients, of which delirium was screened using the 4-AT tool in 39.2% (n=20), on average 90 hours post-operatively. The 4-AT was never documented in a consultant-led surgical post-operative review (100%,n=51). There were clinical concerns of post-operative delirium documented in 7 patients, with the 4-AT documented in 5 of those cases.

Intervention: Interventions included stakeholder discussions to identify key barriers in the assessment and documentation of delirium, multidisciplinary team education and poster reminders across the ward. These were introduced between November-December 2023.

Results: Post-intervention results reviewed between 10th-31st January 2024 showed that the 4-AT was used to screen for delirium in 61.9% of patients (n=13), on average 45 hours post-operatively. The 4-AT was never documented in a consultant-led surgical post-operative review. In addition, 2 patients developed delirium post-operatively with the 4-AT reported in both cases.

Conclusions: This QIP has demonstrated a marked improvement in compliance with national guidelines on the assessment of delirium, highlighting the impact of multidisciplinary education in improving the perioperative clinical pathway for older people undergoing surgery. Future PDSA cycles will focus on improving the documentation of 4AT in the post-operative surgical review.

1. Introduction

Parkinson’s Disease (PD) is a complex neurodegenerative disorder which impacts nearly all aspects of quality of life. Given the known challenges and risks of complications with PD, it is crucial to improve management prior to admission for surgery, in particular accurate medication timing and dose. Therefore a quality improvement project on this subject was initiated.

2. Method

A retrospective analysis was conducted of Surgical attendances to Worthing hospital with the aim to identify patients with Parkinson’s disease (PD) admitted under their care. Each patient’s hospital records were manually screened using Evolve Live software and WellSky EPMA to extract the information pertaining to PD medications for the audit. Statistical analysis was conducted using Microsoft Excel. The cycle was repeated following interventions of posters and education of surgical teams.

3. Results

In both cycles there were patients attending for elective surgery or admitted into hospital. The following is regarding patients who were admitted to hospital and were on PD medications. For the first cycle, 27 admissions were identified and 20 in the second cycle. In the first cycle, 5/27 (18.5%) had their medications accurately documented, which improved to 9/20 (45%) in the second cycle. First cycle, 16/27 (59%) patients had their medications prescribed correctly, which was similar to 12/20 (60%) patients in the second. 17/27 (62.7%) patients missed doses in the 1st cycle, and 9/20 (45%) patients in the 2nd cycle.

4. Conclusion(s)

From the first cycle, it was identified that PD in patients was not recognised as promptly as it should. It was reflected in the high proportion of incorrect prescribing and issues due to delay in medications. In the second cycle, following our interventions, there was improved awareness of PD with fewer prescribing issues and complications during admission.

Introduction: According to the latest NELA report(1), frailty doubles the risk of mortality in patients >65 and above, but review by a geriatrician can significantly reduce this risk. To identify patients at risk, the report recommended that a formal frailty assessment for all patients>65 should be performed. The aim of this audit was to check compliance with this recommendation.

Methods: Data were collected retrospectively from a prospectively maintained electronic hospital records. Patients > 65 years admitted acutely under general surgery were identified from handover lists spanning a period of two weeks. The admission documents were reviewed to check for a formal assessment of clinical frailty score (CFS) had been completed. Following initial results, posters were put up in the SAU doctors office and all clerking doctors made aware via e-mails, WhatsApp groups and teaching to complete a CFS for patients >65 years. Results: In the first cycle, 50 patients were identified and compliance rate was 18%. Following intervention, 51 patients were identified in the subsequent cycle with a compliance rate of 47%. After a second intervention, 99 patients were identified with a compliance rate of 61%.

Discussion: The NELA report highlighted only 23% of patients had a CFS documented and this was similar to the results of the initial audit. The main reason was lack of awareness, which was addressed by creating an awareness among the colleagues via poster, group chats and emails. This brought compliance up to 47% Another reason was doctors being unable to locate the CFS on the electronic clerking document. A second round of intervention by poster, group chat, email communication and teaching achieved a 61% completion rate. The recommendation is to continue to improve the documentation of CFS further and utilize this to get input from geriatricians.