Integrating surgical and medical care

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Integrating surgical and medical care

• Jugdeep Dhesi
• Clinical Lead POPS
• Guys and St Thomas
• London

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What is the problem?

• 20 million in-patient surgical procedures
• 1.3 million complications
• 315000 deaths
• Mortality rate in the UK
• 2.6 million high risk

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Who is the high risk patient?
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What factors make a patient a high risk patient?

• Reduction in physiological reserve
• Comorbidities
• Frailty
• (Age)

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Physiological reserve
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Physiological reserve

• Self reported Metabolic equivalents
• Semi-quantitative tests
• Flights of stairs, TUAG, Gait speed
• Objective tests - CPET

MET Equivalent activity
Good 7-10 Jogging, dancing, tennis
Moderate 4-7 2 flights of stairs, brisk walking, heavy housework
Poor 2-3 Walking indoors or on flat slowly, light housework
Very poor 1 Eating, dressing
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Comorbidities
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Comorbidities

• Simple counts
• Charlson comorbidity index

Cardiac Respiratory Diabetes Renal Neurological
Roche J J W et al. BMJ 20053311374
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Frailty
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Frailty

• Definitions
• ?physiological reserve across multiple organ
  systems

?postoperative complications ?length of hospital
stay ?in-hospital mortality rate ?30-day
mortality rate
Inouye 2007
Partridge et al Age and Ageing, 201241142-7
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Generally, this is the older population
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And theres more and more of them
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What is the surgical pathway?
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GP
Anaesthetist
Specialty med
Surgical OP

PAC

Admissions
The usual pathway of care
Home
Social services
Intermediate care
Care home
Discharge
Complications
SAL
Ward
Ward
HDU/ITU
Surgical juniors
MET/PART
Speciality medicine
General medicine
Elderly care medicine
Anaesthetist (day of surgery)
Surgery
AE
Ward)
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What happens to a patient?
74 yrs old female
Portuguese
Living alone
No support
Osteoarthritis
Diabetes
Hypertension
SOB ?cause ?AF
No surgery
HbA1c 8.2
BP 170/88
ECG - nil acute
Elective colorectal cancer surgery
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The potential problems
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The potential problems

• Preoperative
• Patient refuses surgery
• Delay in surgery (referrals to various
  specialties)
• Cancellation on day of surgery (diabetes plan)
• Intra-operative
• BP, ACS, difficult BP/CO control
• Postoperative problems
• Medical, surgical, functional complications

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What are the postoperative problems and their
consequences?
Age Resp CVS CNS T -emboli An leak
lt65 5 0.8 0.2 1 4
65-74 10 2 0.6 2 5
75-84 12 4 1 2 4
gt85 15 4 1 2 3
p lt0.0001 lt0.0001 lt0.0001 0.0004 0.2607
Patel et al. Lancet 2000 356968974.
30day mortality 30day mortality 1 year mortality 1 year mortality 5year mortality 5year mortality
with without with without with without
Any complication 13.3 0.8 28.1 6.9 57.6 39.5
Khuri et al Ann Surg 2005242326-342
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Never mind dying, how long before I get back to
normal?

• Functional impairment/disability
• Deterioration in function persisting up to
  6months post colorectal surgery
• Lawrence et al J Am Coll Surg 2004 199762-772
• Postoperative cognitive disorders
• Delirium, POCD, ?Alzheimers
• Common, serious, distressing

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...and the NHS/social care sector is at risk

• Medical costs
• Social care costs
• Informal costs

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...and heres what happened to this lady
74 yrs old female
Portuguese
Living alone
No support
Osteoarthritis
Diabetes
Hypertension
SOB ?cause ?AF
No surgery
HbA1c 8.2
BP 170/88
ECG - nil acute
Pain Difficult to control
Post-op ileus On/off sliding scale
Hypovolaemic Fluids
Peripheral oedema Diuretics
Functional decline POC
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What should have happened?
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What should have happened?

• Baseline assessment
• Optimisation
• Assess/communicate risk-benefit of surgery

Factors Risk of Scores/Tools
Surgery related Mortality ASA/PPOSSUM
Morbidity Lee/AKI /Delirium
Patient related Functional decline EFS??
Cancellation/LOS ??
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What should have happened?

• Information provision to the patient
• Honest, clear, easy to understand
• Include assessment of benefit, harm, uncertainty
• Language
• Answer the question
• Whats the mortality related to the procedure?
• Whats going to be the impact on my quality of
  life?
• What would happen if I didnt have the operation?
• Provide range of options (avoid supplier-induced
  demand)
• Shared decision making

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What should have happened?

• Communication between professionals to ensure
• Planned intraoperative care
• Planned postoperative care (where and how)
• Predict complications, plan standardised approach
• Consistent medical input (one team)
• Facilitate MDT
• Ensure early discharge planning
• Ensure cost effective approach

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Whats your experience?
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Is this what happens?

