Perioperative care for surgical patients

Introduction

Orthopaedic surgery is an important treatment for musculoskeletal (MSK) conditions. In the NHS, 25% of all surgical interventions are for MSK conditions and account for 16.1% of the total cost of surgery. Complications following joint surgery include venous thromboembolism, infection, stroke, myocardial infarction, falls and delirium. Remote ischaemic conditioning (RIC) is a technique which induces intermittent ischaemia of a limb, through inflating a tourniquet above systolic blood pressure for intervals that avoid physical injury but trigger several intrinsic protective mechanisms.

Method

A systematic literature search was performed in Pubmed, Medline and Embase for studies investigating RIC in fracture, trauma or orthopaedic surgery, published between 1966 and November 2023. Pre-clinical trials and clinical randomised controlled trials (RCTs) were included. There was insufficient data to conduct meta-analyses, so a narrative review was undertaken. PEDro risk of bias scale was performed on RCTs.

Results

Three pre-clinical trials studied RIC in animal models. Results showed a reduction in markers of oxidative stress and up-regulation of genes involved in osteoblast expression, causing improved fracture healing. 20 clinical RCT manuscripts considered the used of RIC in elective and emergency orthopaedic surgery. In total, 1276 participants were studied, and protocols used one dose of RIC prior to surgery. 17 studies demonstrated statistically significant positive outcomes in RIC compared to control, including known mechanisms of RIC such as oxidative stress, inflammation and oxygenation. Additionally, when measured, post-operative pain was improved and there were fewer cardiovascular complications in at-risk individuals.

Conclusions

There is evidence that RIC has a positive effect in orthopaedic surgery, however the populations and outcomes measured were varied. Repeated use of RIC, including post-operative doses, may result in more profound beneficial effects. There is a need for designed RCTs to test whether this intervention can improve the clinical outcomes in wider populations.

Introduction: It’s estimated that 52% of elective vascular patients are frail, with predictions by 2030, one-fifth of surgical procedures will involve patients over 75. This project aimed to evaluate current practices around frailty recognition and documentation at the South-East Wales Vascular Network's regional surgical centre.

Objectives:

Assess the proportion of patients >65 years with documented frailty assessments using the Clinical Frailty Scale (CFS).

Assess healthcare workers' understanding of frailty and familiarity with the CFS. Identify barriers to recognising and undertaking frailty assessments.

Provide a frailty-focused educational intervention for the multidisciplinary team.

Methods: Data was collected prospectively for 22 patients >65 over two weeks in March 2024. The project team reviewed whether a CFS score was recorded on electronic workstation and independently completed a CFS score. Teaching sessions were organised for the multidisciplinary team on frailty recognition and CFS use. Pre- and post-teaching questionnaires gauged confidence levels in using the CFS.

Results: Out of 22 patients, 10 had recorded CFS scores, with 6 being accurate. For the 12 patients without recorded scores, 8 were classified as frail. The mean age was 76 years. The questionnaire revealed knowledge gaps: none of the nurses knew where to document a frailty score, and only 33% of physiotherapists and 60% of occupational therapists knew where to record a CFS score. Post-teaching, staff confidence in frailty recognition increased significantly.

Conclusions: Identifying frailty enables better perioperative risk assessment and surgical decision-making. Frailty documentation on Ward B2 is inadequate. Data collection highlighted nurses' lower awareness of frailty scoring, necessitating further improvement cycles. 73% of patients were frail, with 36% not previously identified as such. Improving frailty recognition will enhance care planning for frail patients undergoing vascular surgery. Designating a 'Frailty Champion' could improve frailty score documentation and ensure its routine inclusion in assessments on Ward B2 at UHW.

Following COVID and an aging population waiting lists in Swansea Bay for elective procedures along with the rest of the UK had reached an all time high. Many patients have become frailer over time and may no longer be suitable or keen for surgery. There was not an efficient mechanism in place for screening these patients and many were being cancelled on the day or having pre-op assessments close to the time of surgery and found to be unsuitable. As part screening our elective surgical waiting lists for frailty we used a number of mechanisms including a electronically screening questionnaire. This was sent to 78 patients highlighted through power BI as meeting frailty criteria and on surgical waiting lists. The questionnaire consisted of a ‘self CFS’ reworded alongside K Rockwood and questions from the CRANE questionnaire. The patients were sent a link with a brief outline of the purpose of the questionnaire and the potential need to be called to clinic if they had any frailty needs. There was a contact number for a admin assistant if there were queries. If they couldn’t access the technology they could also contact them complete via telephone. Over 50% of patients completed the questionnaire online. Interestingly the majority of patients completing the questionnaire had a clinical frailty score over 4 (calculated via clinicians). A clinician also calculated a frailty score for the patients completing the questionnaire which showed good concordance between patients ‘self score’ and a clinicians score. This work showed that our frailer population are able to use technology to good effect and pending more research there may be a role for patients to ‘self score’ themselves in a clinical frailty score. This is invaluable in cutting down resources needed for screening for frailty in many areas

