Proactive care of older people undergoing surgery

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Proactive care of older people undergoing surgery

• POPS
• Jugdeep Dhesi, Consultant Physician
• Department of Ageing and Health,
• Guys and St Thomas Foundation Trust

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Introduction
Elective surgery in older people improves
function and quality of life Older people have
more post-op complications with longer length of
stay Primary preoperative risk factor is
comorbidity No evidence base for proactive
geriatric care in elective surgery patients
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Service design, development and evaluation

• NSF
• Standard 1, 2 ,3, 4 and 8
• MRC Framework for Complex Interventions
• Phase I
• Pre clinical development phase
• Phase II
• Modelling phase
• Phase III
• Exploratory trial
• Phase IV
• RCT

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Pre-clinical development phase
MRC I

• Are preoperative risk factors prevalent in this
  population?
• 83 65yrs Mean age 77 34 aged 80
• 38.5 2 risk factors for adverse post-op
  outcomes
• Functional dependency 42
• Cardiac disease 32
• Respiratory disease 23
• Neurological disease 14
• Postal questionnaire with social care domains

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• Does the screening tool identify patients at risk
  of operative problems?
• Low (0-1 risk factors) versus high risk(2risk
  factors)
• Longer LOS 11/25 versus 17/24
• Higher mortality 1/25 versus 4/24
• What post operative problems do older surgical
  patients have?
• Wound sepsis 25 Urinary retention 14
• Delirium 20 Constipation 14
• Cardiac arrhythmia 14 Pressure sores 12
• Pneumonia 12 NBM3/7 12
• Dehydration 8

MRC I
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And the money
MRC I
Mean length of stay 18.8 days 22.5
(1-119) Delayed discharge for non-medical reasons
31 complex social package intermediate care
assessment OT equipment
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MRC I

• What is current provision of preoperative
  multidisciplinary assessment in older people?
• What happens to older people who have elective
  surgery deferred for medical reasons?
• How do local GPs view the needs of older surgical
  patients?

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Surgical OP
Waiting list
Admissions office
GP
Procedure
Specialty clinic
PAC
Anaesthetist
Admission
Deferred
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Developmental phase conclusions
MRC I

• High prevalence of modifiable preoperative
  comorbidities
• No standardised process for surgical
  pre-admissions
• Risk of surgical cancellation related to medical
  concerns
• Significant post operative complications delaying
  discharge
• No routine geriatric/MDT input pre- or
  post-operatively

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POPS Hypothesis
MRC II

• Multidisciplinary preoperative intervention
• targeting potentially modifiable risk factors
• will improve post-operative outcomes

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Surgical Outpatients Proactive referral of all
patients aged 75 or over Patients at risk
according to screening criteria Patients
diagnosed as medically unfit
POPS Geriatrician Nurse Specialist OT Physiotherap
ist Social Worker
Pre-operative Multidisciplinary assessment,
treatment and liaison with surgical and
anaesthetic team Consultant assessment
Comprehensive medical management Specialist
Nurse Comprehensive assessment and patient/
carer education Physiotherapy Domiciliary
assessment, muscle strengthening (cardiovascular
training and breathing exercises) OT Home visit,
equipment provision Social Care Post-op
discharge planning
Hospital Admission Post-op consultant
geriatrician/ specialist nurse intervention Therap
y liaison Discharge planning Teaching/ training
Post Discharge Intermediate Care Links with
primary care/ social care Specialist clinic
follow up (falls etc)
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Targeting the right patient
MRC II
Direct access to POPS from all professionals
Uncontrolled BP (160/90) Recent MI, angina,
heart failure Poorly controlled diabetes Chronic
lung disease limiting activities Stroke,
recurrent falls, poor memory, dementia Poor
nutritional status (BMIloss) Needs help with any basic activity of daily
living Likely to need complex discharge
package Direct care pathway for patients deferred
from PAC Medically unfit Screening of waiting
list patients
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POPS Service
MRC II

• POPS Clinic (Health care assistant, Specialist
  nurse, Consultant)
• Scores GDS, AMT, Barthel, Pain
• Risks Nutrition risk, Waterlow
• Assessments Incontinence
• Measurements Obs, Wt, PVRV, PEFR
• Full history/examination
• Investigations MSU, Bloods, ECG
• Multidisciplinary meeting
• Pre-operative goal setting (medical, functional,
  social, psychological)
• Predictions for support required on discharge