• An age old problem 2010
• Remediable factors in processes of
• care in over 80s who died within 30 days of sx
• Knowing the risk 2011
• Prospective review of peri-operative care of
• all in-patient surgery
• Access all ages 2012
• Assess variation in surgical treatment according
• to age examine potential reasons for variation

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The bad news...

• Preoperative care
• Lack of recognition of predictors of poor outcome
• Failure to optimise the patient
• Why?
• 1 in 6 hospitals no pre-admission clinic
• 1 in 5 of high risk not pre-assessed
• Did it matter?
• Non pre-assessed patients had higher mortality
  (4.8 v 0.7)
• Failure to optimise the patient
• Elective and emergency
• Suboptimal pre-operative fluid optimisation

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...and more

• Organisational issues relating to access to
  theatres
• Intra-operative
• Monitoring substandard
• Post-operative management
• 1 in 5 high risk patients managed on ward
• 25 no Early Warning Scores
• Insufficient geriatrician/MDT involvement
• Poor documentation

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Why does this happen?
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Why does this happen?

• Traditional model is not fit for purpose
• Surgical drs cannot (should not?) deliver
  assessment, optimisation, post-op medical care,
  rehabilitation, discharge planning
• Un-standardised medical care
• Reactive rather than proactive
• Insufficient emergency theatres, level 2 and 3
  facilities

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How would you make it better?
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Models of care

• Anaesthetist led preoperative assessment clinics
• Specialty specific eg vascular at Newcastle
• Generic Torbay
• Hospitalist models
• (ERP)

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An alternative model
Day case
Generic PAC (Nurse led)
Specialist PAC (Nurse led)
POPS (proactive care of older people undergoing surgery)
Anaesthetist
Surgical OP

Triage nurse

Admissions
Medical specialties
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The POPS model

• Surgical OP/PAC
• Proactive referral
• At risk according to screening criteria
• Patients diagnosed as medically unfit

Pre-op CGA Consultant CNS Physiotherapy OT Social
worker Patient education
Hospital Admission Post-op consultant
geriatrician/ CNS Therapy liaison Discharge
planning Teaching/ training
Post Discharge Intermediate Care Links with
primary care/ social care Specialist clinic
follow up (falls etc)
Liaison Surgical team Anaesthetists GP Community
service Patient
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CGA methodology

• Pre-operative assessment is complex
• Less likely to mention, masking of symptoms,
  communication issues
• CGA allows objective assessment across multiple
  domains
• Focuses on older people with complex problems
• Allows ID of geriatric giants
• Emphasises functional status
• Uses MDT skills
• Allows development of goal orientated
  interventions
• Effective if targeted, hands on, followed through

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Optimisation

• Use of organ specific guidelines
• Multi-morbidity (eg PD, IHD having vascular
  surgery)
• Polypharmacy (eg antihypertensives)
• Practicalities (eg attending appts)
• Specific issues
• Dementia/Delirium/Mental capacity
• Pre-operative rehabilitation/Functional decline
• Nutrition

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Why does this model make sense?

• Risk assessment
• Recognition of known comorbidity
• Identification of unrecognised disease,
  disability, frailty
• Assessment of functional reserve
• Capacity, consent, advanced directives
• Risk reduction and management
• Medical, functional, psychological and social
  condition
• Prediction of post operative complications
• Planning of postoperative care
• Early identification of medical complications
• Standardised management of medical complications
• Prediction of support required on discharge

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The patient with POPS input
74 yrs old female, Portugese
Living alone with limited support
Osteoarthritis
Diabetes
Hypertension
SOB ?cause
Unresolved pain
HbA1c 8.2
BP 170/88
ECG
Social issues
Treat/physio
Treat/plan
ABPM/treat
Myoview/medical mx
Equipment/POC Psychological support Discharge planning
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What do we now do at GSTT?
Elective known to POPS
Elective not known to POPS
Non-Elective
Pre-assessment MDT Meeting
Ward based MDT Meeting
Complex medical needs
Discharge planning issues
Guys St Thomas
Orthopaedic elective Urology Head and Neck ENT Orthopaedic trauma Upper GI/Lower GI Vascular Plastics
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The benefits
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The benefits
Pre-op ? multiple hospital appts
? lost in the system
? late cancellations
Post-op ? medical/multidisciplinary complications
Standardised mx of complications
Improved quality of overall care
Improved discharge planning
Income Reduced LOS
Reduced readmissions
Improved coding
Communication
Education
Patient and staff satisfaction
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The challenges
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The challenges
Challenge Approach
Culture Identify the units problem
Identify interested and respected clinicians
Present at audit/academic/any meetings
Embed into existing pathways
Be on the wards delivering hands on care
Communication Clinic letters
MDT meetings
Joint surgical medical ward rounds
Workload Targetted approach
Use screening tools
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The future a new specialty?

