Early results from implementation of a novel perioperative

geriatric service in an acute surgical unit

Dr Lauren Styan, Dr Skyle Murphy, Dr Aisling Fleury, Dr Brian McGowan, A/Prof Martin Wullschleger

Division of Surgery, Logan Hospital

AMA QLD Junior Doctors Conference

Introduction

Australia has an ageing population

Geriatric population forecast to double

Health expenditure to increase 7x

General surgery workload to increase 31% by 20201

1. Etzioni et al. Annals of Surgery 2003.

Introduction

Complex management challengesAge related physiological changesMultiple medical comorbiditiesPolypharmacyGeriatric syndromes

Increased in-hospital complications and mortality independent of surgical factors2

2. McVeigh et al. International Journal of Surgery 2013

Introduction

Geriatricians are experts in managing elderly patients

Ortho-geriatric models effective in decreasing LOS, in-hospital morbidity and mortality following hip fracture3

American College of Surgeons and the Royal College of Surgeons of England recommendations

Novel perioperative geriatric service implemented Logan Hospital Surgical Unit in Oct 2014

3. Grigorvan et al. Journal of Orthopaedic Trauma 2014

Purpose

To determine if the implementation of a novel perioperative geriatric service (PGS) into an acute surgical unit improves patient and organizational outcomes

Methodology

Single center, retrospective cohort study

Patients ages 65 years and over

Admitted to acute general surgical unit 1 May 2014 – 31 July 2014 (Pre-PGS) 1 Jan 2015 – 30 March 2015 (Post-PGS)

Primary outcomes included the number and outcome of medical consults, length of stay, in-hospital mortality and discharge destination

Statistical analysis significance level P<0.05

Metro-south HREC approval (Reference no: HREC/15/QPAH/352)

Pre-PGS Post-PGS

Patients admitted to ASU

84 100

Operative management

16 (19%) 30 (30%)

Non-operative management

68 (81%) 70 (70%)

Age (average and range)

73.6 (65-94) 74.5 (65-96)

M:F 47 (56%) :37 (44%) 48 (48%) : 52 (52%)

Results - Demographics

PGS reviewed 36% of patients, resulting in a change to management in 75% of those reviewed.

Review - change to managementReview - no change to managementNo review

PGS review

Pre-PGS Post-PGS Significance

Number of specialist consults

35 (41.6%) 28 (28%) P = 0.06

Intervention following specialist consult

29 (82.8%) 26 (92.8%) P = 0.28

Complications (Medical and Surgical)

9 (10%) 18 (18%) P = 0.16

ICU admissions 4 (4.76%) 5 (5%) P = 0.6

In-hospital mortality 0 1 (1%)

Length of stay (average)

3.98 4.05 P=0.9

Discharge to previous residence

79 (94%) 93 (93%) P=0.5

Results – Primary Outcomes

Pre-PGS Post-PGS Significance

Patients managed operatively

16 30

Patients requiring 1+ specialist consults

3 (19%) 4 (13%) P = 0.68

Complications Medical – 2 (13%)

Surgical – 2 (13%)

Medical – 8 (27%) Surgical – 5 (17%)

P = 0.45 P = 1

ICU admissions 1 (6%) 5 (17%) P = 0.65

In-hospital mortality 0 0

Length of stay (median)

6 3 P = 0.45

Discharge to previous residence

15 (93%) 28 (93%) P = 1

Results – Subset analysis of operative management

Hospital wide acceptance of a perioperative geriatric service

Trends towards improved utilization of hospital resources Decreased specialist consultations and increased

interventions from specialist consults Similar in-hospital patient outcomes Reduced length of stay in sub-analysis of operative

management

Cost of admission to ASU per day $1200-1400

Future directions Large scale review with greater statistical powerLong term outcomes

Conclusions

Questions?

AIHW 2013. Australia's welfare 2013. Australia's welfare no. 11. Cat. no. AUS 174. Canberra: AIHW.

Treasury (The Treasury) 2010. Australia to 2050: future challenges. Intergenerational report series no. 3. Canberra: Treasury

Etzioni DA, Liu JH, Maggard MA, et al. The aging population and its impact on the surgery workforce. Ann Surg 2003;238:170–7.

McVeigh TP, Al-Azawi D, O’Donoghue GT et al. Assessing the impact of an ageing population on complication rates and in-patient length of stay. International Journal of Surgery. 2013:11(9);872-875

Grigorvan KV, Javedan H, Ruldolph JL. Ortho-Geriatric Care Models and Outcomes in Hip Fracture Patients: A Systematic Review and Meta-Analysis. J Orthop Trauma. 2014 Mar;28(3):e49-55

American college of Surgeons National Surgical Quality Improvement Program

United Kingdom National Emergency Laparotomy Audit

References