Jugdeep Dhesi & Jason Cross Dept of Ageing and Health

Guy’s and St Thomas’ , London 

Life Expectancy in the UK

Age in 2014

Men Women

65 18.9 21.4

75 11.7 13.5

85 6.1 7.2

90 4.3 5.0

ONS

Increasing numbers of older people

Ageing associated with degenerative, metabolic & neoplastic disease

Such conditions often require elective or emergency surgery

Increasing numbers of older people have surgery

But older people still have less surgery than would be expected

Clinician reported outcomes Morbidity Mortality

Patient reported outcomes Recovery (change in trajectory of disease/disability) Experience, satisfaction

Process related outcomes Harm and complaints LOS, readmissions Cost (in‐hospital, rehab, formal and informal )

Assess risk factors

Not ‘fit’ for surgery’

V 

Fit for surgery

Admit to SAL/Sx wardSurgical ward

Discharge to community HDU/ITU

Identify and modify risk factors 

Improve ‘fitness for surgery’

Shared decision making 

Risk management 

Identify risk factors

Modify risk factors

Make patient fitter

Less complications, managed better

Improve outcomes

Clinical pathway

Skeletal muscle 

conditioning Cardiopul fitness

Frailty

Anaemia

Manage comorbidity

Nutrition

Medical complications Rehabilitation Discharge Follow up

74 yrs old FLiving aloneNo support‘Difficult’ historian

OsteoarthritisDiabetesHypertensionSOB ?cause 

Anaemia

No surgeryHbA1c 8.2%BP 170/88ECG NADCXR NADHb 100g/l

Elective colorectal cancer  (orthopaedic/vascular/gynae/any) surgery

Pain Opiates Post‐op ileus On/off ‘sliding scale’Hypovolaemic (AKI) FluidsAnaemia BloodPeripheral oedema Diuretics(Apathy) Hypoactive delirium Anti‐depressantsFunctional decline POC

Refuses surgery Referred for medical opinion

Cancelled on day of surgery

• 4 in 5 high risk patients to general ward

• Management on wards by junior staff

• Poor recognition of medical problems

• Reliance on on‐call staff

• Multiple medical team involvement

Knowledge Assessment, optimisation, post‐op medical care, rehabilitation, discharge planning

Behaviours Reactive approach Unstandardised and uncoordinated medical management

Attitudes Cultural, traditional, silos of care

Medical specialties

Day case

Generic PAC (Nurse led)

Specialist PAC (Nurse led)

POPS (Proactive care of Older People undergoing 

Surgery)

Anaesthetist

Surgical OP

Triage nurse

Admissions

POAC MDTMs

Surgical OP/PACReferrals• Screening criteria• ‘Medically unfit’  • Support required for decision making

Pre‐op CGAConsultantCNSOTSocial worker

Hospital AdmissionWard roundsMDMsCase conferencesEducation and training

Post DischargeIntermediate CarePrimary careSocial careSpecialist clinics

LiaisonPatientSurgical teamAnaesthetistsGPCommunity service

The POPS model

Comprehensive geriatric assessment (CGA)

Holistic, multidimensional, interdisciplinary assessment of an individual

Formulation of  a list of needs and issues to tackle an individualised care and support plan tailored to an individual’s needs, wants and priorities

Risk assessment Recognition of known comorbidity Identification of unrecognised disease, disability, frailty Assessment of functional reserve

Optimisation Medical, functional, psychological & social condition Application of organ specific guidelines Use of multidisciplinary interventions

Collaborative decision making  Risk/harm versus benefit Consent, capacity, advance directives  Communication

Risk management Prediction of post operative complications Planning of postoperative care promoting Early identification of medical complications Standardised mx of medical complications

Prediction of support required on discharge

OADiabetesHTNSOB ?cause‘Difficult’ historian

PainHbA1c 8.2%BP 170/88Ischaemic ECG AnaemiaDeconditioningCog impair’tSocial issues

Treat/physioTreat/planABPM/treatMedical optimisationIv ironExercise programmeDelirium risk/mxEquipment/POCPsychological supportDischarge planning

