Perioperative care for surgical patients

Introduction

In-hospital CPR has survival rates of 15-20% [BMA Decisions on CPR, 3rd edition, 2016], further reduced with frailty and multimorbidity. Successful CPR is associated with significant morbidity and prolonged suffering. Do not attempt resuscitation (DNACPR) is an advanced medical decision, aimed at preventing harm where CPR is considered futile.[GMC Guidance.p128-145]

Aims

To reduce the burden of inappropriate CPR within surgical specialties using the following standards:

1. DNACPR status reviewed on admission, and all decisions implemented within 24hours of clerking.

2. DNACPR decisions implemented prior to surgery.

3. To assess clinician perceptions regarding DNACPR decisions.

Methods

This second cycle follows the intervention of a poster and departmental education in January 2020. A survey was sent to clinicians of all grades in Trauma and Orthopaedics (T&O) and General Surgery in January 2023. Data on implementation of DNACPR decisions was retrospectively collected over January and February 2023 for all T&O emergency and elective admissions >60-years-old.

Results

26 survey responses were obtained with all participants having had DNACPR discussions. 80.7% self-reported as confident/very confident in having these discussions. Out of 264 patients included, 80 discussions took place, of which 64 (80%) were implemented. 69% were implemented within 24hours of clerking, a 23% increase from cycle 1. 90% of community DNACPRs (9/10) were applied within 24hours, however the one remaining patient received inappropriate CPR. Of the 47 patients with DNACPR who had surgery, 87% were implemented prior to surgery, a 12% increase from cycle 1.

Conclusion

Improvement was demonstrated on both standards between cycles. This QI focused on implementation of DNACPR following discussions, however, did not consider patients in whom DNACPR may have been appropriate but not discussed. Further areas to explore include appropriateness of CPR/ DNACPR decisions in advance of surgical interventions and the understanding behind limitations of treatment offered separate to CPR.

Background:

An estimated 10% >65-year-olds and 25-50% >85-year-olds live with frailty in the UK, ¹ making up a greater proportion of surgical caseloads. Perioperatively, frailty is an independent risk factor for adverse outcomes.^2,1  Timely recognition and assessment is vital in prevention, however, awareness of frailty and the Clinical Frailty Scale³ (CFS) is limited amongst clinicians.⁴

Methods:

A survey was completed by doctors of all grades across surgical specialties in Sandwell General Hospital. Questions explored recognition of frailty, use of CFS, and their influence in perioperative decision making.

Results:

A total of 33 Doctors completed the survey (33.3% Junior Doctors). Whilst 97% believed they look after frail patients, 69.7% were aware of the CSF but only 30.3% had used the scale.

All doctors thought frailty plays a role in their decision making post-operatively, however >87% rated their confidence in recognising frailty ≤3/5.

Key Messages:

Across all grades, there is an awareness of the importance of frailty, however a lack of confidence in its recognition. Need for further education is evident, particularly regarding the CFS. In this respect, focused education sessions are being implemented for all grades of doctors to consolidate knowledge and facilitate a multidisciplinary approach to decision making in surgery

Background Clinicians are increasingly aware of the association of frailty syndrome and adverse outcomes. The British Geriatric Society recommends that clinical frailty scores (CFS) are assessed for all patients on admission to surgery, to optimise peri-operative care.

Method For in-patients over one month (June 2023), the concordance with guidelines was recorded and any ‘missing’ scores retrospectively completed (Rockwood CFS). Clinical metrics included length of stay.

Results 110 patients were admitted under vascular surgery. The median age was 67 (IQ 61-79). 73 (66%) were aged >65-years and 42 (58%) of these patients were frail or at risk of frailty (CFS 4-9); 37% of all admissions. 10 (14%) patients >65-years had their CSF documented, only 3 (4%) had this documented in an easy-to-access “AdHoc” form. 3 frail patients had formal assessment by a geriatrician during admission. Higher frailty score directly correlated with longer hospital admission (p=0.002), the average stay was 4 days longer in the frail cohort.

