Jugdeep Dhesi & Jason Cross, Proactive care of older people

undergoing surgery (POPS), Dept of Ageing and Health,

Guy’s and St Thomas’ , London

Average Number of New Cases Per Year and Age-Specific Incidence Rates per 100,000 Population, UK

The NSQIP top 7 EGS Intestinal obstruction, perforation, ischemia, Gallbladder disease, Gastroduodenal ulcer disease, Diverticulitis, Abdominal wall hernia

Mean age 67 years Approx 40% >70 years

0

1,0

00

2,0

00

3,0

00

4,0

00

5,0

00

Patie

nts

<31 31-40 41-50 51-60 61-70 71-80 81-90 >90

McCoy J Trauma Acute Care Surg. 2015;78(5):912-8;

Common postop complications Incisional surgical site infection (6.7%) Pneumonia (5.7%) Myocardial infarction, Stroke, Major bleeding Organ/space surgical site infection, Thromboembolic process, Urinary tract infection

McCoy J Trauma Acute Care Surg. 2015;78(5):912-8;

Incisional surgical site infection (6.7%) Pneumonia (5.7%) Myocardial infarction, Stroke, Major bleeding Organ/space surgical site infection, Thromboembolic process, Urinary tract infection

30day mortality 1 year mortality 5year mortality

with without with without with without

Any complication 13.3% 0.8% 28.1% 6.9% 57.6% 39.5%

Thompson Arch Surg 2003, Hamel, JAGS 2005;53:424-9

McCoy J Trauma Acute Care Surg. 2015;78(5):912-8;

Incisional surgical site infection (6.7%) Pneumonia (5.7%) Myocardial infarction, Stroke, Major bleeding Organ/space surgical site infection, Thromboembolic process, Urinary tract infection

30day mortality 1 year mortality 5year mortality

with without with without with without

Any complication 13.3% 0.8% 28.1% 6.9% 57.6% 39.5%

CONCLUSION: Of the potential postoperative targets for quality improvement, pneumonia, myocardial infarction, stroke, and major bleeding have the strongest associations with subsequent mortality. Since pneumonia is both relatively common after emergency surgery and strongly associated with postoperative death, it should receive priority as a target for surgical quality improvement initiatives.

Copyright © 2016 American Medical

Association. All rights reserved.

Percentage of Patients Discharged to Postacute Care (PAC)

Facilities According to Age, Number of Postoperative

Complications, and Functional Status

…as well as on patient reported outcomes

Lawrence J Am Coll Surg 2004 JAMA Surg. 2016;151(8):759-766

Barnett, Lancet 2012

• 4 in 5 high risk patients to general ward

• Management on wards by junior staff

• Poor recognition of medical problems

• Reliance on on-call staff • Multiple medical team

involvement

Assessment of risk

Modification of risk

Care in the right place

Optimal management of complications

Documentation of outcomes that matter

Shared decision making

Right team at the right time in the right place Preoperatively

Screening, assessment and investigation

Optimisation

Shared decision making (Advanced care planning)

Intraoperatively

Timely, tailored surgical and anaesthetic care

Right destination

Postoperatively

Proactive identification & standardised mx of comps ▪ Surgical, medical, rehabilitation and discharge planning

70% describe inadequate training in mx of complex older patients

85% often need medical advice

68% difficulty in accessing medical support

92% felt need for closer collaboration

Ideal components of a collaborative geriatric medicine-surgical service

Medical Optimisation 79%

Mental Capacity Assessment 71%

Quantifying Medical Risks of Surgery

64%

Managing Medical Complications

87%

Communication with patients and families

38%

Post-op rehab/ discharge planning

92%

Shipway J Surg Ed 2015

‘Routine daily input from medicine for older people should be available to elderly patients undergoing surgery and is integral to inpatient care pathways in this population’ An Age Old Problem 2010

‘Geriatricians play a key role in helping to evaluate

and manage risk and promoting shared decision approaches. Effective MDT working to bring together physician, surgeon, anaesthetist and geriatrician is critical’ Access All Ages 2012

