Jugdeep Dhesi Dept of Ageing and Health

Guy’s and St Thomas’ , London

Perioperative medicine aims to Provide better care before, during & after surgery Reduce variation, improve outcomes

The RCoA programme The PSH programme

10 million having surgery

1.6 million as in-patients

250,000 defined as high risk

10 million having surgery

1.6 million as in-patients

250,000 defined as high risk

80/20 rule

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 )

Marcantonio, Ann Intern Med 2001;:637-43

Am J Surg 2011;:789–796

Patel, Lancet 2000; 356;968-74

30day mortality

1 year mortality

5year mortality

with without with without with without

Any complication 13.3% 0.8% 28.1% 6.9% 57.6% 39.5%

Khuri, Ann Surg 2005;242:326Hamel, JAGS 2005;53:424-9Thompson Arch Surg 2003

<80yrs >80 yrs

Vascular 4.1% 9.4%

Thoracic 6.3% 13.5%

Orthopaedic 1.2% 8.3%

0

1,0

00

2,0

00

3,0

00

4,0

00

5,0

00

Patie

nts

<31 31-40 41-50 51-60 61-70 71-80 81-90 >90

Data from 2015

Copyright © 2016 American Medical

Association. All rights reserved.

Percentage of Patients Discharged to Postacute Care (PAC)

Facilities According to Age, Number of Postoperative

Complications, and Functional Status

Who is at risk of adverse postop PROM?

Lawrence J Am Coll Surg 2004JAMA Surg. 2016;151(8):759-766

Poor cognitive recovery

Poor experienceNCEPOD An age old problemFrancis reportAIHW

Silverstein Br J Anaesth 2009, Partridge Int J Ger Psych 2014 Nadelson Br J Anaesth 2014

Most cost comes from

Late cancellations

Length of stay

Readmissions

Social care costs

Informal care costsCourtesy Sydney care home team

Shapter, Anaesthesia, 2012; 67:474-8

Theou JAGS 2014;901-906

Barnett, Lancet 2012

Wilson Br J Anaesth 2010;105:297, Pham ANZ J Surg 2014, Roche BMJ 2005;331:1374, Makary 2010, Partridge Age & Ageing 2012;41:142, Hubbard 2016

Older people are the most likely to need the specialty of perioperative

medicine

Assessment of risk

Modification of risk

Care in the right place

Optimal management of complications

Documentation of relevant outcomes

Shared decision making

Clinical pathway

Skeletal muscle

conditioning Cardiopul fitness

Frailty

Anaemia

Manage comorbidity

Nutrition

Medical complications Rehabilitation Discharge Follow up

74 yrs old F

Living alone

No support

‘Difficult’ historian

Osteoarthritis

Diabetes

Hypertension

SOB ?cause

Anaemia

No surgery

HbA1c 8.2%

BP 170/88

ECG NADCXR NAD

Hb 100g/l

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

Declines surgery

• Understanding - Info poorly communicated

• Understanding –Sensory/cognitive impairm’t

• Health literacy – life expectancy, impact of ca/stoma

• Burden of intervention

Referred for medical opinion

• Anaemia

• Diabetes

• Shortness of breath

Cancelled on day of surgery

• Not followed fasting or medicines instructions

• Concern about medical status (anaemia, SOB)

Day of surgery

admission

Surgery with

consultant sx/anaesth

management

GDFT

HDU post op

Ward at 48 hours

Pain Opiates

Post-op ileus On/off ‘sliding scale’

Hypovolaemic (AKI) Fluids

Anaemia Blood

Peripheral oedema Diuretics

(Apathy) Hypoactive delirium Anti-depressants

Functional decline Carers (Rehab)

• 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

Jan 2009-2012111 public, 61 private 11,000 patients>40% >80 years>80% emergency

Duke University, US

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

= Comprehensive Geriatric Assessment

Guys and St Thomas’ NHS Foundation Trust

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

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 promting

Early identification of medical complications Standardised mx of medical complications

