As the world’s population ages, older people are increasingly presenting to the hospital with surgical problems that require assessment and management. Older patients face different challenges than their younger counterparts, including an increased risk of complications, death, and functional decline.1,2 The presence of frailty, cognitive impairment, and multiple comorbidities also contributes to poorer postoperative outcomes and necessitates holistic and comprehensive care.1,3,4
Collaboration between surgeons and geriatricians is known to improve outcomes for older patients with hip fracture.5 Evidence is emerging for similar models of care in other surgical populations—including patients with vascular and gastrointestinal conditions.6-8 Furthermore, a recent study demonstrated the benefit of geriatrician review in reducing mortality of older people undergoing emergency laparotomy.9 Nonetheless, translation into clinical practice has been slow.10-12 Whether a similar model of care would improve outcomes for patients in the acute general surgery setting is less clear.
Prince of Wales Hospital, Sydney, Australia—a 450-bed metropolitan teaching hospital and tertiary referral center—has a long history of collaborative care for older patients with orthopaedic and vascular surgical problems. Patients admitted with general surgery conditions were noted to have a high rate of hospital-acquired complications with significant levels of functional dependency and unplanned readmission. This problem is particularly common among older patients undergoing emergency laparotomy.10 Given the success of the established models of collaborative care, the departments of general surgery and geriatric medicine sought to determine whether similar benefits could be achieved in the emergency general surgery population, with a view toward improving their outcomes.
Putting the quality improvement (QI) activity in place
Prince of Wales Hospital has a well-established department of geriatric medicine that operates a shared model of care for older orthopaedic trauma and vascular surgery patients. Input into other surgical specialties was otherwise provided on an individual consult basis.
Over the course of a year, approximately 500 older (75-plus years old) patients are admitted to the general surgery service for emergency care. Less was known about these patients until a 2016 observational cohort study (n = 303) was undertaken, which demonstrated that many (41 percent) patients experienced complications during admission, with the most common complication being delirium (18 percent). A significant proportion (26 percent) of patients also experienced decline in mobility and function during their stay.
Armed with the information from the observational cohort study, literature demonstrating how collaborative care can improve outcomes, and a shared desire to improve care for older general surgery patients, senior members of both departments agreed to pilot a new model of care. We decided to focus on older emergency general surgery patients because this population appeared vulnerable, experiencing a high rate of complications.
Before proceeding, funding had to be secured with an understanding that the work would be time-limited and if it failed to add value, the service would cease. Likewise, success would then necessitate ongoing financial support.
Discussions took place with key stakeholders, and grant funding for innovation and translational research grants was sought from the local Health District and State Department of Health, respectively.
This study follows several international initiatives and guidelines for older surgical patients. In the U.K., geriatrician review is considered a standard of care for older people undergoing emergency laparotomy and is known to improve outcomes for this population.9,13 Similarly, the perioperative medicine model of care for older people undergoing surgery has been well described in the literature, with evidence of increasing uptake of similar collaborative models of care between surgeons and geriatricians across the U.K.12,14
In the U.S., the American Geriatrics Society, American Society of Anesthesiology, American College of Surgeons, and the Society for Perioperative Assessment and Quality Improvement have produced guidelines for older surgical patients. These standards include a recommendation that high-risk, older surgical patients receive geriatrician review, with comprehensive geriatric assessment considered the gold standard for managing frailty.15-18
Implementing the QI activity
To address identified opportunities to improve care, we decided to use a collaborative model of care with each patient receiving shared care from a general surgeon and a geriatrician. The model was introduced September 19, 2016, and was delivered to patients ages 75 and older admitted to a general surgical specialty on an emergent basis, with a planned period for the pilot to run until January 31, 2018.
In addition to shared care, all patients received physiotherapy from extra hours resourced by the grant. Patients underwent comprehensive geriatric assessment on admission and were reviewed daily, Monday through Friday, by an aged care fellow who worked closely with nursing and allied health staff on the ward to ensure the delivery of coordinated care and facilitate early discharge planning.
The Care of Older People in Surgery (COPS) service includes a geriatrician (0.2 full-time equivalent [FTE]), geriatric registrar (0.6 FTE), and physiotherapist (0.5 FTE). This service operates collaboratively and in tandem with the usual surgical services, which include an acute surgical unit for emergency general surgical admissions that is composed of a general surgeon, a surgical registrar, senior resident, and clinical nurse consultant. Funding was sought through two grant initiatives, including an innovation grant locally via the South Eastern Sydney Local Health District as well as at the state level with a translational research grant through New South Wales Health. The cost of this initiative totaled $284,000 (AUD) over 18 months.
Results
After initial discussions, the model of care was introduced. Throughout implementation multiple problems were encountered. These ranged from a high volume of allied health referrals, beyond that generated directly by the COPS service; lack of experience among nursing staff in caring for patients with delirium; and access to food immediately upon upgrade of diet.
For each problem encountered, “plan, do, study, act” cycles were used to identify the root cause and appropriate solutions. Following are solutions that have been implemented:
- Daily rapid rounding with allied health staff for all patients on the general surgical ward to promote greater efficiency and prioritization of referrals.
- A range of education strategies to allow nursing staff to gain greater knowledge and feel more confident in managing older, delirious patients.
- An additional refrigerator was purchased for the ward and stocked with a range of options for older patients to consume upon diet upgrade.
More broadly, although an overarching goal was to improve collaboration between the general surgery and geriatric departments, not all staff bought in to the model from day one. Concerted efforts to meet with consultants and senior staff semi-regularly, continued support at an executive level, and promotion of communication at all levels within the team with their surgical counterparts allowed for the development of professional relationships. By the end of the implementation period, communication occurred freely, allowing for better medical and surgical decision-making, as well as more efficient discharge planning.
TABLE 1. PATIENT OUTCOMES BEFORE AND AFTER COPS INTRODUCTION
