Perioperative care for surgical patients

Introduction:

In-hospital CPR has survival rates of 15-20%[BMA. Decisions on CPR, 3^rdedition, 2016], further reduced with frailty and multimorbidity. Successful CPR is associated with significant morbidity and prolonged suffering. Do not attempt resuscitation (DNACPR) is an advanced medical decision, aimed at preventing harm where CPR is considered futile.[GMC Guidance.p128-145]

Aims:

To reduce the burden of inappropriate CPR within surgical specialties using the following standards:

1. DNACPR status reviewed on admission, and all decisions implemented within 24hours of clerking.
2. DNACPR decisions implemented prior to surgery.
3. To assess clinician perceptions regarding DNACPR decisions.

Methods

This second cycle follows the intervention of a poster and departmental education in January 2020.

A survey was sent to clinicians of all grades in Trauma and Orthopaedics (T&O) and General Surgery in January 2023. Data on implementation of DNAR decisions was retrospectively collected over January and February 2023 for all T&O emergency and elective admissions >60-years-old.

Results

26 survey responses were obtained with all participants having had DNACPR discussions. 80.7% self-reported as confident/very confident in having these discussions.

Out of 264 patients included, 80 discussions took place, of which 64 (80%) were implemented. 69% were implemented within 24hours of clerking, a 23% increase from cycle 1. 90% of community DNACPRs (9/10) were applied within 24hours, however the one remaining patient received inappropriate CPR. Of the 47 patients with DNACPR who had surgery, 87% were implemented prior to surgery, a 12% increase from cycle 1.

Conclusion

Improvement was demonstrated on both standards between cycles. This QI focused on implementation of DNACPR following discussions, however, did not consider patients in whom DNACPR may have been appropriate but not discussed. Further areas to explore include appropriateness of CPR/ DNACPR decisions in advance of surgical interventions and the understanding behind limitations of treatment offered separate to CPR.

Introduction; Patients living with frailty admitted under Emergency Surgery are vulnerable to complications, longer lengths of stay and readmission. Perioperative Care of the Older Person in Surgery (POPS) services are well evidenced and recommended by many national reports. Whilst they are well established in the other home nations, our POPS pilot in Craigavon Area Hospital is the first in N.Ireland.

Method; Our POPS Pilot in the Emergency Surgical Unit aimed to identify all patients over 65 living with frailty and deliver high quality comprehensive geriatric assessment (CGA). This consists of 4 sessions/week provided by 2 Consultant Geriatricians.

Results; Since our pilot began in January 2022 we have performed CGA on 285 patients, delivered education sessions, increased Frailty awareness, supported junior staff, championed our allied-health professionals and participated in multi-disciplinary team meetings. Typical interventions include delirium prevention and management, medication review, shared decision making and discharge planning. 87.5% of patients seen receive a medication review with discontinuation of several medications. This is vital for prevention of drug adverse events and financially accounts to an approximate saving of £21,545/year in 2022. Both patient and medical staff feedback have been positive and in periods of more intense activity, there has been a promising trend towards lower lengths-of-stay. 30-day readmission rates in the over-65s have also improved, falling from 22% in May-July 2021 to 14% for the same period in 2022. This was evident despite the increased total admissions.

Conclusion; Restrictions and obstacles remain, however with a limited team we have already shown a reduction in readmission rates and made meaningful changes to patient care. With adequate resources, we hope to provide a more consistent service and meet the national CPOC/BGS guidelines to provide good quality perioperative care for people living with frailty undergoing elective and emergency surgery.

Introduction:

Inappropriate catheterisation poses a risk to orthogeriatric patients both in the pre-op and post-op phase. Introducing a foreign object increases the risk of infections, sepsis and seeding of infection to the newly implanted prosthetics for surgical neck of femur (NOF) fracture patients. Furthermore, catheterisation also increases the length of hospital stay and risks of bladder deconditioning and failed attempts at trial without catheter. Therefore, it is essential that nursing and medical staff are aware of the appropriate indications of catheterisation.

Method:

We retrospectively reviewed 40 patients within a one month period who were admitted to the orthogeriatric ward and underwent surgery for their NOF fracture. We examined whether catheterisation and indications were documented on the electronic patient records (EPR), we also reviewed where the catheterisation took place (e.g. on the ward or in the Emergency Department (ED)). Indications were compared to our hospital guidelines for catheterisation.

Results:

1 Patient had a long-term-catheter and was not used in the data analysis. Of the remaining 39 patients, 23 (60%) were catheterised. Majority of these cases (83%) were documented appropriately, with the most common indication being that of urinary retention (47%) especially in the post-op phase. However, 'NOF fracture/immobility' was the second most common documented indication (37%), majority of which (86%) were done in the ED prior to transfer to theatres/ward.

Conclusion:

NOF or immobility is not an automatic indication for catheterisation and catheterisation in these patients is not considered a routine pre-op measure for hip fracture surgery. More education needs to be done with the medical and nursing staff especially in the emergency department regarding this, including encouragement of use of other methods such as pads and bed-pans in the pre-op phase.