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Documentation

• Surgical details
• Medical problems, drug list
• Scores and risks
• Social circumstances
• History, Examination, Investigations
• Pre/peri/post operative plan

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MRC II
POPS Service

• Home visits
• Preoperative therapy home visits (acute /
  community posts)
• Equipment provision with independent budget
• Preoperative social worker assessment of
  postoperative needs (care package, intermediate
  care)
• Surgical ward rounds
• Postoperative consultant geriatrician and nurse
  specialist rounds on surgical ward (medical
  input, discharge planning)
• Post-discharge
• follow-up with community liaison

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MRC III
Exploratory trial

• Before and after
• Evaluate consecutive POPS patients undergoing
  elective orthopaedic surgery
• Obtain clinical and process data for continual
  improvement of evolving service
• Prompt information to bid for mainstream funding

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Case-mix
Pre-POPS
Post-POPS
N54
N54
Age
75.06.1
74.1 6.2
female
53.7 (29)
66.7 (36)
Cardiac (AF/CCF/IHD)
33 (18)
55 (27)
Diabetes
13 (7)
20.4 (11)
Renal
3.7 (2)
22.2 (12)
Hypertension
51.9 (28)
80 (43)
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Medical complications
MRC III
Pre-POPS
Post-POPS
N54
N54
Delirium
18.5 (10)
5.6 (3)
Pneumonia
20 (11)
4 (2)
Cardiac problems
ACS
7.4 (4)
3.7 (2)
Arrhythmia
13 (7)
7.4 (4)
Heart failure
3.7 (2)
0
Thrombosis
11 (6)
2 (1)
Wound sepsis
22.2 (12)
3.7 (2)
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Multidisciplinary complications
MRC III
Pre-POPS
Post-POPS
N54
N54
Uncontrolled pain
29.6 (16)
1.9 (1)
NBM 4days
9.3 (5)
0
Catheter4/7
20.4 (11)
7.4 (4)
Constipation
29.6 (16)
16.7 (9)
Dependent transfers
14.8 (8)
0
Bedridden 3days
27.8 (15)
9.3 (5)
Pressure sores
18.5 (10)
3.7 (2)
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Resource issues
MRC III
MRC III
Pre-POPS
Post-POPS
N54
N54
Length of stay
15.813.2 (2-80)
11.5 5.2 (4-26)
Delayed discharge
70.4 (38)
24.1 (13)
- medical problems
37 (20)
13 (7)
- slow rehabn.
13 (7)
7.4 (4)
- wait for OT or equipment
20.4 (11)
3.7 (2)
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Satisfaction

• Patient
• Satisfaction questionnaires
• Staff
• Satisfaction questionnaires
• Regular attendance at audit meetings

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Conclusions
MRC III

• Pre/post evaluation
• Period effect between assessments
• Observer bias
• Case mix bias
• RCT
• Useful in evaluating cost effectiveness
• Embedded effects of team
• Time line precluded usefulness in obtaining long
  term funding

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Delirium

• Pre-operative assessment /management
• Identification of risk factors
• Ensuring appropriate investigation and management
• Involvement of psychiatrist if necessary
• Education
• Informing patient and family
• Informing surgical staff, anaesthetic staff, pain
  team
• Peri-operative management
• Development and implementation of delirium pathway

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Respiratory complications

• Atelectasis, LRTI, exacerbation, resp failure
• Pre-operative risk assessment
• Patient related factors
• COPD, Function, ASAII, CCF
• Surgery related factors
• Site, duration, emergency
• Investigations
• Albumin (CXR, ABG, PFTs, CPET)
• Pre-operative interventions
• EBM Education (smoking, inhalers) Rehab
• Peri- and post-operative management
• Early recognition
• Involvement of PART/therapies

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Cardiovascular complications

• Pre-operative assessment/management
• Recognition
• Investigation and management according to ACC/AHA
  guidelines (in house)
• Development of referral pathways
• Risk stratification (beta-blockers, iv nitrates)
• Peri-operative management
• Management plan
• Early regular review
• Standardised protocols (beta blockers for AF)

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Neurovascular complications

• Preoperative management
• Clinical risk assessment (carotid dopplers)
• Risk modification
• Referral pathways to vascular surgeons
• Peri-operative
• Minimisation of fluctuation in blood pressure
  control

