Ageing and Complex MedicineP-POSSUM Advanced Chronological Age. 12-month survival curves EGS Total...
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Arturo Vilches - Moraga Ageing and Complex Medicine 28 th September 2018
Transcript of Ageing and Complex MedicineP-POSSUM Advanced Chronological Age. 12-month survival curves EGS Total...
Arturo Vilches-Moraga
Ageing and Complex Medicine
28th September 2018
Improving surgical outcomes (POP-GS)
Improving surgical outcomes (POP-GS)
19%90%
Surgery in the older person
• Elective surgery
Surgery in the older person
• Elective surgery
Surgery in the older person
• Emergency surgery
Emergency General Surgery hospital admissions
J Trauma Acute Care Surg. 2014;77: 202-208
7.1% of admissions are EGS
N 27,668,887 between 2001-2010
Emergency General Surgery hospital admissions
J Trauma Acute Care Surg. 2014;77: 202-208
30% EGS >70 years of age
7.1% of admissions are EGS
Emergency General Surgery hospital admissions
30% EGS >70 years of age
7.1% of admissions are EGS
30%Surgical intervention
N 105,002 between 2000-2014
Indicators of poor prognosis in EGS/ Em Lap
Advanced Chronological Age
Indicators of poor prognosis in EGS/ Em Lap
ASA Class III-V Complications Time of day
P-POSSUMAdvanced
Chronological Age
12-month survival curves EGS
Total Deaths
Alive Proportion Alive
598 175 423 70,7%
12-month survival curves EGS
Total Deaths
Alive Proportion Alive
598 175 423 70,7%
Surgery
Age 75-79
Age 80-89
Age 90 or older
Procedure
Medical
12-month survival curves EGS
Wald p Odds Ratio 95% Confidence Interval
ASA Class III-V 21,012 ,000 2,627 1,738 3,971
Dependent personal ADLs 15,108 ,000 2,470 1,566 3,898
Clinical Frailty Scale 5-9 11,384 ,001 1,944 1,321 2,860
24 hour Care 5,310 ,021 1,790 1,091 2,937
Impaired cognition 3,965 ,046 1,459 1,006 2,117
Cognitive impairment
Clinical Frailty
Functional impairment
ASA Class
12-month survival curves Emergency Laparotomy
12-month survival curves Emergency Laparotomy
Wald p Odds Ratio 95% CI
Not reviewed by POP-GS 11,234 ,001 6,620 2,192 19,993
Clinical Frailty Scale 5-9 8,337 ,004 5,403 1,719 16,982
ASA Class III-V 4,098 ,043 2,704 1,032 7,081
Cumulative
Survival
Cognitive impairment Clinical Frailty
Indicators of poor prognosis in EGS/ Em Lap
Cognitive impairment
Mobility impairment
Functional impairment
Lack of social support
Sphincter disturbance
Malnutrition
Delirium
ASA Class III-V Complications Time of day
P-POSSUMAdvanced
Chronological Age
FrailtyPolypharmacy
Collaborative working
• Skills
• Goal
• Vision
• Leadership
• Communication
• Quality improvement
• Creativity
• Research
Our final objective
Vision: Collaborative Care
Royal College of Surgeons.
• Proactive, daily case finding service for patients over 74-years of age
The set up: Salford-POPS-GS in-reach Service
• Proactive, daily case finding service for patients over 74-years of age
• Core team: Senior nurse, physiotherapist, Occupational therapist, geriatrician (4 DCC PA
shared between 2 consultants)
The set up: Salford-POPS-GS in-reach Service
Salford-POPS-GS
Salford-POPS-GS
Continuity of care
Before February 1st 12.2 Median
After February1st
8.4 Median
0
5
10
15
20
25
30
35
40
Patients Discharge Median LOS (admission month) Patients admited
9 days3
days
Continuity of care
0
5
10
15
20
25
30
35
40
Patients Discharge Median LOS (admission month) Patients admited
9 days3
days
Before February 1st 12.2 Median
After February1st
8.4 Median
Advanced Clinical Practitioner
Aim:
• Implement 0.5WTE Band 8a ACP to provide an older persons’ surgical liaison service into general surgical wards, by October 2018
Objectives:
• Increase compliance with NELA standard ‘Assessment by MCOP Team patients aged ≥70 years’ from78% to the expected 80% target within 6 months
• Decrease median LOS surgical patients≥75 years by 1 day within 6 months
• Improve accuracy in coding by undertaking CGA
Proposal for a Acute Surgical Abdominal Pain care pathway
Community Hospital
Relative/sCarer/s
Home
Residential Home
Intermediate Care
Rapid Response Team
Surgical Triage Unit
Emergency Department
Emergency Admissions Unit
Acute General Surgical Ward
ICU/ SHDU
Nursing Home
Out patients
Acute Physicians
Single Organ Specialists
Voluntary Sector
SurgeonsAnaesthetists
Geriatricians
Pathway Manager
Social Worker
General Practitioner
District Nurses
Specialist Nurses
Dieticians
IV Team
Pharmacists
Physiotherapists
Occupational Therapist
Palliative Care Team
Nursing Staff
Advance Nurse Practitioner
Auxiliary Nurses
Radiology Team
Porters
Bed Managers
Care Home Staff
Patient
ResearchSRFT/GSTT
POP-GS-UK Registry
Key messages: EGS older people
• CGA - Surgical and non surgical factors - interventions
• Targeted, patient centred interventions - Quality of life
• Collaborative working
Key messages: EGS older people
• CGA - Surgical and non surgical factors - interventions
• Targeted, patient centred interventions - Quality of life
• Collaborative working
Frailty
Disclosure of conflict of interests
• 850-bedded urban teaching hospital serving 240.000
• Tertiary renal, neurosurgery, major trauma and stroke centre
• Foundation Trust …