‘Geriatricians should work more closely alongside teams both inside and outside hospital’ RCS Nov 2014

Surgical OP/PAC Referrals • Screening criteria • ‘Medically unfit’ • Support required for decision making

Pre-op CGA Consultant CNS OT Social worker

Hospital Admission Ward rounds MDMs Case conferences Education and training

Post Discharge Intermediate Care Primary care Social care Specialist clinics

Liaison Patient Surgical team Anaesthetists GP Community service

The GSTT POPS model

Proactive care of older people undergoing surgery

Parameter Screening Assessment

Physiological status

Reported exercise tol

METS

Multimorbidity Disease specific tools

Frailty Simple question EFS

Cognition 4AT MoCA

Nutrition MUST Dietitician

Social/function Structured history

Barthel, NEADL

Diagnosis

Management decision

Surgery (40%) Procedure Medical

As IP

(25%)

<48 hrs

(15%) Trauma Acute Care Surg 2013 JAMA 2016, BJS 2013

Risk assessment CROM

PROM Shared decision making

Process

Preoperative care (inc conservative management)

Medical optimisation

Fluids, AKI, delirium, sepsis, drug management

Communication with patient/carers

Capacity, consent, shared decision making

Advance care planning – ceilings of care

Communication across teams to optimise mx

Focus on reducing risk of predictable comps

Ensuring proactive approach to diagnosis & mx

Ensuring continuity of postoperative care

NEWS/Medical/geriatric complications Psychological health mx Goal setting/rehabilitation Discharge planning

POC, ICT, care home

Communication

Patient

Family/carers

Primary/community care

Nursing handover Surgical handover Joint ward rounds MDTMs Physical presence

Partridge, Age & Ageing 2014

NELA data shows that for patients ≥70 years 10% assessed postop by EM 1/5 hospitals 0% assessed by EM

Ensuring a clear focus

Courtesy of

Dr Vilches-Moraga

…with shared documentation…

Courtesy of

Dr Vilches-Moraga

…resulting in…

Before February 1st 11 Median

After February1st 7 Median

Length of stay (mean 13 median 9)(↓ 4 days) 30 day readmission rate (↓ 13.2%) Times seen by non surgical doctor (↓ 18%) Medication reviews (↑51%) Coding/recognition complications ↑↑ Coding comorbidities ↑↑

Courtesy of

Dr Vilches-Moraga

Chelmsford

Imperial

Belfast Edinburgh

Nottingham

Guildford

Southmead

North Tees Salford

GSTT, London

Cambridge

Kings, London

Oxford

Portsmouth

Royal Free, London

Derby

Leicester

(Ann Surg 2016;264:437–447)

76 year old gentleman Incarcerated hernia Requires emergency surgery Discussed at EGS handover meeting

Concerns raised

Nursing home resident

Patient confused ‘has dementia’

Would palliative care be more appropriate

CGA on the ward PMH

Confused and agitated

Atrial fibrillation on warfarin

HTN

Osteoarthritis / multiple joints / severe

Collateral History from family / care home

▪ Residential care

▪ MCI

▪ Independent with personal cares

Confusion

AF

Warfarin

Anaemia

Immobility

High Surgical risk

Consent

Delirium pathway / advice

Plan detailed / IV Digoxin

Discussed / Vitamin K

Haematinics obtained

Air mattress

Best interest discussion Family involved Documentation Consent form 4 Proceeds to surgery

Delirium NOT dementia Mild cognitive impairment

Rate controlled

INR high (2.4)

Hb 11 / stable for surgery

High risk PA breakdown

Morbidity 81%, Mortality 14%

Lacks capacity (delirium) Good QOL Living independently

Issue Assessment Intervention

Ileus

AF

AKI

Delirium

Functional decline

Dietetic review TPN

IV Digoxin /Advice / pathway

Fluid resus / Pathway followed

Haloperidol (not used) / pathway

Early therapy Rehab referral

Albumin dropping NMB prolonged

Fast rate

Baseline 3a 20% increase in Cr

Acute / multi-factorial

Global weakness Deconditioned

Issue Assessment Intervention

Delirium resolved day 5 post op 14 day IP stay Early therapy input facilitates d/c to rehab unit 4 week stay at rehab – back to residential care

