Perioperative care for surgical patients

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.

Aims

Understanding patients’ wishes regarding CPR before surgery is crucial. This study aims to assess the impact of a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decision on anaesthetists' actions during theatre.

Methods

We used WhatsApp, to present a scenario of an 83-year-old with ischemic heart disease, cognitive impairment, and an acute hip fracture. Anaesthetists were asked how they would handle various intraoperative events and whether a prior DNACPR decision would influence their actions.

Results

A total of 74 UK anaesthetists, all but one of them consultants, completed the anonymous survey. A surprising number N=27, (37%) of respondents indicated that prior knowledge of a DNACPR decision would have altered their preparedness to anaesthetise the patient.

Despite a pre-existing DNACPR decision N=68 (92%) stated that they would attempt electrical cardioversion if a patient became hypotensive with a regular broad complex tachycardia, as would N=65 (88%) in response to ventricular fibrillation during surgery. N=36 (49%) would initiate chest compressions in theatre if patient failed to respond to electrical cardioversion, but only N=2 (3%) would continue with intubation, ventilation and discussion with critical care if the patient failed to respond to three cycles of compressions and cardioversion.

Conclusion

It is important for anaesthetists to discuss the nuances of different elements of CPR as part of patients’ pre-operative assessment, as it is much more likely to be successful in theatre than in the ward or community settings that most DNACPR discussions will consider.

Raising the topic of resuscitation can lead to anxiety among patients and their families, Our study has shown that most anaesthetists will set aside a DNACPR decision anyway if problems arise in theatre.

Introduction

It is estimated that by 2030, 1 in 5 people undergoing surgery will be over the age of 75. These patients are often frail with a higher risk of post-operative complications including delirium. They are also more likely to have multiple co-morbidities and an increased anticholinergic burden due to polypharmacy. Anticholinergics are often linked with an increased risk of dementia, delirium, and falls.

Methods

This retrospective cohort study analysed anonymised data from 50 emergency general surgery patients the POPS team reviewed between December 2023 and February 2024 at the University Hospital of Wales. Objectives included measuring ACB (anticholinergic burden) scores on admission and discharge and evaluating subgroup analysis such as the relationship between CFS (clinical frailty score), known or new cognitive impairment and ACB score.

Results

66% of patients were female, the median age was 82 and median CFS was 6. 32% had delirium on admission, 40% had a Charlson comorbidity score of 5 or 6 and the median length of stay was 17 days. 74% of patients had no known cognitive impairment while 8% had dementia on admission. Small bowel obstruction (34%) was the commonest diagnosis and emergency laparotomy was the most common surgery type (56%). The median number of medications on admission and discharge was 9. Median ACB score on discharge reduced from 1.5 to 1 and 86% showed a stable or reduced ACB score. There was a positive correlation between frailty and delirium as well as frailty and ACB score. The correlation between delirium and ACB score was unclear. 

Conclusion

CGA by the POPS team reduces the anticholinergic burden of this patient cohort. Increasing frailty appears to be associated with an increased risk of delirium and ACB score on admission, however the relationship between anticholinergic burden and delirium is unclear in this small patient cohort. 

Introduction

There is a high prevalence of diabetes in patient populations undergoing Vascular Surgery. Appropriate and responsive management of diabetes in the perioperative setting is critical for reducing morbidity and perioperative complications e.g. diabetic emergencies, poor wound healing, delirium. The aim of this project was to review current practice for perioperative management of older people with diabetes against guidance outlined by the Centre for Perioperative Care (CPOC) on a regional vascular surgery ward.

Methods

A retrospective observational evaluation design was conducted from May-June 2024. Data were collected for patients all aged >60years with a pre-admission diagnosis of diabetes admitted to the ward in this period. Standards of care were derived from CPOC guidance. Data were collated and analysed using descriptive statistics.

Results

28 patients were included (20 male, 8 female). The mean age was 72 years. 86% (n=24) had Type 2 Diabetes and the remainder had Type 1. 82% (n=23) were emergency admissions and 93% (n=26) had surgery at some point in their admission. Only 38% (n=10) were prioritised as first patient on operating lists. There was mixed concordance with guidance on administration of oral diabetes medication perioperatively. However, all patients on SGLT2 inhibitors had these withheld appropriately. There was inconsistency in the frequency of capillary blood glucose (CBG) monitoring with variable responses to episodes of hypo and hyper-glycaemia and variable rate insulin prescriptions were not consistently utilised when indicated.

Discussion

This study has highlighted several areas for improvement of the perioperative management of diabetes in older vascular patients. The next stage of this work will involve a multi-component quality improvement initiative to provide education and support for all healthcare professionals involved in caring for this patient group.

Introduction NELA (National Emergency Laparotomy Audit) and British Geriatric Society guidance states patients aged ≥ 80 years, or ≥ 65 years and frail, should have a comprehensive geriatric assessment (CGA) from a perioperative frailty team within 72 hours of admission or critical care step-down. Patients aged ≥ 65 years represented 55.3% of those undergoing emergency laparotomy; and frailty doubled the mortality rate in this group, but post-operative geriatrician review was associated with reduced mortality (NELA project team, RCoA, 2023).