Prediction of support required on discharge

Admission on day of surgeryDetailed info to anaesthetist

Proactive planning and communication of post-op needs

Medical complications, managed in a proactive standardised manner working with the junior surgical team

Expertdischarge planning

Pain Opiates

Post-op ileus On/off ‘sliding scale’

Hypovolaemic (AKI) Fluids

Anaemia Blood

Peripheral oedema Diuretics

‘Not engaging, apathetic’ Anti-depressants

Functional decline POC

Refuses surgery Referred for medical opinion

Cancelled on day of surgery

Unrecognised disease/syndromes

Suboptimal control of comorbidity

Unrecognised complications

Poor coordination of care

OA

Diabetes

HTN

SOB ?cause

‘Difficult’ historian

Pain

HbA1c 8.2%

BP 170/88

Ischaemic ECG

Anaemia

Deconditioning

Cog impair’t

Social issues

Treat/physio

Treat/plan

ABPM/treat

Medical optimisation

Iv iron

Exercise programme

Delirium risk/mx

Equipment/POCPsychological supportDischarge planning

Based on the history and cognitive testing Ms X has likely dementia. This raises the following issues;

a) CapacityDisplays capacity to consent to proposed procedure – but requires adequate

time and clear explanation

b) Delirium riskCognitive impairment and poor vision put Mrs X at risk of developing POD. Patient has been counselled about this. When admitted please ensure that; i) Trust delirium guideline is printed, filed in notes and followedii) Deliriogenic drugs are avoided where possible iii) Adequate hydration is maintainediv) Falls risk is assessed (using STRATIFY)v) Day night routine is maintainedvi) Sensory impairments are optimised (I have told Ms X to bring in her

glasses

c) Long term managementPlease could GP monitor and consider referral to memory assessment services.

Risk of complications

Delirium, change in trajectory

Falls, functional decline

What carers can do to support the patient?

In hospital

At discharge

Where and how carers can seek support for themselves?

Admit day of surgery

Advocate same day admission / day surgery

Minimise unnecessary unit / ward moves

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-POPS n=54 Post-POPS n=54

Age 75.075.0+6.1 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)

Wound sepsis 22.2% (12) 3.7% (2)*

Harari et al,

Age Ageing

2007;

36: 190–96.

So… does this approach work?

Accepted BJS Partridge Oct 2016

02

04

06

08

0

Pe

rcen

tage

Medical complications (p=0.002) Surgical complications (p=0.04) Delayed discharge (p=0.05)

Control Intervention Control Intervention Control Intervention

Percentage of patients with complications and delayed discharge by trial arm

Year What happened?

2003 Start of charity funded project

2005 (BP) Mainstream funding for POPS service

2008 (BP) Funding for additional CNS and consultant (2009)

2010 Used remaining grant funding to secure 1 year research SpR

2011 Research grant for POPS Vascular RCT

2012 FY2 became deanery funded, rebadged money for OOPE

2013 (BP) 3 PAs for the amputee rehab unit

2014 (BP) Funding for 4 PAs = WTE Gynae POPS CNS

2014 (BP) 7 Pas for vascular POPS consultant (2015)

2015 FY programme (with 2 OOPE, 1 consultant)

Guys St Thomas’

Orthopaedic – electiveUrologyHead and NeckENT

Orthopaedic – traumaUpper GI/Lower GIVascularPlasticsGynaecology

Elective – known to POPS

Elective – not known to POPS

Amputee Rehab Unit

Emergency

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

All >65 years

Vascular Complex triple AAA

Lower GI Colorectal malignancy (ERP)

Upper GI OG malignancy (ERP)

Gynae Major gynaeonc (ERP)

Urology Cystectomy

Surgeon or CPOAC Frailty, multimorbidity, functional dependency Difficult decision

Referral

• Sx, POAC, MDM, Ward

• Booking

• Comm’n

Nurse

(30mins)

