Perioperative care for surgical patients

Introduction

Patient and public involvement and engagement (PPIE) is essential to delivering patient centred, quality research. Older adults constitute an increasing proportion of the surgical population but are unintentionally excluded from traditional models of engagement.

We describe the process and outputs of conducting PPIE to support future research examining the scale up of CGA-based perioperative services such as POPS (Perioperative medicine for Older People undergoing Surgery).

Methods

Patients undergoing elective surgery at four NHS hospitals in England and Wales were asked to consider participation in PPIE. Twenty-two expressed interest; nine offered to participate, six declined due to their own or relative’s ill health, two withdrew, five did not respond.

Six were able to participate on proposed dates. Three had access to email and video calling to join a group Microsoft Teams call. Three took part in 30-minute individual telephone calls. A patient representative from Centre for Perioperative Care (CPOC) acted as peer facilitator for the interview structured around five pre-agreed questions.

Results

Six older patients contributed through PPIE to codesign research examining perioperative services for older people, with three volunteers for long-term involvement as part of a research steering group. The group offered insight into their experience of traditional and POPS-led perioperative pathways.

This group emphasised the need for coordinated care, delivered by clinicians with a holistic understanding of the whole perioperative pathway, the need to reduce duplication of information provision and diagnostic testing and a proactive approach to hospital discharge planning.

Participants agreed that POPS services should be established nationwide and that research should focus on implementation and scale-up. The need for PPIE in the dissemintation of future research findings was highlighted.

Conclusion

Involving older adults in PPIE is possible and necessary to deliver healthcare services, including novel perioperative care pathways, tailored to service users.

Background: This Quality Improvement project was undertaken at University Hospitals of Derby and Burton. The team comprised a speciality doctor and improvement fellow previously employed as an operating department practitioner (ODP). Senior sponsors comprised a consultant geriatrician and Divisional Nurse Director.

Introduction: Delirium impacts up to 40% of older hospital inpatients and is associated with mortality, institutionalisation and deconditioning. We aimed to increase diagnosis and management of delirium to reduce complications, length of stay and readmissions.

Method: An initial audit measured delirium prevalence using 4AT in patients aged >65 on arrival to the Surgical Assessment Unit (SAU) and 48 hours later. Staff answered questionnaires relating to delirium awareness and screening. A series of plan-do-study-act (PDSA) cycles then tested small-scale changes to improve delirium practice on SAU. We developed, implemented, and iteratively improved 4AT and delirium sections in care plans. We developed and delivered teaching and supporting materials around the PINCHME acronym to SAU staff. 4AT and delirium care plan completion rates were monitored. Staff knowledge before and after teaching was tested.

Results: 36% of 111 consecutive emergency surgical admissions audited were likely to have delirium based on 4AT. 5% were coded as having delirium and 19% had delirium documented in their notes. Average length of stay was 7, 10 and 5.3 days for the whole cohort, those with and without delirium respectively. These data convinced SAU managers of need for change. Improvements around 4AT screening were associated with a rise in average 4AT completion rate from 40% to 64%. Completion rates were highly dependent on the improvement team, rising as high as 100% after interventions but falling back between these. Knowledge scores improved from 43% to 92% following teaching.

Conclusion: Improvements correlated with higher delirium screening and detection rates, and staff knowledge improved. Interventions were not sustained. We are now exploring delirium champions as a way of sustaining change.

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.

Introduction:

Polypharmacy is commonly defined as the concomitant use of five or more medications. This is a common problem in frail elderly patients and more so on the surgical inpatients where it is not regularly reviewed by the surgical team.

Methods:

We reviewed retrospectively the data on vascular inpatients from 2015-2016 and after the set-up of the perioperative services in 2022-23. Patients above 65 years of age with a clinical frailty score of 4 or more or with two or more co-morbidities were selected from both groups. In total 130 patients were selected from each group and their notes were reviewed in terms of polypharmacy review, before and after the introduction of the perioperative service in the trust.

