Proactive care of older people undergoing surgery (POPS service)

Background

The rate of older people undergoing surgical procedures is increasing faster than the rate of population ageing [4]. Surgery offers mortality and symptomatic benefits in older people [5-7] but postoperative outcomes are worse than they are for younger patients [8-12]. Medical co-morbidities and geriatric syndromes (such as cognitive impairment, postoperative delirium and frailty) adversely impact postoperative outcomes [13-19] and increase length of stay (LOS) [10, 15]. Current preoperative assessment does not proactively recognise or optimise these common issues in order to reduce postoperative risk. This leads to patients being inappropriately declined surgery, cancellations, poor postoperative outcomes and a protracted length of hospital stay for the older surgical patient.

The Comprehensive Geriatric Assessment (CGA) is an established approach which identifies medical, psychosocial and functional needs and optimises them by using a clearly defined plan for management and follow up. [20] CGA improves survival and function [20] and yet is relatively understudied in the preoperative context within the older surgical population. Furthermore, the structured involvement of geriatricians in the peri- and postoperative period is also effective in reducing adverse postoperative outcomes in the older patients. [21]

Challenges

• The key issues in providing care to the older person undergoing surgery are:
• Identifying which older patients would benefit from preoperative assessment (based on the CGA) instead of standard care.
• Providing optimal management of medical conditions prior to surgery.
• Predicting postoperative complications and attempting to mitigate their development during the preoperative period.
• Providing timely interventions from a specialist team for the older person, on the surgical wards.
• Encouraging the identification and management of geriatric syndromes by the surgical teams.

A pilot study, examining the feasibility of preoperative CGA intervention for older surgical patients, found that older patients undergoing elective surgery had high levels of modifiable preoperative co-morbidity, but rarely received geriatric or multidisciplinary team input before surgery. Twenty percent of those aged 65 and over, had their surgery delayed for preventable medical reasons and there was a high incidence of significant postoperative problems delaying discharge. Opinion was also gathered from ‘front-line’ workers (e.g. surgical nurses, GPs) and patients about the potential value of a preoperative intervention service.

Following this scoping work, the POPS pilot was commenced. The POPS team comprised a consultant geriatrician, nurse specialist in older people, occupational therapist, physiotherapist and social worker. A questionnaire was posted to patients aged 65 years and over, awaiting surgery and those highlighted with potential risk factors, known to lead to poor postoperative outcomes, were invited to clinic. Direct referrals from local consultants and GPs were also encouraged.

Preoperatively, the patient was screened using a CGA, based on validated screening methods or tools. Identified problems were then managed to optimise the patient.  Education on exercise, nutrition and pain management was provided.  Therapy input involved anticipation of needs at hospital discharge and proactive provision of equipment.

Postoperatively, the geriatrician and nurse reviewed patients on the surgical wards providing direct intervention and staff education in early detection and treatment of medical complications, delirium, early mobilisation, pain management, bowel-bladder function, nutrition and discharge planning. Following discharge, the POPS team provided a follow-up therapy home visit in those with functional difficulties and outpatient clinic review in those with on-going medical problems. Thereafter, patients were linked with pre-existing services as needed, for example falls programmes, continence service, outpatients and the voluntary sector.

Two cohorts of older elective orthopaedic patients were studied. One was referred to the POPS service the other received routine preoperative care. Despite higher comorbidities in the POPS cohort they had reduced medical complications (pneumonia 20 per cent vs 4 per cent [p=0.008], delirium 19 per cent vs 6 per cent [p=0.036]), multidisciplinary issues (pressure sores 19 per cent vs 4 per cent [p=0.028], delayed mobilisation 28per cent vs 9per cent [p=0.012]) and LOS (4.5 days) [22].

The project was funded by a grant from the Guy’s and St Thomas’ Charity (formerly the Charitable Foundation).

Solutions: the current service

Following the results of this research study, the POPS service was substantively funded. The current POPS team includes 1.6 geriatricians, 2 clinical nurse specialists, occupational therapist, social worker and an administrator.

The service is now embedded into the pre-assessment pathway, assessing 800 new patients preoperatively annually. POPS lead ward MDMs and attends joint medical-surgical ward rounds in most surgical specialities in the Trust. The team annually case manages 1200 postoperative elective and emergency inpatients. In addition, POPS has been instrumental in setting up daily pre-assessment clinic MDMs, where POPS provides, together with an anaesthetist, a forum for pre-assessment clinic nurses to present and discuss patients with unstable medical conditions, functional needs and issues regarding optimisation.

POPS also undertakes an active role in education, training, audit and research in order to underpin the ongoing development of the service with a robust evidence base and disseminate and translate effective management of issues affecting the older surgical population