Collaborative Older Persons Elective Surgery Risk Assessment for Treatment Efficacy

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Initiative Type

Evidence Review

Model of Care

Status

Close

Added

06 September 2018

Last updated

05 February 2024

Summary

Health systems in Australia and worldwide have been required to develop models of care which improve patient outcomes and satisfaction while reducing associated costs. These pressures are further compounded by an ageing population who require increased access to health care services. Redesigning models of care enables health services to systematically change and improve the way care is delivered. The COOPERATE 1 project proposed a framework for clinical redesign of preoperative assessment and management of older Queenslanders undergoing elective surgery. This was prompted by an evidence base showing older people were more likely to suffer postoperative complications including morbidity, mortality and functional decline; and that co-morbidity alone did not adequately capture the health status of older people undergoing surgery.

COOPERATE 2 reports on the operationalisation of the framework that was proposed in COOPERATE 1. An operational plan was formulated to guide and support the implementation of the COOPERATE framework. Together the operational plan and the COOPERATE 1 report, provided guidance to implement the redesigned model of care for older elective surgical patients.

Key dates

Feb 2018

Aug 2018

Partnerships

Statewide Older Persons’ Health Clinical Network (SOPHCN), Statewide Anaesthesia and Perioperative Care Clinical Network (SWAPNet) and Surgical Advisory Committee (SAC)

Aim

Provide a parallel pathway to effectively and efficiently assess, manage and plan the preoperative surgical journey for older persons.

Benefits

Optimises and supports management of the patient’s preoperative risks associated with their planned surgery/procedure and anaesthesia.
Integration with primary care optimises the patient’s preoperative wellbeing.
Prepares the patient, family and carer for the whole surgical/procedural journey.

Background

With ageing of the Australian population, the number of older people, particularly the oldest old (aged 85 years and older), accessing surgery is increasing. Surgery in older people can still offer significant benefits in terms of quality and quantity of life. However, older people are more likely to suffer complications from or die after surgery. Some of this increased risk is due to multi-morbidity which can be quantified using risk calculators such as the American College of Surgeons National Quality Improvement Program Risk Calculator (ACS NSQIP®), and some due to geriatric syndromes. Geriatric syndromes are frequently under-recognised in the preoperative setting without screening, therefore integrating routine screening pre-operatively is recommended.

There is evidence to support interventions which mitigate risk and improve outcomes for older people in whom geriatric risk factors are identified. Comprehensive geriatric assessment (CGA) is a multidisciplinary geriatrician-led method of assessing and managing the complex care needs of older people. When undertaken in the preoperative setting, it has been shown to reduce post-operative length of stay (LOS) and complications such as delirium.

Solutions Implemented

The development of the decision support tool and the preoperative screening framework to guide and support clinicians in the provision of preoperative assessment, planning and management of the older person undergoing elective surgery.

This decision support tool provides a suggested parallel pathway to effectively and efficiently assess, manage and plan the preoperative surgical journey for an older person.

Evaluation and Results

Across three hospitals caring for older elective orthopaedic and colorectal surgery patients, COOPERATE 2 identified that screening was inconsistent between sites and surgical groups, and often did not use recommended or valid tools. Barriers that impacted upon both the accurate completion of screening and the absence of clear pathways for acting on abnormal results were identified. This potentially leads to common risk factors being unrecognised or not acted upon. At Logan hospital these barriers were investigated in greater depth. It was clear there are a large number of stakeholders who need to be considered, and that there are many logistic considerations in terms of staffing, timing, space and processes which need to be addressed for screening to successfully translate to integrated actions.

COOPERATE 2 integrated screening by an additional trained CN into preoperative clinics utilising the proposed COOPERATE 1 care pathway. Over a two-month period we screened 86% (24/28) eligible older patients, 4/28 (14%) were not screening due to CNC rostered day off cycle. Of the patients that were screened, 19/24 (79%) screened positive on at least one risk factor, most commonly polypharmacy (67%) or frailty (58%). Eight participants (33%) had 3 or more risk factors identified on screening and were referred to a geriatrician for comprehensive geriatric assessment (CGA), with 5 (21%) undergoing a CGA. Actions from CGA included diagnosis, including two new cases of cognitive impairment identified, advance care planning, medication optimisation, and discharge planning. One patient elected to pursue non-operative intervention. Screening was considered acceptable by all 15 patients interviewed post-discharge.

Recommendation
This project has shown that older Queenslanders undergoing elective surgery have geriatric risk factors which may influence their postoperative outcomes, and without screening would remain undetected. Implementing routine screening for and management of geriatric risk factors was feasible in the preoperative setting at Logan Hospital, but required dedicated nursing, pharmacy and medical resources, and engagement of a range of stakeholders to integrate into existing processes. The process of screening for and management of these risk factors is accepted by patients and their families. Larger scale evaluation of the feasibility in different settings, resource requirements, and clinical outcomes of preoperative screening is required to inform integration of these processes into routine care.