Scores

Investign

Doctor/ CNS(30mins)

• Assessm’t

• Optimis’n

• Risk benefit

Admin(30mins)

• Chasing info

• Letter

• Liaison

• TCI

POPS Clinic 4x week

One stop assessment and optimisation clinic

1000-1200 new out patients per year

MDM

In patient work

1200 elective and 1000 emergency

Joint surgeon-geriatrician ward rounds

Mon-Fri presence on wards 8-4pm

Board rounds/MDTMs, Prn reviews, telephone, email advice

Case conferences/family meetings

Parameter Screening Assessment

Physiologicalstatus

Reported exercise tol

METS

Multimorbidity Disease specific tools

Frailty Simple question EFS

Cognition 4AT MoCA

Nutrition MUST Dietitician

Social/function Structured history

Barthel, NEADL

Diagnosis

Management decision

Surgery (40%)Procedure Medical

As IP

(25%)

<48 hrs

(15%) Trauma Acute Care Surg 2013JAMA 2016, BJS 2013

Risk assessment CROM

PROMShared decision making

Process

Medical optimisation

Fluids, AKI, delirium, sepsis, drug management

Communication with patient/carers

Capacity, consent, shared decision making

Advance care planning – ceilings of care

Communication across teams to optimise mx

Focus on risk of predictable complications

Ensuring proactive approach to diagnosis &mx

Ensuring continuity of care

NEWS/Medical/geriatric complications Psychological health mx Goal setting/rehabilitation Discharge planning

POC, ICT, care home

Communication

Patient

Family/carers

Primary/community care

Nursing handoverSurgical handoverJoint ward roundsMDTMsPhysical presence

2006 2016

Consultant 0.8 4.3

SpR 0.2 3

FY 1 11 (6 FY1, 5 FY2)

CNS/AHP 1 2

OT 1 1

Physio 1 0

Social worker 1 1 unfilled

Admin 1 1

Secretary 0.3 1

Delivering evidence based clinical practice

Do we have the evidence to inform practice ?

How do we translate into routine care? (behaviours, attitudes)

How do we change culture and when should we not?

Education and training (knowledge)

Is our workforce ready? Which workforce?

How do we ensure they are?

Research and QIP

Making it relevant to the ‘messy’ patient, the context and the workforce

Understanding service and trust priorities

Top three for a service delivery manager

Trust core values

Collecting ‘relevant’ data Engagement with and embedding within

established teams

Eg Transformation team, Delirium and dementia team, End of life care team

Using the available workforce Ensuring visibility

Annual report, Audit meetings, Grand rounds

Partridge, Age and Ageing 2014

Chelmsford

Imperial

Belfast Edinburgh

Nottingham

Guildford

Southmead

North TeesSalford

GSTT, London

Cambridge

Kings, London

Oxford Portsmouth

…with data to support the developments

Before February 1st

11 MedianAfter February1st

7 Median

Length of stay (mean 13 median 9)(↓ 4 days) 30 day readmission rate (↓ 13.2%) Times seen by non surgical doctor (↓ 18%) Medication reviews (↑51%) Coding/recognition complications ↑↑ Coding comorbidities ↑↑

Courtesy of

Dr Vilches-Moraga, Salford

…is a complex undertaking requiring ….

collaboration across specialties and disciplines

whole system reorganisation (cultural change)

upfront funding

…which raises many questions

Are surgical liaison services generic or subspecialised?

Is this primary care, anaesthetics, organ specific medicine, general medicine or geriatric medicine?

Can we embed specialist knowledge or do we have to embed the specialist?

www.popsteam.co.uk British Geriatrics Society POPS SIG POPS annual education conf (register via BGS) POPS OOPE/Fellow posts (advertised March/April) Research posts

RCoA Perioperative medicine programme UCL Perioperative Medicine MSc EBPOM, NELA Age Anaesthesia Association (May)

jugdeep.dhesi@gstt.nhs.uk