The older surgical patient: minimizing risk and maximizing outcomes

Where are we now?

Over the past 50 years we have seen advancements in surgical technique and anaesthetic management that have improved perioperative mortality in all surgical subspecialties and across all ages. However, if we compare the older surgical population to the younger, the older remain at higher risk of both mortality and morbidity. ^1,2 This excess risk of adverse postoperative outcome occurs as a consequence of reduced physiological reserve and an increased prevalence of co-morbid disease (multimorbidity). ^3,4 Physiological reserve is known to diminish with age and may be measured in terms of organ function (for example, cardio-respiratory function) or by assessing syndromes such as frailty. This diminished reserve capacity, either alone or coupled with co-morbidity, reduces the ability of an older person to respond to the stress of an acute illness and/or surgery. While this has implications in terms of mortality, it more frequently causes both short-term and long-term morbidity. Studies have demonstrated that older people take up to three months to recover functional abilities post gastrointestinal surgery ⁵ and that up to a third do not recover pre-morbid functional status following hip fracture surgery. ⁶ Unsurprisingly, in the face of the growing older population, the associated financial costs for the health, social care and informal sector are considerable and increasing.

Despite these reported adverse postoperative outcomes, we know that older people have much to gain from surgery. This is in terms of improvement in symptoms, physical function and quality of life even in the oldest old, including centenarians. ^7,8 Significant postoperative functional gains can be seen in the most disabled of patients, ⁹ and surgical procedures can enhance quality of life through symptom and pain control even in frail nursing-home patients. ¹⁰

Unfortunately, numerous reports have demonstrated that we are failing in the care for this high-risk population. As far back as 1999, National Confidential Enquiry into Patient Outcome and Death (NCEPOD) reported deficiencies in care for older surgical patients in ‘Extremes of Age’. ¹¹ The issues raised included unnecessary prolonged waits for theatre, inadequate high dependency and intensive care input, insufficient senior clinician input and poor team working. A decade later the 2010 NCEPOD report, ¹² ‘An Age Old Problem’ explored remediable shortcomings in the care of people aged over 80 years who had died within 30 days of elective and emergency surgery. It opened with the statement ‘this report makes depressing reading’, followed by the primary finding that older surgical patients received good care in only one-third of cases. The majority of the patients included in the report were admitted as emergencies (83%). Over one-third of the patients had operations to repair hip fractures, with a further 31% undergoing emergency abdominal surgery. On this occasion issues raised included inadequate preoperative preparation, with insufficient focus on risk factors and optimization, a lack of considered decision-making, poor escalation of care and unplanned admission to levels 2 and 3 care. Recommendations from NCEPOD included increased input from elderly medicine physicians, a focus on risk assessment and optimization, improved emergency theatre access, better intraoperative monitoring and planned postoperative care. However, it did not provide a clear framework for how this could be achieved.

More recently, NCEPOD has focused on assessment and management of risk in surgical patients. Although ‘Knowing the risk’ is not specific to the elderly, many of the high-risk patients were aged over 65 years and the report concluded that overall care was good in less than half of cases. ¹³ It identified specific deficiencies in risk assessment, in particular poor identification of the high-risk patient, which led to underuse of intraoperative monitoring, and high-risk patients returning to ward care rather than levels 2 and 3 care (high dependency or intensive care beds). The surgical pathway was frequently disjointed and non-patient-centred with considerable variation in patient outcome. To many of us working with older surgical patients, the findings of these reports come as no surprise and confirm our everyday experiences.

Has progress been made?

Evidence from numerous reports, surveys and audits suggest that our efforts over the past decade have not solved problems related to care of older people, whether it is in surgical or other settings. However, important issues have been brought into the public domain and generated increasing discussion in patient forums, the media and within medical specialties. Since the publication of the National Service Framework for Older People ¹⁴ and documents such as ‘Anaesthesia and Peri-Operative Care of the Elderly’ ¹⁵ , we have seen some progress.