Conclusion Despite the high prevalence of frailty among vascular admissions, the overwhelming majority did not have CFS scores recorded in line with BGS Guidance, perhaps increasing risks for these patients. Ongoing quality improvement has focussed on educating foundation staff responsible for clerking surgical patients on the importance of assessing and documenting CFS.

Background

Hip fracture in the elderly is associated with significant morbidity and mortality. These patients often have serious co-morbidities, including cardiac conditions, and are at risk of developing perioperative decompensation. Heart failure represents a common and serious perioperative condition in hip fracture patients1. We conducted a quality improvement project to identify incidence of perioperative pulmonary oedema and the possible risk factors.

Method

Retrospective analysis of patients aged 60 years and older admitted with hip fracture over a one month period. Perioperative period was taken as time from admission to day 5 post surgery. Intravenous fluids administered pre-op, intra-op and for 5 days post-op were reviewed. Pulmonary oedema was diagnosed on clinical and radiological findings.

Results

50 patients admitted: 14 (28%) male; 36 (72%) female. Mean age: 82 years, 94% (47) admitted via emergency department. Comorbidities: 48% hypertension, 30% atrial fibrillation/flutter, 18% cardiac failure, 14% dementia. Pre-operative clinical review identified 14 (28%) patients as high risk for developing cardiac decompensation perioperatively. 57% (27/47) of patients admitted via accident and emergency received intravenous fluids pre-operatively. None of these patients had vital signs suggestive of hypovolaemia. Rate of fluid administration: 10/27 (37%) 1 litre over 4 hours, 5/27 (22%) 1 litre over 2 hours, 2/27 (7%) 1 litre over 1 hour. Intra-operatively 43 patients (86%) received intravenous fluids, 18 patients (36%) received ≥ 2 litres of fluid. 6 (12%) patients developed pulmonary oedema in the perioperative period

Conclusion

Fluid overload in our cohort may be an underestimate as many patients were anticipated to be at high risk of developing pulmonary oedema with consequent very careful fluid management and diuretic administration. Intravenous fluid administration requires careful assessment and monitoring in elderly hip fracture patients.

References

1. Michael W Cullen 1 , Rachel E Gullerud, Dirk R Larson et al J Hosp Med 2011 Nov;6(9):507-12.

Introduction

Increased frailty is associated with increased post-operative morbidity and mortality in older patients undergoing emergency laparotomy. NELA recommend documentation of frailty in surgical patients over 65.

Using QI methodology, we introduced a ‘CARE tool’ for surgical doctors aiming to improve their documentation of an older person’s medical history (including CFS and delirium).

Method

A collaborative team representing geriatric medicine, anaesthetics and surgery devised the acronym CARE (Cognition, Assistance at home, Record the CFS, Exercise tolerance).

The tool was tested using QI methodology over 2 PDSA cycles. Cycle one introduced the tool into electronic patient records (EPR) and presented it at the surgical faculty meeting. Cycle two introduced the tool specifically to surgical FY1 doctors during induction.

The EPR surgical clerkings of patients over 65 years old admitted to general surgery were sampled weekly over seven weeks to assess CARE tool completion.

Post-intervention, we surveyed the surgical doctors assessing their understanding of frailty and perceived value of the CARE tool.

Results

At baseline: 12% of confusion, 92% dementia status, 0% CFS, 30% assistance at home, 8% exercise tolerance were documented.

Following PDSA cycle one, use of the CARE tool was 40%. There was an increase in the documentation of confusion (40%) and CFS (40%). Dementia status and assistance at home were documented in similar frequency pre and post-cycle.

During cycle two, CFS documentation increased to 55% but identification of confusion dropped to 25%. The survey demonstrated that frailty, CFS scoring and delirium screening were better understood by junior doctors than Consultants and registrars.

Conclusions

Our project showed mixed success in improving documentation using the CARE tool. The survey demonstrated a good understanding and knowledge of frailty in surgical FY1s. Ongoing frailty teaching is planned for the surgical department.