Introduction: Within our hospital, the Surgical Acute Frailty Team (SAFT) delivers perioperative care to the older emergency surgical population. SAFT focuses on early identification of frailty using the Clinical Frailty Scale and subsequent comprehensive geriatric assessment delivery. The most common referral reason to the team is delirium therefore widespread awareness and timely management is essential. Given the challenging clinical environment, SAFT decided to implement a blended teaching programme to support with delivering frailty education to the surgical multidisciplinary team. The aim of the education programme was to improve confidence in frailty identification, delirium assessment and management.

Methods: Teaching sessions targeting all healthcare professionals were delivered by members of SAFT. Education was delivered in two formats: ‘tea trolley teaching’ and small group classroom-based lectures. ‘Tea trolley teaching’ provides focussed ward-based education with a sweet treat provided as an incentive to attend. Feedback was gathered real-time before and after sessions to identify areas of knowledge improvement.

Results: 53 healthcare professionals attended these face to face teaching sessions. Prior to receiving this education, only 26% of participants felt confident in the identification of frailty. This improved to 91% post education. There was also significant improvement in participants’ confidence with delirium assessment from 23% to 74%. A similar improvement was also recorded in confidence with use of the TIME bundle for delirium management from 13% to 60%.

Conclusions: Delivering our education programme using a blended learning approach has improved participants’ confidence with frailty identification, delirium assessment and management. Future plans include the expansion of the teaching curriculum to include other common frailty-related topics, with the goal of improving the perioperative care of older adults within the emergency surgical setting.

Introduction

There is a high prevalence of diabetes in patient populations undergoing Vascular Surgery. Appropriate and responsive management of diabetes in the perioperative setting is critical for reducing morbidity and perioperative complications e.g. diabetic emergencies, poor wound healing, delirium. The aim of this project was to review current practice for perioperative management of older people with diabetes against guidance outlined by the Centre for Perioperative Care (CPOC) on a regional vascular surgery ward.

Methods

A retrospective observational evaluation design was conducted from May-June 2024. Data were collected for patients all aged >60years with a pre-admission diagnosis of diabetes admitted to the ward in this period. Standards of care were derived from CPOC guidance. Data were collated and analysed using descriptive statistics.

Results

28 patients were included (20 male, 8 female). The mean age was 72 years. 86% (n=24) had Type 2 Diabetes and the remainder had Type 1. 82% (n=23) were emergency admissions and 93% (n=26) had surgery at some point in their admission. Only 38% (n=10) were prioritised as first patient on operating lists. There was mixed concordance with guidance on administration of oral diabetes medication perioperatively. However, all patients on SGLT2 inhibitors had these withheld appropriately. There was inconsistency in the frequency of capillary blood glucose (CBG) monitoring with variable responses to episodes of hypo and hyper-glycaemia and variable rate insulin prescriptions were not consistently utilised when indicated.

Discussion

This study has highlighted several areas for improvement of the perioperative management of diabetes in older vascular patients. The next stage of this work will involve a multi-component quality improvement initiative to provide education and support for all healthcare professionals involved in caring for this patient group.

Introduction NELA (National Emergency Laparotomy Audit) and British Geriatric Society guidance states patients aged ≥ 80 years, or ≥ 65 years and frail, should have a comprehensive geriatric assessment (CGA) from a perioperative frailty team within 72 hours of admission or critical care step-down. Patients aged ≥ 65 years represented 55.3% of those undergoing emergency laparotomy; and frailty doubled the mortality rate in this group, but post-operative geriatrician review was associated with reduced mortality (NELA project team, RCoA, 2023).

Method The Perioperative Care of Older People Undergoing Surgery (POPS) service was established in our trust in October 2020 in response to NELA recommendations. Over three years our service has grown from one whole-time equivalent geriatrician and one 0.6WTE nurse practitioner, to a team of six, adding a clinical nurse specialist, physician associate, junior clinical fellow and memory link worker. With staff training, all surgical admissions aged ≥ 65 are screened for frailty to enable identification of patients who will benefit most from CGA and subsequent support during the admission. An internal database was established to prospectively capture patient demographics and outcomes.

Results Added team capacity has allowed us to see more patients year-on-year, including more patients not requiring laparotomy. Median frailty score and age have increased from 5 to 6, and 77 to 80 years, respectively, without a significant change in median length of stay. Mean trust compliance with NELA guidance around geriatrician review has improved significantly from 3% to 88% post POPS establishment.