Some of the most significant improvements have been seen in hip fracture care, a previously neglected area of surgery. The specialties of geriatrics, orthopaedics and anaesthetics have worked jointly to ensure change in clinical care, audit and quality improvement. Initiatives have included the ‘blue book from the British Geriatrics Society and British Orthopaedic Association, ¹⁶ the NHS Hip Fracture Perioperative Network ¹⁷ which encourages cooperation and exchange of ideas, the provision of evidence-based clinical guidance, a clinical pathway and quality standards from the National Institute of Clinical Excellence (NICE) ¹⁸ and the establishment of the National Hip Fracture Database (NHFD). ¹⁹ The latter allows care to be audited against six evidence-based standards and enables benchmarking of local performance in hip fracture care against national data. The linkage of data with clinical targets has formed the basis for the best practice tariff. This ‘carrot’ approach has shown year-on-year improvements in clinical care. However, the provision of daytime trauma operating lists and consultant orthogeriatric cover remains patchy, and despite these initiatives there are still 10-fold differences in ‘non-operation’ rates and similar differences in quality processes.

Emergency abdominal surgery presents similar (but unresolved) challenges to hip fracture care; high rates of postoperative complications, a high mortality rate rising to more than 40% in the over-80-year-olds, consumption of the highest proportion of critical care resources and wide variation in outcome. ²⁰ Patients often require immediate access to senior multidisciplinary decision-making, radiology, possibly levels 2 or 3 care, invasive monitoring and appropriate investigations before surgery takes place. For this group the Royal College of Surgeons has worked with the Department of Health, to produce ‘The High Risk General Surgical Patient’. ²⁰ This report is not age-specific, but the issues do disproportionately affect older patients. It provides practical solutions in the form of care pathways, escalation strategies, an ‘end of surgery bundle’ to define ongoing postoperative care and advocates a national audit of unscheduled general surgical admissions. However, it focuses on perioperative sepsis and has not addressed the need for improved medical care and rehabilitation on the surgical wards. In terms of collating national data the NHS Emergency Laparotomy Network ²¹ has been established. The network recently conducted an audit in 37 acute hospitals in England & Wales (BJA in press) highlighting devastating mortality figures for this patient cohort. The audit has formed the basis of a national laparotomy audit due to start in 2013. If this follows the success of the NHFD it will be a very positive contribution to improving the patient outcome and experience.

In elective surgery we have seen the widespread establishment of Enhanced Recovery Programmes (ERP), advocated by the NHS Institute and Department of Health. ²² This approach emphasizes the need for a patient-centred pathway, focusing on the provision of the best possible pre-, intra- and postoperative care. Promising results are being seen; however, little data are available for older people.

It is reassuring to see the emerging focus on high-risk surgical patients. However, the current initiatives do not provide a framework for the care of the older surgical patient, who is more likely to require tailored preoperative optimization and coordinated postoperative care. The evidence suggests that an urgent and radical review of care provision for this group of complex and high-risk surgical patients is needed.

What do we need to do? New approaches to the patient pathway

We suggest that provision of a high-quality and cost-effective service for the high-risk older surgical population requires new models and pathways of care. These models should allow the full scope of preoperative assessment, from recognition and optimization of the relevant issues, to formal risk assessment, to shared decision-making and appropriate perioperative planning. This in turn would allow the translation of existing evidence into routine clinical practice, particularly in those with complex co-morbidities and functional dependence. The same process should be applied in either the emergency or the elective setting although time constraints would influence both clinical practice and timely involvement of various specialists.

In the UK, most elective patients undergo preoperative assessment in protocol-driven nurse-led clinics. Patients identified as having complex anaesthetic concerns or undergoing specific types of complex surgery are referred to an anaesthetist. These clinics provide a thorough review, risk assessment and allow informed decision-making, but if optimization is necessary then the patient may require further assessment and management by physicians. In other units general physicians or geriatricians with an interest in perioperative medicine have taken on the role of preoperative assessment. One such model (proactive care of older people undergoing surgery, POPS) ²³ ensures that older patients with medical co-morbidities or functional dependence are followed throughout the surgical journey by a multidisciplinary elderly care medicine team. Preoperatively, the team utilizes comprehensive geriatric assessment methodology to assess and optimize the patient for surgery, predict postoperative complications and postoperative rehabilitation or care needs. The team follows the patient through the surgical journey and provides regular medical input during the postoperative period. The team aids the surgical team in early identification and standardized management of medical complications as well as in early, safe and effective discharge planning. This constitutes a proactive rather than reactive approach. It allows discussion between geriatricians, surgeons and anaesthetists regarding the risk–benefit ratio of surgery in patients with complex co-morbidities and proactive decisions regarding escalation and the postoperative level of care.