Introduction: 

Elderly patients are susceptible to opioid-induced constipation (OIC) and often remain constipated despite regular laxative prescription. Naloxegol is a gastrointestinal opioid antagonist licensed for OIC in patients failing laxative therapy. Naloxegol’s higher unit price than standard laxatives may disincentivise hospital pharmacies from stocking and supplying it. We present a quality improvement project and cost-analysis on the use of naloxegol in treating OIC in the real-world setting of a post-operative geriatric ward. 

Methods: 

Initial audit- 

Review of inpatient notes from October-November 2022 identified patients on opioids who failed laxative therapy during admission (bowels not opening for ≥3 days, despite 4 consecutive days of laxatives). Number of bowel motions per week following failure of laxatives and number of laxative doses received were recorded. Total cost of laxatives was calculated for each patient. 

Intervention - 

From December 2022-January 2023, naloxegol was given to patients with OIC failing laxative therapy. Laxatives were stopped on receipt of naloxegol.  

Results: 

Baseline audit identified 63.9% patients on opioids had failed laxative therapy. Following laxative therapy failure, average number of bowel motions/week was 2.65. Accounting for length of admission, average cost of laxatives per patient per day was £0.13. 

During the intervention period 67.2% patients on opioids failed laxative therapy. 13 were prescribed naloxegol. Average number of bowel motions on naloxegol was 5.1/week. Average combined cost of laxatives and naloxegol per patient per day was £0.71. 

Conclusions: 

We demonstrate that naloxegol is effective in treating OIC in those failing laxative therapy, at an average cost of £0.58 per patient per day more than those on standard laxative regimes. While difficult to quantify, constipation is detrimental to patient experience and recovery and incurs indirect costs. On balance, we believe this cost margin to be acceptable, and naloxegol a beneficial treatment for OIC in geriatric patients failing laxative therapy.

Introduction The pathway for referral to elective perioperative clinic involves frailty screening patients at the point of referral1. This is adequate If waiting times are short. At Swansea Bay 6,458 patients>65 years are awaiting surgery with up to 5 year waits for cholecystectomies. Opportunity to medically optimise patients prior to surgery are lost using a traditional approach. We aimed to develop a screening tool to identify frailty in patients awaiting surgery. Method The cholecystectomy list (750 patients) of which 258 were> 65years. Older people were sent a postal questionnaire gaining 96 responses. 58.3% felt their health deteriorated since being referred for surgery. 50% stating they had unmet healthcare needs and 17.5% stating unmet social care needs. Frailty was identified using this questionnaire, telephone interview or electronically by the Hospital Frailty Risk Score (HFRS). 193 patients were successfully contacted utilising an expanded CRANE questionnaire. All patients triggering on HFRS, CFS>4 or any concern on the CRANE questionnaire were offered a clinic appointment. Each interaction was then classified into change or no change in medical management of patients. 92 patients had no interventions, 35 had an intervention following the initial CRANE telephone questionnaire that did not require further input, 31 had an intervention following clinic. CFS>4 identifies 56% of the patients that under go any form of intervention. HFRS identifies 34% and the CRANE questionnaire identifies 42%. In patients who need a clinic review HFRS identifies 19%, CFS>4 identifies 59% and CRANE identifies 87%. Conclusion The CRANE questionnaire is a useful screen for patients on a waiting list who will benefit from an elective perioperative clinic. References 1 Guidelines of perioperative care CPOC.

 Introduction In the presence of multiple co-morbidities and frailty, older people undergoing emergency laparotomy warrant higher supportive care. It is evident that geriatrician input to perioperative care plays a crucial role to improve patient experience and outcomes ( 1, 2). Whilst we recognised the need for a surgical liaison service and increased compliance with NELA we had limited resources to give. We created an automatic email alert to enable us to see NELA patients and make the maximum use of our clinical time. Method An automated email alert was created in July 2022 to identify patients undergoing laparotomy based on theatre coding, we then set up filtering by age and frailty. A surgical liaison service was already established but we were able to target NELA patients from September 2022. Retrospective analysis of local data for Morriston Hospital extracted from 2022 National Emergency Laparotomy Audit allowed comparison of compliance to expected standards by the SOPAS (surgical liaison) service before and after intervention. Results There were 225 patients who required emergency laparotomy at Morriston hospital in 2022. 50 patients met NELA criteria of which 30% were > 64 with high CFS and 70% over 80. A 3 month period (March-May) prior to the intervention and 3 months following (Sept-Nov). We showed an increased in compliance with NELA standards from under 10% to over 50% with this intervention. Conclusion Significant improvement of 5% to 50% compliance with NELA standards was observed after the intervention of email alert; further to this we noted an issue with the alert working through December 2022 where many patients were not seen. This corresponded with a period of increased mortality. Our aim going forward is to upscale this to align with the BGS Position Statement. (3