• Implementation of guidelines
• Patient centred rather than disease centred
• New approach, collaborative
• Education and training
• UG and PG, across specialties and disciplines
• Evidence base
• Establish networks, health services research

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Putting it into clinical practice eg
dementia/delirium

• Prediction tools
• Inouye
• (severe illness, visual impairment, cog
  impairment, dehydration)
• Brigham and Womens Hospital Delirium (BWD)
• (preop meds, substance, previous delirium,
  psych/neuro disease)
• Delirium elderly at risk (DEAR)
• (functional impairment)

• Consideration of risk
• Minimisation of risk
• Evidence based
• Non-evidence based
• Communication
• Patients and families
• Anaesthetic surgical staff
• Ward staff
• Consent

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POPS - Communication

• Based on the history and cognitive testing Ms X
  has likely dementia. This raises the following
  issues
• a) Capacity
• Displays capacity to consent to proposed
  procedure but requires adequate time and clear
  explanation
• b) Delirium risk
• Cognitive impairment and poor vision put Mrs X at
  risk of developing POD.
• Patient has been counselled about this. When
  admitted please ensure that
• Trust delirium guideline is printed, filed in
  notes and followed
• Deliriogenic drugs are avoided where possible
• Adequate hydration is maintained
• Falls risk is assessed (using STRATIFY)
• Day night routine is maintained
• Sensory impairments are optimised (I have told Ms
  Holmes to bring in her glasses
• c) Long term management
• Please could GP monitor and consider referral to
  memory assessment services as appropriate.

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POPS in hospital care

• Anaesthetic considerations
• Day case? Short stay?
• Maintain O2, normocapnia
• Correct glucose/electrolytes
• Use drugs with short half lives, adjust doses
• Avoid centrally acting drugs ?Volatile
  agents
• Ward measures
• HELP type approach
• Medication
• to treat or not to treat? when to start ?
• how long to keep meds going for?

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Practicalities
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If improvement is to be attained we need an
institutional approach with surgeons, physicians,
anaesthetists, critical care teams and managers
working in harmony and National Standards for
the National Health Service.
Norman Williams RCS
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Case mix postoperative medical comps
Pre-POPS n54 Post-POPS n54
Age 75.075.06.1 74.1 6.2
Cardiac 33 (18) 55 (27)
Diabetes 13 (7) 20.4 (11)
Renal 3.7 (2) 22.2 (12)
Hypertension 51.9 (28) 80 (43)
Delirium 18.5 (10) 5.6 (3)
Pneumonia 20 (11) 4 (2)
ACS 7.4 (4) 3.7 (2
Arrhythmia 13 (7) 7.4 (4)
Heart failure 3.7 (2) 0
Thrombosis 11 (6) 2 (1)
Harari et al, Age Ageing 2007 36 19096.
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Postoperative multidisciplinary issues
Pre-POPS Post-POPS
Uncontrolled pain 29.6 (16) 1.9 (1)
NBM gt4days 9.3 (5) 0
Cathetergt4/7 20.4 (11) 7.4 (4)
Dependent transfers 14.8 (8) 0
Bedridden gt3days 27.8 (15) 9.3 (5)
Pressure sores 18.5 (10) 3.7 (2)
Length of stay 15.813.2 11.5 5.2
Delayed discharge 70.4 (38) 24.1 (13)
- medical problems 37 (20) 13 (7)
- slow rehabn. 13 (7) 7.4 (4)
- wait for OT/equipment 20.4 (11) 3.7 (2)
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Is the service transferable?
Post operative complications Pre COPS N50 Mean 73yrs COPS N52 Mean 70yrs RR reduction ()
Delirium 12 (6) 1.9 (1) 83.3 (70)
Pneumonia 16 (5) 0 100 (82)
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 gt48hrs 26 (13) 1.9 (1) 92 (67)
Constipation 32 (16) 7.7 (4) 75 (44)
No food gt48hrs 8 (4) 0 100 (100)
Urinary retention 48 (24) 23 (12) 50 (64)
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Outcome Measure Pre COPS n50 COPS n52 Change (days)
Length of stay Pre COPS n50 COPS n52 Change (days)
Hip replacement 7.2 6.4 -0.8 days
Knee replacement 8.5 6.4 -2.1 days
Delayed discharges
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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Targeting the right patient

• gt65years and 2 or more of the following
• Hypertension
• Diabetes
• Respiratory disease COPD/Asthma
• Ischaemic heart disease/Heart failure/Arrhythmias
• Cerebrovascular disease (TIA/CVA)
• Cognitive impairment
• Frailty/functional dependence
• Abnormal results bloods/ECGs

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What scores do we have to assess risk of
mortality?

• ASA
• Useful in population studies
• Independent predictor of morbidity, mortality,
  LOS
• Does not predict risk for individuals
• Low reliability, lack of subtlety
• PPOSSUM
• Also developed as an audit tool
• (6) Surgical and (12) physiological parameters
• Overestimates ??

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Is the usual pathway a good model?
YES NO
Pre-op care Quick screening procedure Potential delays
Inexpensive No focus on optimising
Reduces day of surgery cancellation No emphasis on reducing post-op comps
Safe in terms of peri-op comps
Peri-op care Patient cost savings related to admission on day of surgery Anaesthetist involved late
Post-op care Its traditional!! Sx team looking after medical problems
Inefficient discharge planning