In most trusts, immediate postoperative care is provided by anaesthesists with access to levels 2 and 3 care. Care after days 2 or 3 is generally provided by surgical juniors, with reactive input from on-call medical teams, anaesthesia, acute pain teams and critical care outreach. Yet, we know that 70% of deaths occur on surgical wards after four days. ¹² In the USA we have seen the emergence of the hospitalist model, with physicians co-managing patients with surgical teams. There are emerging data demonstrating reduced complications, improved efficiency and increased satisfaction among patients and staff. ^24,25

Various models of perioperative care for older surgical patients are developing and will vary according to local supply and demand. However, they all emphasize the need for cross- and multidisciplinary working, utilizing the skills of surgical, anaesthetic, organ specialist and elderly medicine teams. The pathway must be patient centred ensuring the patient is in the best possible condition preoperatively, receives the best intraoperative care, and is proactively managed postoperatively. The focus must be on preventing morbidity, recovering functional status and reducing mortality. With the Royal College of Physicians having recently established the Future Hospital Commission ²⁶ (reviewing ‘all aspects of design and delivery of inpatient hospital care’) this maybe an opportune moment to radically rethink the way in which we provide care for medically complex patients in surgical settings.

What we need to do? Change clinical practice

Within these new models of care we need to ensure translation of the evidence base and implementation of best clinical practice into routine clinical care.

What we need to do? Cross-disciplinary working

For too long medical specialities have worked in silos, with lack of recognition of the benefits of a multispecialty approach. The successful initiatives have been those where there has been cross-disciplinary working, for example the NHFD. We must learn from this and encourage specialist societies in anaesthesia, surgery and medicine to seek ‘cross border’ cooperation. This is vital for developing models of care which are patient-centred and responsive to their needs, rather than fitting the patient into existing pathways. It will allow dissemination of good practice, education and training, and research. Interdisciplinary platforms such as NHS Networks and national audits should drive data collection, and quality improvement initiatives. This year the Association of Anaesthetists Annual Congress has sessions by the British Geriatrics Society (BGS) and the Association of Surgeons of Great Britain & Ireland. Similarly, the BGS has a multispecialty session on care of the older surgical patient.

Health-care professionals across all disciplines should understand the basics of diagnosis, risk assessment and management of older people, particularly in the context of our ageing population. Education and training should focus on the physiology of ageing, management of multimorbidity, the importance of cognitive problems and shift towards a bio-psycho-social model. To achieve this, both undergraduate and postgraduate curricula require review, the latter not only in medicine but also in surgery and anaesthesia. If a doctor chooses to become a surgeon it does not negate his or her responsibility to being able to manage an older patient. Some inroads have been made. Deaneries are reviewing surgical training and emphasizing the need for training in perioperative medicine. We have established cross-disciplinary training programmes in perioperative medicine, and are developing joint training posts between anaesthetics and geriatrics. However, much needs to be done and an ‘entire culture change’ is required. ³³

The lack of high-quality perioperative research studies involving patients who are aged over 80 years hinders our progress. Much of the guidance is extrapolated from data in younger patients. Why are older patients excluded? Often they have multimorbidity, are taking multiple medications or may be cognitively impaired. ³⁴ A good example of exclusion of older people in studies is enhanced recovery protocols for elective orthopaedic surgery. Almost all the studies include ASA 1 to 3 patients who are cognitively intact. One particular study, investigating the incidence of postoperative delirium on a ‘fast track’ (nomenclature used in Denmark, interchangeable with enhanced recovery) recruited ‘patients who were healthy and cognitively intact’. ³⁵ We must ensure ‘real patients with real problems are included in research studies. The traditional randomized controlled methodology may not be appropriate and funding bodies must recognize the importance of complex intervention studies (often pre- and postintervention) in this group of complex patients.

Conclusions

To summarize, we have made some progress in care provided to older surgical patients but we have a considerable way to go in ensuring high-quality and dignified care to all.

To achieve this goal we need to ensure our hospitals develop patient-centred clinical models and pathways of care, to ensure education and training reflects the demography of our population (i.e. older, more multimorbidity, higher levels of functional dependency) and that we constantly review our practice aiming for the highest standards. ‘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).