Method The Perioperative Care of Older People Undergoing Surgery (POPS) service was established in our trust in October 2020 in response to NELA recommendations. Over three years our service has grown from one whole-time equivalent geriatrician and one 0.6WTE nurse practitioner, to a team of six, adding a clinical nurse specialist, physician associate, junior clinical fellow and memory link worker. With staff training, all surgical admissions aged ≥ 65 are screened for frailty to enable identification of patients who will benefit most from CGA and subsequent support during the admission. An internal database was established to prospectively capture patient demographics and outcomes.

Results Added team capacity has allowed us to see more patients year-on-year, including more patients not requiring laparotomy. Median frailty score and age have increased from 5 to 6, and 77 to 80 years, respectively, without a significant change in median length of stay. Mean trust compliance with NELA guidance around geriatrician review has improved significantly from 3% to 88% post POPS establishment.

Conclusions Introduction and expansion of a POPS service at our trust has resulted in an increased number of patients receiving geriatrician-led CGA, though meeting 100% of NELA standard likely requires a second consultant or cross-cover arrangement. However, we are reviewing more patients, who are on average older and frailer, without an increase in length of stay.

BACKGROUND:

At Sheffield Teaching Hospitals, an Older Surgical Patients Pathway (OSPP) began in 2014, introducing a Consultant Geriatrician working in a liaison role within General Surgery.

BGS reports in its 'Case for more Geriatricians' that the number of people aged over 85 is set to double by 2045. An increase in patient age and complexity is already being seen across a range of services including admissions to general surgery.
We look to characterise this increase to make the case for an expansion of the OSPP service.

METHODS:

1. We identified patients aged over 75 admitted under General Surgery in July to December of 2014 and 2023.

2. We analysed these patients for their 30 day mortality, theatre episodes, length of stay and Hospital Frailty Risk Score (an automatic calculation from hospital records using a weighted count of frailty- related diagnoses).

RESULTS:

The number patients aged over 75 admitted in the 6 months from July to December has increased from 646 in 2014 to 847 in 2023.

The increase in this age group is associated with an increase in the number of patients with a hospital frailty score greater than 20 (from 18 to 69) and those with a length of stay longer than 15 days (from 93 to 124).

Additionally, between 2014 and 2023 patients aged over 75 had an increase in total theatre episodes (from 107 to 125) and 30 day mortality (from 48 to 63).

We propose that this increase in number and complexity of older patients supports the expansion of OSPP Service, for example by the addition of a ST3+ level doctor.

Pain management is essential for quality care in all inpatient settings, where pain may stem from trauma, acute medical conditions, or surgery. Patients with cancer or chronic pain often experience acute exacerbations or may develop acute pain related problems.

This audit aimed to assess adherence to best practices in pain management for hospitalized patients and compare current pain management services in UK.

We conducted an 8-week audit at Derriford Hospital, Plymouth, using patient records from seeEHR. We assessed the effectiveness, safety, and immediacy of pain relief actions and whether patients with complex pain were referred to the Integrated Pain Service (IPS). We also examined if discharge summaries detailed the analgesia provided. Additionally, we surveyed medical staff (doctors and nurses) on their pain management knowledge.

The audit included 50 patients: 32 (64%) from geriatric wards, 10 (20%) from oncology, and 8 (16%) from haematology wards. Patients on at least step 2 of the pain ladder were included. Results showed that analgesia was 74% effective and 26% ineffective. Analgesia was 100% safe, with no antidote used. Immediate action was taken in 96% of cases and a delayed action in  4% cases.

However, none of the discharge summaries (0/50) mentioned pain relief provided, and no patients (0/50) were referred to IPS. The medical staff survey revealed that 50% were unsure when to refer to pain teams. All doctors knew the pain ladder.

The audit indicates timely, effective, and safe pain relief but highlights the need for improved referral practices to IPS for complex pain and detailed analgesia records in discharge summaries. Educating staff on hospital pain management protocols is crucial.

This project is significant for all healthcare professionals and enhances patient care quality. Recommendations were made after the first cycle, and data collection for the second cycle is ongoing.

Aim

Emergency laparotomy is associated with a high mortality and morbidity. Early identification of high-risk patients allows for timely involvement of other members of the multidisciplinary team, including care of the elderly (CoE) specialists. This improves the likelihood of a successful post-operative recovery. This study investigated the adherence to the NELA guidelines regarding the use of the clinical frailty score and input from the CoE team.

Methods

A prospective analysis was conducted, collating data on patients undergoing an emergency laparotomy in one centre in East London. Data collected included the date of admission, findings at operation, clinical frailty scores, and input from CoE team members.

Results

16 patients had an emergency laparotomy during May 2024. Ages ranged from 44 to 92. 11 patients were aged 65 years or older but none had a clinical frailty score within 4 hours of admission, as per NELA guidelines. 6/11 (55%) were reviewed post-operatively by the CoE team during their inpatient stay. These findings were reported at the monthly morbidity and mortality meeting. Our interventions included a surgical teaching session, posters in the department and a stamp for CoE review kept in CEPOD theatre for use post-laparotomy. The second cycle showed significant improvement with a 33% increase in CFS and a 12% improvement in care of the elderly reviews.

Conclusions

In conclusion, it is known that older patients have a poorer post-operative outcome, which is improved by perioperative CoE input. With this audit, we improved awareness within our department regarding older, frail patients and began to see a change regarding assessing patients mobility and need for CoE input. However, we are still not doing this for all of our patients so there are still improvements to be made. Interestingly, in terms of interventions, we found that teaching and discussion had the greatest impact.

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.