Introduction

Our perioperative service for older people undergoing surgery (POPS) commenced preoperative assessment of co-morbid and frail patients undergoing elective orthopaedic surgery in 2021. As part of the comprehensive geriatric assessment (CGA) and shared-decision-making process (SDM), we wanted to analyse the decisions our patients made around surgery and how many regretted having surgery.  

Methods

• Review of all orthopaedic patients seen by POPS between September 2021-December 2022

Intervention

• CGA and SDM on all patients
• Data collected: comorbidities, Clinical Frailty Scale (CFS), SDM outcome.
• Decision regret scale was sent out 6 months post op from August 2022.

Results

• 111 patients assessed. Median age 89 (range 60-97). Median CFS 4 (range 1-7)
• Median comorbidities 12 (range 2-22).
• Surgery considered: knee 43%, hip 33%, shoulder 10%, spine 6%, revision hip 5%, and revision knee 3%.
• 77% wanted to proceed with surgery and 13% did not after SDM. 5% were deemed not fit enough and 5% are still awaiting final decision outcomes.
• Decision regret data has been returned by 10/14 (71%) of patients who proceeded. None regretted their decision. 

Conclusion

The majority of patients seen by POPS wish to proceed with orthopaedic surgery. However, 13% did not wish to proceed following SDM which is similar to the 14% of patients who regretted undergoing surgery in other settings¹. Of those that have returned the 6-month post op questionnaires, none have regretted their decision. Understanding how optimisation and appropriate SDM impacts on the patient experience is important as frailty impacts adversely on patient reported outcomes in elective hip and knee surgery. Frail patients are also less likely to report their postoperative outcomes in national data sets compared to less frail patients².

1. CPOC website
2. Cook et al (2022). The impact of frailty on patient reported outcomes following hip and knee arthroplasty. Age and Ageing.

Background Prehabilitation in clinical trials improves fitness, improves quality of life, reduces complications, and reduces hospital length of stay It is not standard of care in routine clinical practice. This prospective observational study reports the outcomes of a clinical AHP prehabilitation service for older people undergoing major cancer surgery. Methods The LUHFT Prehab service commenced in August 2017, patients prior to major abdominal surgery for cancer were eligible for referral, this was inclusive of 8 different surgical specialties. Referred patients were invited to attend a multi-disciplinary prehabilitation clinic inclusive of physiotherapy, occupational therapy and dietetic support. In a review of the past 12 months clinical frailty score was recorded at baseline and pre surgery. Patients were given individualised exercise, wellbeing, and nutrition plans, and provided with support via 121 or group based follow up. Where distance was a barrier, telephone clinics were undertaken. Results Over a 12-month period 477 patients were referred over the age of 65, of these 436 underwent baseline frailty assessment. Of these 380 went on to have surgery with an average period of 40 days between initial prehab assessment and their elective admission. In these patients 50 scored 5 or above on the clinical frailty scale, 105 fell within the vulnerable category and 163 in managing well at baseline. Of those patients reassessed pre surgery 100% of patients with a frailty score of 5 or above either improved or maintained their score. Of those that scored a frailty score of 4, 94% either improved or maintained their score. Conclusion A prehabilitation service is feasible and improves frailty in the lead up to major abdominal elective surgery in a cohort that would otherwise be expected to decondition due to the nature of their disease. Prehabilitation should be part of standard care for older patients undergoing cancer surgery.