Results:

Average age of the patients in both groups combined was 75 years. Average polypharmacy number per patient before and after the perioperative service were 6.8 and 10.7, respectively. In 2022-23, all the 130 patients had a polypharmacy review by a Consultant Geriatrician. In 2015-16, polypharmacy was reviewed only if there was an adverse effect to the drug, for example bradycardia caused by beta blockers. There was no routine review of polypharmacy. 0.06 Medications were stopped per patient in 2015-16, in contrast to 1.7 per patient in 2022-23. Most common causes of discontinuation of medications were falls, confusion, postural hypotension, drowsiness, electrolyte imbalance or medication no longer needed.

Conclusions:

Polypharmacy optimisation should routinely be practised in frail vascular surgical patients as it leads to avoidance of undesirable side-effects, improves patient compliance to medications, and has a huge financial benefit from deprescribing.

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. 

Background

Perioperative management of diabetes is a strong predictor of post-operative outcomes for patients undergoing major elective surgery. The national confidential enquiry into patient outcome and death (NCEPOD) has specific recommendations for diabetes care in the perioperative phase. We aimed to audit current practice in East Sussex Healthcare Trust (ESHT) against these recommendations prior to the introduction of a recognised programme designed to improve the perioperative pathway for patients with diabetes (IP3D).

Methods

A retrospective audit of 30 patients with diabetes who underwent major orthopaedic or colorectal surgery. Data was collected on basic demographics, quality of initial referral, preoperative assessment, intraoperative diabetes management and postoperative recovery.

Results

Mean patient age was 73 (57-91), with the majority having type-2 diabetes (93%, n=28). Initial referral letters mentioned diabetes in 77% (n=23) of cases; 7% (n=2) included the latest HbA1c. 97% (n=29) had a pre-operative HbA1c; mean was 50.9mmol/mol (39-74). 43% (n=13) of patients were scheduled in the first third of the operating list. Blood glucose was measured preoperatively in 93% (n=28), intraoperatively in 40% (n=12) and postoperatively in 77% (n=23). Postoperatively, three patients had hypoglycaemic events and five had hyperglycaemic events. One patient had deficient wound healing due to poorly controlled diabetes.

Conclusions

Perioperative management of patients with diabetes at ESHT does not currently meet the NCEPOD standards. This shortfall will be addressed by the implementation of the IP3D programme and supported by a perioperative diabetes specialist nurse. The programme will focus on educating and supporting patients perioperatively whilst improving diabetes knowledge amongst surgical staff.

Introduction: Delirium is a common and serious complication in frail older patients undergoing emergency hip fracture surgery, often resulting in prolonged hospital stays, increased morbidity, and a greater risk of long-term cognitive decline. Recognizing and managing delirium effectively is critical in improving patient outcomes. However, initial assessments indicated variability in the confidence and capability of surgical postgraduate doctors to assess and manage delirium appropriately. A baseline survey revealed that 50% of staff were not familiar with hospital delirium guidelines, and 62% rated their confidence in managing delirium as 3 out of 5. Additionally, over one-third of staff inappropriately used the AMT10 as a delirium screening tool, and many lacked confidence in interpreting the 4AT score.

Method: To address these gaps, we implemented a multipronged educational program to improve staff knowledge and confidence in delirium assessment and management. This approach included formal teaching sessions, the display of delirium infographics in ward areas, and the dissemination of key information via email and WhatsApp. The program emphasized the appropriate use of the 4AT for screening and highlighted common delirium triggers and their management.

Results: Post-intervention analysis showed an improvement in both the confidence and accuracy of delirium assessment among staff. All staff were able to use the 4AT correctly, and everyone reported increased confidence in assessing delirium. Management practices revealed that pain, infection, constipation, and electrolyte abnormalities were generally well-addressed in patients. However, there remained a lower frequency of medication reviews, along with insufficient attention to nutrition and hypoxia as potential contributors to delirium.