Introduction Predicting outcomes after hip fracture is important for identifying high-risk patients who may benefit from additional care and rehabilitation. Pre-operative scores based on patient characteristics are commonly used to predict hip fracture outcomes. Mobility, an indicator of pre-operative function, has been neglected as a potential predictor. We assessed the ability of pre-fracture mobility to predict post-operative outcomes following hip fracture surgery.

Methods We analysed prospectively collected data from hip fracture surgery patients at a large-volume trauma unit. Mobility was classified into four groups. Post-operative outcomes studied were mortality and residence at 30-days, medical complications within 30- or 60-days post-operatively, and prolonged length of stay (LOS, ≥28 days). We performed multivariate regression analyses adjusting for age and sex to assess the discriminative ability of the Nottingham Hip Fracture Score (NHFS), with and without mobility, for predicting outcomes using the area under the receiver operating characteristic curve (AUROC).

Results 1919 patients were included, mean age 82.6 (SD 8.2); 1357 (70.7%) were women. Multivariate analysis demonstrated patients with worse mobility had a 1.7-5.5-fold higher 30-day mortality (p≤0.001), and 1.9-3.2-fold higher likelihood of prolonged LOS (p≤0.001). Worse mobility was associated with a 2.3-3.8-fold higher likelihood of living in a care home at 30-days post-operatively (p<.001) and a 1.3-2.0-fold higher likelihood of complications within 30-days (p≤0.001). addition mobility improved nhfs discrimination for discharge location, auroc 0.755 [0.733-0.777] to nhfs+mobility 0.808 [0.789–0.828], los, 0.584 [0.557-0.611] 0.616 [0.590–0.643].

Conclusions incorporating assessment into risk scores may improve casemix adjustment, prognostication following hip fracture, identify high-risk groups requiring enhanced pre, peri post-operative care at admission. this implies that information available admission could facilitate prognostication, planning, bed management aversion, as well informing discussions between clinical teams patients about recovery.

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:

Perioperative medicine for the Older Patient undergoing Surgery (POPS) is an established, evidence based medically led service across many Trusts. However, with consultant workforce constraints, the aim was to determine if an alternative ACP led model of care, with consultant geriatrician oversight, delivered the same benefits.

Method:

• A senior nurse, with POPS expertise, was seconded for one year to oversee the project. NHS Elect network supported, from February to October 2022, with monthly meetings, data analysis and facilitated shared learning from other sites

• An ACP from the medical frailty service worked alongside to develop perioperative expertise and allow future sustainability.

• Geriatrician with interest in perioperative care was appointed in May 2022 and contributed to service development and delivery.

• Patients with frailty were identified proactively through the daily board round and surgical handover. Those identified were reviewed using a comprehensive geriatric assessment. Medical advice was sought as required.

• Prospective data collected on all patients seen

Results:

Patient data analysed (n=404) from January to August 2022. Length of Stay (LOS) reduced for patients over 65 years of age living and with frailty by 4 days (17 to 13 days). Variation in LOS reduced from 46 to 26 days. Readmission rate was 6% (26/404). Average Trust rate of 11%. Introduction of POPS improved the National Emergency Laparotomy Audit geriatric specialist input from 10% in Q1 2020/2021 to 91% of patients in Q4 2021/22.

Unmeasured benefits include upskilling of nursing staff on the wards identifying frailty and discharge planning. Shared decision making influencing non-surgical treatment for patients for better outcomes. Reduction in calls to medical registrar post POPS introduction.

Conclusion:

This pilot successfully demonstrated the role of ACP in service design, care coordination and timely medical review to deliver a reduction in length of stay and readmission rate.

Introduction: Living with frailty is a risk factor for increased short and long term mortality. We aim to describe the uptake of escalation of care and resuscitation status discussions in frail older patients admitted to general, colorectal, and upper gastrointestinal wards.

Methods: Prospective observational study of all patients aged 65 years and over admitted under general surgery 11th February to 11th March 2022 and a second cohort of patients hospitalised between 1st and 31st of October 2022. We scored frailty using the clinical frailty scale (CFS) and identified escalation of care discussions through review of electronic patient records.

Results: We included 196 patients, average age 75.9 (65-97), 90 (46%) females and 106 (54%) males, 107 (54.6%) emergency (EM) and 89 (45.4%) electives (EL). 64 (32.7%) patients were frail (F = CFS ≥5) and 132 (67.3%) non frails (NF = CFS≤ 4). Length of stay was 14 days, 14.9 in F and 11.4 in NF, 14 EM and EL 18.3. Surgery was carried out in 14 (25.9%) F and 33 (40.7%) NF. In total 6 patients died in hospital: 4 F (7.3%) and 3 (3.7%) NF individuals, one without resuscitation decision. Resuscitation discussions had in 20 (36.4%) F vs 4 (4.9%) NF, 19 (16.8%) EM and 6 (6.7%) EL. Percentage of discussions increased in frail patients from 24% to 42.4% overall, and 92% non-frail patients were not offered discussion.

Conclusion: 1 in 3 patients in our cohort of older adults hospitalised under surgery were frail. Higher frailty scores were associated with increased in-hospital mortality. 30% frail and 8% non-frail older patients underwent resuscitation discussions. We advocate early proactive discussions of resuscitation status and advance care planning in high risk surgical patients.

