BGS Position Statement: Older patients undergoing emergency laparotomy
This position statement sets out the British Geriatrics Society recommendations for assessment of older patients being considered for emergency laparotomy.
An increasing number of older people are undergoing emergency laparotomy. This is the result of an ageing population, advances in surgical techniques, improved education and training in perioperative medicine, benchmarking and publication of standards and outcomes by professional stakeholders, and quality improvement programmes. The median age of patients entered into the National Emergency Laparotomy Audit (NELA) database over years 1-4 was 67 years, with 57% aged 65 years or over.
NELA patients aged 65 years or over have worse clinical outcomes compared to their younger counterparts. These include longer length of hospital stay (median 15.2 days vs 11.3 days) and higher 30-day and 90-day mortality (15.3% vs 4.9% and 20.4% vs 7.2%). In addition, there is an association between frailty, which is known to increase with age, and increased 90-day mortality following emergency laparotomy (aOR for patients who were mildly frail and moderately/severely frail was 3.18 and 6.10), 1-year hospital visits (7.2 vs 2.0) and care level (aOR for an increase in care level was 4·48 for vulnerable patients, 5·94 for those mildly frail and 7·88 for those moderately or severely frail, compared with patients who were fit).
Geriatrician-led comprehensive geriatric assessment and optimisation (CGA) has been shown to reduce mortality, length of hospital stay, postoperative medical complications and improve coding of complications and interventions in older surgical patients. Acknowledging this evidence, and in view of the negative impact of frailty on postoperative outcomes, there has been an increase in geriatrician input to emergency laparotomy patients over the first four years of NELA. Despite this increase, NELA data reports only one in five patients aged >65 years presenting for emergency laparotomy undergoing frailty assessment, and just one in three of these being reviewed by a geriatrician.
In order to improve care in patients undergoing emergency laparotomy through access to frailty assessment and comprehensive geriatric assessment and optimisation, the BGS recommends that:
- All patients being considered for, or undergoing emergency laparotomy aged 65 years or more, should undergo a frailty assessment using the Clinical Frailty Scale.
- All patients being considered for emergency laparotomy aged ≥ 65 years with a Clinical Frailty Score ≥5 (or aged ≥ 80 years with any frailty score) should receive geriatrician-led multidisciplinary comprehensive geriatric assessment (CGA) within 72 hours of admission to a ward or step down from critical care to a ward.
- The provision of geriatric medicine support should be consultant-led throughout the patient pathway and integrated in the perioperative clinical care pathway.
- Routine data collection in patients aged over 65 years being considered for or undergoing emergency laparotomy should include cognitive and functional status and discharge destination.
- Older patients undergoing emergency laparotomy – observations from the National Emergency Laparotomy Audit (NELA) Years 1-4. Age and Ageing (in press)
- Fifth Patient Report of the National Emergency Laparotomy Audit. NELA Project Team. Fifth Patient Report of the National Emergency Laparotomy Audit. RCoA London 2019
- Parmar LK, Law J, Carter B et al on behalf of the ELF study group. Frailty in older patients undergoing emergency laparotomy. Results from the UK observational Emergency Laparotomy and Frailty (ELF) study. Annals of Surgery 2019. doi: 10.1097/SLA.0000000000003402.
- Carter B, Hewitt J, Parmar KL, et al on behalf of the ELF study group. Association between preadmission frailty and care level at discharge in older adults undergoing emergency laparotomy. Br J Surg. 2020 Feb;107(3):218-226. doi: 10.1002/bjs.11392.
- Lee KC, Streid J, Sturgeon D et al. The Impact of Frailty on Long-Term Patient-Oriented Outcomes after Emergency General Surgery: A Retrospective Cohort Study. J Am Geriatr Soc. 2020. doi: 10.1111/jgs.16334
- Shipway D, Koiza L, Winterkorn N et al. Embedded geriatric surgical liaison I associated with reduced inpatient length of stay in older patients admitted to gastrointestinal surgery. Future Healthcare Journal 2018; 5 (2): 108-16