Conclusion: Our educational intervention significantly enhanced staff confidence and competence in detecting and managing delirium in the trauma and orthopaedic ward setting. Following these improvements, the next phase of our project is to introduce a standardized delirium care bundle in the surgical setting. This care bundle aims to establish a structured approach to delirium management, thereby minimizing delirium-related complications and improving overall patient care.

Introduction: The incidence of dementia among patients in perioperative settings is on the rise, presenting significant challenges for healthcare professionals in delivering adequate and appropriate care to this patient population. In order to gain a deeper understanding of the perioperative care needs of patients with dementia, thirty healthcare professionals were interviewed. The focus was on their experiences and perspectives regarding the fulfilment of these needs. Key factors influencing perioperative care were identified and categorized into three main themes: patient-related factors, healthcare professional-related factors, and healthcare environment-related factors. Methods: Thirty interviews were conducted with a diverse group of healthcare professionals, including anaesthetists, surgeons, nurses, and other perioperative staff. Thematic analysis was employed to process and interpret the data, identifying recurring themes and sub-themes that reflect the complexities of perioperative care for patients with dementia. Results: The analysis revealed three primary themes: 1) Factors related to the patient with dementia: Cognitive impairment and comorbidities uniquely challenge perioperative care. The unfamiliar hospital environment often exacerbates cognitive symptoms, and adherence to postoperative protocols can be problematic. Family involvement is crucial in supporting these patients. 2) Healthcare Professional Factors: Perceptions of dementia, communication issues, pain assessment, and the need for personalized care were highlighted. Training and education deficits among healthcare professionals were evident, impacting the quality of care. 3) Institutional Factors: Organisational policies and resource allocation significantly affect the provision of dementia care. Support for healthcare professionals through ongoing education and the development of dementia-specific guidelines were identified as essential needs. Conclusion: Effective perioperative care for patients with dementia requires addressing multifaceted challenges. Improving communication, enhancing education and training for healthcare professionals, involving family members, and ensuring institutional support are critical steps. A comprehensive, empathetic approach can lead to better outcomes and experiences for patients with dementia in the perioperative setting.

This service evaluation reviewed the impact of the Perioperative Care of Older People Clinic (POPS) on Anticholinergic Burden (ACB) in older surgical patients and identified areas for improvement. The study assessed 75 patients aged ≥65 years, revealing widespread anticholinergic use. Among patients on anticholinergics, 34% experienced a reduction in ACB post-POPS review. However, maintaining these changes at ≥6 months was challenging, with 50% of patients experiencing a change in their ACB score due to new prescriptions or the re-initiation of old medications. The study identified communication gaps at the POPS-primary care interface affecting de-prescribing efforts, underscoring the need for improved discharge letters, systems to flag high ACB patients and a universal ACB tool.

Introduction

The UK's ageing population is increasingly undergoing surgery, and older adults are at higher surgical risk partly due to anticholinergic use. POPS is a relatively new initiative aimed at reducing ACB in this demographic, but the sustainability of these reductions is not well understood. This service evaluation aims to fill this gap and suggest solutions for maintaining reduced ACB levels.

Methods

Retrospective data from 75 patients from 2022-2023 who met the criteria for ACB evaluation pre- and post-POPS review, with follow-up at ≥6 months, were included. Results Post-POPS, ACB was reduced in 34% of patients, with a median decrease of -2. However, ACB increased again in 50% of patients at ≥6 months, with re-initiation of amitriptyline and furosemide contributing to the rise in 67% of these cases.

Conclusions

CGA effectively reduces ACB in older surgical patients, but sustaining these reductions poses significant challenges. Communication difficulties at the POPS-primary care interface likely contribute to the re-initiation of medications, indicating a need for standardised discharge summaries and a universal system for evaluating and flagging high ACB patients to maintain improvements.