89 year old lady / on admissions

ward

Proactive case finding with assessment

Multimorbidty

Abdominal pain

No surgical issues / requesting transfer

to elderly care

Nurses report patient has care

needs / daughter struggling

Constipation

Frail with functional

Social care

Laxatives prescribed / advice

OT referral and assessment

Discussed / advice / community ref

Faecal loading on imaging

Risk of falls / increased care

Living with daughter / requesting care input

Issue Assessment Intervention

Proactive case funding with holistic

assessment

Admission avoidance with

appropriate community referral

Delivering evidence based clinical practice

Do we have the evidence to inform practice ?

How do we translate into routine care?

Education and training

Is our workforce ready? Which workforce?

How do we ensure they are?

Research and QIP

Making it relevant to the ‘messy’ patient, the context and the workforce

NELA, EBPOM www.popsteam.co.uk British Geriatrics Society POPS SIG (www.bgs.org.uk) POPS annual education conf (March, register via BGS) POPS Clinical Fellow posts (advertised every April) RCoA Perioperative medicine programme UCL Perioperative Medicine MSc Age Anaesthesia Association (May 2017) jugdeep.dhesi@gstt.nhs.uk

Clinical services

Patient not specialty centred services

Whole system reorganisation (cultural change)

Funding (CCGs)

Workforce/education/training

Surgeons, anaesthetists, physicians, geriatricians

Alternative workforce – ANP

Research

Patient centred, new methodologies

Cognitive impairment Functional impairment Undernutrition Frailty

Three way between geriatricians, surgeons, anaesthetists

Health care professionals across disciplines

Surgical teams, nursing staff, therapists

e.g. AF, delirium, catheter related issues, rehabilitation

Patient and carers

e.g. delirium, rehabilitation

Date of download: 9/26/2016 Copyright © 2016 American Medical

Association. All rights reserved.

From: Postacute Care After Major Abdominal Surgery in Elderly Patients: Intersection of Age, Functional

Status, and Postoperative Complications

JAMA Surg. 2016;151(8):759-766. doi:10.1001/jamasurg.2016.0717

Univariable and Multivariable Estimates for Odds Ratio (OR) of Discharge to Postacute Care (PAC) Facility According to Patient

Age, Number of Postoperative Complications, and Functional Status

Figure Legend:

Date of download: 9/26/2016 Copyright © 2016 American Medical

Association. All rights reserved.

From: Postacute Care After Major Abdominal Surgery in Elderly Patients: Intersection of Age, Functional

Status, and Postoperative Complications

JAMA Surg. 2016;151(8):759-766. doi:10.1001/jamasurg.2016.0717

Percentage Discharged to Each Postacute Care (PAC) Setting for Functionally Independent and Dependent Patients by Number of

Postoperative Complications

Figure Legend:

“With an ageing population

there are more patients who

we’re now being able to offer

surgery to that previously we

weren’t. What that means is that

the volume of the workload is

increasing but, also, the

complexity of the workload that

we’re undertaking is getting

greater. And ... their

expectations are very high.”

(Interview participant)

Wilson Br J Anaesth 2010;105:297 Roche BMJ 2005;331:1374 Makary 2010 Partridge Age & Ageing 2012;41:142

Day % of comps

Examples

<1 17% Hypotension, MI

1-3 43% CCF, PE, resp failure

4-7 17% LRTI

8-30 24% Sepsis, CVA

Day % of deaths

<1 8%

1-3 8%

4-7 11%

8-30 73%

Thompson Arch Surg 2003, Finlayson J Surg Res 2015, Moonesinghe BJA 2014

27.7 million EGS admissions Over 10 yr period admissions increased by 27.5% 30% required surgery Mean age 58.7yrs

J Trauma Acute Care Surg 2014;77(2):202-8.