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Renal impairment
Pre operative management Identification and
Management (RCP/RAA) Peri-operative
management Fluid balance monitoring Advice
regards medications Involvement of renal
physicians
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Haematological issues

• Anaemia
• Iron supplementation
• EPO
• Jehovahs Witnesses
• Thromboprophylaxis
• Peri-operative bridging guidelines

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Continence retention

• Pre-operative assessment/management
• Routine screening, Hx, Ex (PR/PV)
• Urine dipstick, MSU, PVRV
• Risk of peri-operative retention
• Need for pharmacological agents
• Education
• Reassurance
• Pelvic floor exercises, fluid intake, mx
  strategies
• Peri-operative management
• Education for surgical staff, mx plan
• Catheter guidelines, TWOC guidelines

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Nutrition

• Screening
• Management
• Mouth care, Swallowing issues
• Advice on diet with follow up
• Supplements
• Protected mealtimes

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Is the service transferable?

• Bolton
• Addenbrookes
• St Georges
• Plymouth
• Glasgow
• Shropshire
• Birmingham

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Outcome Measure
Pre COPS n50 Mean age 73 yrs
COPS n52 Mean age 70 yrs
Change (days)
Length of stay
All conditions
7.9 days
4.5
-3.4 days
Hip replacement
7.2
6.4
-0.8 days
Knee replacement
8.5
6.4
-2.1 days
Post operative complications
Relative risk reduction ()
Delirium
12 (6)
1.9 (1)
83.3 (70)
Pneumonia
16 (5)
0
100 (82)
Cardiac arrhythmia
10 (5)
1.9 (1)
80 (43)
Angina/CCF
8 (4)
0
100 (67)
DVT/PE
10 (5)
0
100 (84)
Uncontrolled pain
34 (17)
9.6 (5)
71 (94)
Bed ridden for 2 days or more
26 (13)
1.9 (1)
92 (67)
Constipation
32 (16)
7.7 (4)
75 (44)
No food for 2 or more days
8 (4)
0
100 (100)
Urinary retention
48 (24)
23 (12)
50 (64)
Delayed discharges once surgically well
All
46 (23)
34.6 (18)
22 (66)
Medical issues
24 (12)
11.5 (6)
50 (65)
Slow rehabilitation
18 (9)
5.8 (3)
67 (43)
Delayed OT/Equipment
16 (8)
0
100 (82)
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Side effects of service

• Trust wide nursing document
• Development and implementation of guidelines
• Standardisation of management of common
  post-operative complications
• Education
• Across health care professionals
• Across departments
• Use of different methods
• (understanding of value of geriatricians!!)
• Standardisation of Pre-assessment pathway

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Day case
Surgical OP
Generic PAC (nurse led)
Triage nurse
Medical specialties
Specialist PAC (nurse led)
Admissions
POPS
Anaesthetist
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Why is the POPS model successful?

• Developed an unusual partnership
• Patient centred
• Built on existing services
• Used EBM methodology (CGA)
• Used innovative ways of working
• Provide a continually responsive service
• Training
• Cost savings
• Involvement in trust-wide initiatives

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Recent developments
Expansion to cover 65yrs emergency admissions
across surgery
Complex co-morbidities
Ward based MDM
Discharge planning issues
Preliminary results Reduced LOS, Reduced
deferrals/cancellations, High ward staff
satisfaction
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Current projects

• Indications for echos
• Optimisation of diabetes
• Deferrals/Cancellations
• 1200 procedures in urology, 1/3 not taking place
  on planned dtae
• Reasons
• Planning
• Medical (MRSA, UTI, anticoag, cardioresp)
• Patient DNA
• Amputees
• LOS
• Falls on surgical wards

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Future

• Local
• Expand to cover remaining surgical specialties
• National
• Promote involvement of geriatricians in
  peri-operative management of older people
  undergoing surgery
• Research
• Local research programme (falls/CPET/anaemia/delir
  ium)
• National database?

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POPS is TOPS

• Feeling apprehensive and afraid
• Unsure and alone
• Need a little more attention than you may get at
  home?
• Need someone to LISTEN
• Someone to really care
• To give you back the confidence that is no longer
  there.
• Let POPS take the strain for just a little while
• And once again youll smile
• POPS IS TOPS THE TEAM WITH PURPOSE!!!