Admission on day of surgeryDetailed info to anaesthetist

Planned individualised intraoperative care

Proactive standardised mx of ileus, diabetes, fluid balance by joint team

Appropriate discharge plans

POPS Letter

Pre and post studyOrtho elective, Age and Ageing, 2007;36:190‐196

Randomised controlled trial Single centre elective aortic & lower limb 

vascular 40% reduction in LOS No increase in readmission Predominantly due to ▪ reduction in medical complications ▪ streamlining of process (reduction in SD of LOS)

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

Costs Reduced LOS

Reduced readmissions

Improved coding

Cancer pathways

18 week pathway

Day of surgery admission

Communication

Education

Patient and staff satisfaction

Guys St Thomas’

Orthopaedic – electiveUrologyHead and NeckENT

Orthopaedic – traumaUpper GI/Lower GIVascularPlastics

Elective – known to POPS

Elective – not known to POPS

Non‐ElectiveWard based MDTMs

POPS Clinic

Joint surgical ward rounds

CPOAC MDTMs

Amputee Rehab Unit

Jason Cross ANP – POPS team

Putting it into practice – case studies 

IHD

PPM

CKD 4

DM

MCI

Falls

Continue aspirin

Arranged  / site OK

No contrast confirmed / risk discussed

Pre op plan

Counselled / info given

POPS OT 

Stable / BNP 450 

Requires check as >6 months 

Stable with risk of AKI & dialysis

Referral to specialist  / Hba1c >10% 

MoCA 21/30 / High Delirium risk

Multi‐factorial / risk of f/decline  

Issue Assessment Intervention

77 year old elective / Fem distal bypass for PVD Direct referral from consultant 

High surgical risk 

Morbidity 97%Mortality 56%

Patient symptomatic

Requiresintervention

Patient concern over risk

Unsure of options

Risk discussed with surgery / POPS presence

Less invasive procedure

Angioplasty and stent

Good symptomatic relief

CommunicationVerbal 

EmailClinic letter

Identify and modify risk factors 

Improve ‘fitness for surgery’

Shared decision making 

Risk management 

Multimorbidty 

Abdominal  pain  

No surgical issues / requesting transfer to 

elderly care

Nurses report patient has care needs  / daughter 

struggling 

Proactive case finding  with expedited assessment

89 year old lady / on admissions ward

Constipation

Frail with f/decline

Social care 

Laxatives prescribed / advice

OT referral and assessment 

Discussed / advice / community ref 

Faecal loading on imaging

Risk of falls / increased care

Living with daughter / requesting care input 

Issue Assessment Intervention

Patient home after bowels 

opened

Proactive case funding with 

holistic assessment 

Admission avoidance with appropriate community referral 

76 year old gentleman Incarcerated hernia Requires emergency surgery  Discussed at EGS handover meeting  Concerns raised Nursing home resident Patient confused ‘has dementia’ Would palliative care be more appropriate

AF

Warfarin

Anaemia

Immobility 

High Surgical risk

Confusion

Consent

Plan detailed / IV Digoxin 

Discussed / Vitamin K 

Haematinics obtained

Air mattress 

Discussion

Delirium pathway / advice 

• Best interest discussion• Family involved • Documentation• Consent form 4 • Proceeds to surgery 

Rate controlled

INR high (2.4)

Hb 11 / stable for surgery

High risk PA breakdown

Morbidity 81%, Mortality 14%

Delirium NOT dementiaMild cognitive impairment  

• Lacks capacity (delirium)• Collateral history • Good QOL• Living independently

Issue Assessment Intervention

Ileus

AF 

AKI

Delirium 

Functional decline

Dietetic reviewTPN

IV Digoxin / advice / pathway 

Fluid resus / AKI pathway 

Haloperidol (not used) / pathway 

Early therapy Rehab referral 

Albumin droppingNBM prolonged

Fast rate

Baseline 3a 20% cr rise

Acute / multi‐factorial

Global weaknessDeconditioned

Issue Assessment Intervention

Delirium resolves at day 5 

14 day hospital stay

Early therapy referral to rehab 

unity 

4 week stay at rehab then home

Surgical OP/PACReferrals• Screening criteria• ‘Medically unfit’  • Support required for decision making

Pre‐op CGAConsultantCNSOTSocial worker

Hospital AdmissionWard roundsMDMsCase conferencesEducation and training

Post DischargeIntermediate CarePrimary careSocial careSpecialist clinics

LiaisonPatientSurgical teamAnaesthetistsGPCommunity service

The POPS model