Introduction

About 300,000 people living with Frailty undergo operations annually. Current evidence suggests that comprehensive geriatric assessment (CGA) pre-operatively enhances shared decision making (SDM), equity of access to surgery, length of stay (LOS) and mortality. Multiple NCEPOD reports, the National Emergency Laparotomy Audit (NELA) and National Hip Fracture Database (NHFD) programs have highlighted the unmet need in caring for these patients. Our aim was to introduce a novel combined Geriatrician/Anaesthetist pre-assessment clinic to provide better SDM and perioperative optimisation to improve outcomes for elective colorectal surgery.

Method

We performed combined CGA and Anaesthetic pre-operative assessment in patients undergoing elective colorectal surgery aged ≥65 years between July 2021 to August 2022. Data including Clinical Frailty Score (CFS), LOS, Type of surgery, P-POSSUM Score, 30-day mortality and 90-Day mortality were analysed.

Results

We reviewed 48 patients in 14 months. 69% patients underwent surgery and 27% declined after a comprehensive SDM process. The median age of operated patients was 80 (65-94) compared with 74 in 2020-21. 58% of patients operated were over 80, compared to 24% in 2020-21, prior to clinic inception. The median CFS was 4. 55% of patients had a LOS ≤7days (73% in 2020-21), 32% was 8-14days (18%) and 13% was >14days in hospital (9%) respectively. 32% had a P-POSSUM score of ≥5% whereas 10% had a score of >15%. The overall 30-day and 90-day mortality rates for our cohort was 0%, compared with 0% and 3% respectively in 2020-21.

Conclusion

Our data suggests that our clinic has enhanced equity of access to curative colorectal cancer surgery for older adults. 90 days mortality remained 0% owing to excellent patient selection and enhanced perioperative care. Importantly, 27% of patients declined surgery after an extensive process of SDM. Further work needs to be completed assessing decision regret and satisfaction with SDM (SDMQ9).

Introduction
As part of a planned care initiative undertaken with the Bevan Commission to improve surgical waiting lists in Swansea Bay we contacted patients on the waiting list for a cholecystectomy, undertook frailty screening and invited those with frailty markers to undergo clinic based geriatric assessment . Clinical governance requires patient input into the setup of any service (1). A patient satisfaction survey following clinic, along with a patient focus group were conducted. Methods 27 patients completed an online survey regarding their experience at clinic. 8 patients attended the focus group, all had attended clinic. Those we hadn't seen face to face declined or were unable to attend. The group was run by a team who were independent of the project, recorded on teams and transcribed. Results Post clinic survey 100% (27/27 patients) knew why they were invited to clinic, >80% found it useful and 92% felt their health needs were covered. The focus group highlighted a number of issues regarding frustration with administration of the list, feeling ‘forgotten about’ and as though they ‘didn’t matter’. They attended multiple pre-op assessments but had no communication, they felt our clinic was their first meaningful clinical contact.

Conclusions

Patient reported experience is a key part of service development however bias is often evident. (2) It was clear that patients valued the face to face aspect of clinic and the focus group. One clear theme from our focus group highlights administration and communication which are potentially modifiable within our resources. A theme of desiring patient choice and continuity of care between specialities was evident, which we hope to address with a unified pathway for perioperative care. 1) Clinical governance - GOV.UK (www.gov.uk) 2) The use of focus group discussion methodology: Insights from two decades of application in conservation, T O Nyumba. 2018

Introduction
The NHS backlog in Elective Surgery are a subject of societal concern and political pressure. Over 6,400 patients >65 yrs are currently awaiting surgery at Swansea Bay. What role, if any, can geriatricians play in improving patient and organisational outcomes? Intervention We wrote to all 258 patients on the Cholecystectomy waiting list > 65 yrs with a letter explaining the project and a patient experience questionnaire. An attempt to contact all patients by telephone was made with an intention to ask questions about their health, activities of daily living and frailty and complete a CRANE questionnaire. Patients who were identified as frail either by the CFS or HFRS, with complex co-morbidities and any concerns raised by the CRANE questionnaire were offered a clinic appointment. Clinic outcomes were prospectively recorded. Patients who attended clinic were asked about their experience through another questionnaire and focus groups. Results from phase A (January 2023) The waiting list had 258 patients, 193 (75%) patients spoken to on telephone. 32 of these have been seen clinic to date with another 11 due to attend. These clinics have identified spinal wedge fractures, abdominal aortic aneurysm requiring surveillance, potential malignancy (referred for imaging), possible new diagnosis of RA, optimisation of cardiac drugs (5 patients), polypharmacy management, hyponatraemia; amongst others with several patients referred to other frailty or specialist services. This process was able to reduce the waiting list by 36 patients or 14% of those >65yrs on the waiting list. The focus groups and questionnaires showed patients valued the service.

Conclusion
This project demonstrates that proactive management can yield a substantial benefit, both in optimising patients experience and health outcomes and by producing an organisational benefit by reducing the overall waiting list size and allowing anaesthetic led perioperative clinics to function more efficiently.