Conclusions Introduction and expansion of a POPS service at our trust has resulted in an increased number of patients receiving geriatrician-led CGA, though meeting 100% of NELA standard likely requires a second consultant or cross-cover arrangement. However, we are reviewing more patients, who are on average older and frailer, without an increase in length of stay.

BACKGROUND:

At Sheffield Teaching Hospitals, an Older Surgical Patients Pathway (OSPP) began in 2014, introducing a Consultant Geriatrician working in a liaison role within General Surgery.

BGS reports in its 'Case for more Geriatricians' that the number of people aged over 85 is set to double by 2045. An increase in patient age and complexity is already being seen across a range of services including admissions to general surgery.
We look to characterise this increase to make the case for an expansion of the OSPP service.

METHODS:

1. We identified patients aged over 75 admitted under General Surgery in July to December of 2014 and 2023.

2. We analysed these patients for their 30 day mortality, theatre episodes, length of stay and Hospital Frailty Risk Score (an automatic calculation from hospital records using a weighted count of frailty- related diagnoses).

RESULTS:

The number patients aged over 75 admitted in the 6 months from July to December has increased from 646 in 2014 to 847 in 2023.

The increase in this age group is associated with an increase in the number of patients with a hospital frailty score greater than 20 (from 18 to 69) and those with a length of stay longer than 15 days (from 93 to 124).

Additionally, between 2014 and 2023 patients aged over 75 had an increase in total theatre episodes (from 107 to 125) and 30 day mortality (from 48 to 63).

We propose that this increase in number and complexity of older patients supports the expansion of OSPP Service, for example by the addition of a ST3+ level doctor.

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.

Poster presentation Aim:

Improve the care of patients aged 65+ presenting with trauma to the emergency department by ensuring earlier senior reviews (ST4+) and consideration of trauma calls and appropriate imaging.

Method:

Staff survey to assess awareness of older trauma and its management. Data analysis and collection followed by use of PDSA cycles to implement change. Teaching session on primary survey assessment and management of older trauma. Development of older trauma standard operating procedure.

Results:

Improvement was seen in both primary outcomes over a period of 8 months. Documentation of primary survey improved from 30% from the initial 5 weeks to 52% over the final 5 weeks on average. Senior doctor review or discussion improved from 30% average in the first 5 weeks to 80% averaged across the final 5 weeks. There was no evidence of effect on waiting times in the emergency department for these patients.

Conclusion:

This quality improvement initiative has positively impacted the early assessment of older trauma patients, aiming to mitigate the likelihood of missed injuries and adverse outcomes. While we haven't formally assessed more complex outcome data, a notable achievement is the initiation of a cultural shift among our frontline medical and nursing staff. This shift involves approaching older trauma patients with a heightened index of suspicion. Among the interventions, the most straightforward and reproducible was the implementation of regular educational emails. We anticipate continued progress and hope that this poster serves as inspiration for other departments. Encouraging a review of how they assess and treat this expanding cohort of vulnerable, complex, and potentially critically ill patients. Unfortunately, it is not uncommon that for our growing elderly population, a trip and fall can lead to fatal consequences. We aspire for this work to contribute towards broader efforts in changing that narrative.

1. Introduction

Parkinson’s Disease (PD) is a complex neurodegenerative disorder which impacts nearly all aspects of quality of life. Given the known challenges and risks of complications with PD, it is crucial to improve management prior to admission for surgery, in particular accurate medication timing and dose. Therefore a quality improvement project on this subject was initiated.

2. Method

A retrospective analysis was conducted of Surgical attendances to Worthing hospital with the aim to identify patients with Parkinson’s disease (PD) admitted under their care. Each patient’s hospital records were manually screened using Evolve Live software and WellSky EPMA to extract the information pertaining to PD medications for the audit. Statistical analysis was conducted using Microsoft Excel. The cycle was repeated following interventions of posters and education of surgical teams.

3. Results

In both cycles there were patients attending for elective surgery or admitted into hospital. The following is regarding patients who were admitted to hospital and were on PD medications. For the first cycle, 27 admissions were identified and 20 in the second cycle. In the first cycle, 5/27 (18.5%) had their medications accurately documented, which improved to 9/20 (45%) in the second cycle. First cycle, 16/27 (59%) patients had their medications prescribed correctly, which was similar to 12/20 (60%) patients in the second. 17/27 (62.7%) patients missed doses in the 1st cycle, and 9/20 (45%) patients in the 2nd cycle.

4. Conclusion(s)

From the first cycle, it was identified that PD in patients was not recognised as promptly as it should. It was reflected in the high proportion of incorrect prescribing and issues due to delay in medications. In the second cycle, following our interventions, there was improved awareness of PD with fewer prescribing issues and complications during admission.