Care of older people in surgery (COPS)

Care of older people in surgery (COPS) Who, what, and does it make a difference Professor Jacqueline Close Geriatrician - POWH Clinical Director Falls, Balance and Injury Research Centre

Early Mobilisation Devas M, BMJ, 1974

Orthogeriatrics

Orthogeriatrics Reduction in complications Reduction in LOS Reduction in mortality Better functional outcomes?benefits beyond hip fracture

(PAC -1.8%) (PAC -7.6%) Neuburger et al. Medical Care: 2015; 53:686-691

Neuburger et al Age and Ageing 2017; 46:187-193

The Holy Trinity

25 hospitals 3519 patients 34 hospitals 5178 patients 57 hospitals 9408 patients

The Population Mean age 84yrs 70% female 71% from home 41% have known cognitive impairment 55% used an assistive device before the fracture

Pre-operative cognitive assessment

Nerve Blocks

Time to Surgery

PJ Devereaux et al, CMAJ 2014. doi10:1503/cmaj.130901

HIP ATTACK HIP Fracture Accelerated Surgical TreaTment And Care track Trial International randomized controlled trial of 3000 patients with a hip fracture that requires a surgical intervention. Rapid medical clearance with targeted arrival to the operating room within 6 hours of diagnosis of a hip fracture requiring surgical repair. Primary endpoints - 90 days Composite - mortality, nonfatal myocardial infarction, nonfatal pulmonary embolism, nonfatal pneumonia, nonfatal sepsis, nonfatal stroke, and nonfatal life-threatening and major bleeding All-cause mortality ClinicalTrials.gov Identifier: NCT02027896

Mortality Pain Antipsychotic use Physical restraint use Pressure ulcers

Outcomes at 6 months If you survive 6 months and had surgery, you are less likely to have pain or a pressure injury but more likely to be physically restrained

31% dead at 6mths 54% dead at 6mths Berry et al, JAMA 2018, doi:10.1001/jamainternmed.2018.0743

Comfort Care After Fracture 21% utilized any form of palliative care service in the last 6 months Of those who survived 6 months, only 1.1% had a do not hospitalize order

Venturing beyond orthogeriatrics Why Will we add value Which patients Which specialties What will success look like

Geriatric Patient Not defined by age Partially defined by comorbidity Better defined by function physical and cognitive

Frailty associated with everything that matters

Impact of age, CCI and Frailty in the Surgical Setting All Surgical Patients Christina Norris, unpublished data

What to do with Frailty Screening Prognostication Decision making Intervention this is where we need more evidence

2018 There is evidence that CGA can improve outcomes in people with hip fracture. There are not enough studies to determine when CGA is most effective in relation to surgical intervention or if CGA is effective in surgical patients presenting with conditions other than hip fracture.

Multidisciplinary CGA using agreed protocols & guidelines. Tailored intervention and management plan - documented in the electronic medical record Primary outcome - LOS Surgical intervention AAA repair Lower limb by pass surgery Post-operative care delivered by the surgical team Secondary outcomes - new comorbidities, complications, dependency, delay in discharge BJS, 2017

Multidisciplinary CGA using agreed protocols & guidelines. Tailored intervention and management plan - documented in the electronic medical record Primary outcome - LOS Surgical intervention AAA repair Lower limb by pass surgery Post-operative care delivered by the surgical team Secondary outcomes - new comorbidities, complications, dependency, delay in discharge BJS, 2017

BJS, 2017

Cognition MOCA 30/30 Now a certified genius according to his doctor!!

24% develop a delirium

Intervention 3 nursing protocols Orienting / communication Oral and nutritional assistance Early mobilisation

To assess the effectiveness of interventions for preventing delirium in hospitalised non-intensive Care Unit (ICU) patients. RCTs of single and multicomponent pharmacological and non-pharmacological interventions 39 trials (32 in surgical patients) 16,082 participants 22 different interventions

Intervention Studies Participants Quality RR Multicomponent intervention Cholinesterase inhibitors 7 1950 Moderate RR 0.69 (0.59-0.81) 2 113 Very low RR 0.68 (0.17-2.62) Antipsychotics 3 916 Very low RR 0.73 (0.33-1.59) Haloperidol 2 516 Very low RR 1.05 (0.69-1.6) Olanzapine 1 400 Moderate RR 0.36 (0.24-0.52) Melatonin 3 529 Low RR 0.41 (0.09-1.89) BIS guided anaesthesia 2 2057 Moderate RR 0.71 (0.6-0.85)

Which Patients Age Comorbidity Function physical and cognitive Elective v Emergent Only surgical intervention Which speciality

COPS Observational Cohort Study Apr-Aug 2016 Delivery of Shared Care Model Sep 16-Apr 18 Evaluation of new model Ongoing

COPS 303 patients (140 elective, 163 emergency) Age 75+, mean age 81, 41% female 91% community dwelling 59% mobilized independently 14% cognitively impaired Christina Norris

Observational Cohort Study Surgery undertaken in 65% 30% in General Surgery vs 81% in Plastic Surgery Median ALOS 4.0 days Emergency admissions 5.0 days Elective 2.5 days Most patients return directly home (86%) Rehabilitation in 7% (11% vs 3% in emergency vs elective)

Observational Cohort Study Complication rate 40% Higher in emergency admissions (50% vs 31%) No significant difference between those who undergo surgery and those who do not (47% vs 38%) Most common complications Delirium 18% Cardiovascular (AF, CCF, ACS) 15% AKI 14% Infection 13%

Surgical Specialties Less than 50% screen for CI A third screened for malnutrition Less than half reviewed by physiotherapist High rates of functional decline Communication Care coordination

Delivery of Shared Care Model Partly pragmatic / partly informed People aged 75+ Emergency admissions Acute & general surgery Colorectal surgery Upper GI surgery Oncological surgery

Models of care Consult Service Invited to review Issue specific Time limited Intermittent No onus to make changes Often driven at junior level Shared Care Joint responsibility Joint accountability Shared decision making Must come from the top Mutual understanding, trust and respect

Models of care Consult Service Invited to review Issue specific Time limited Intermittent No onus to make changes Often driven at junior level Shared Care Joint responsibility Joint accountability Shared decision making Must come from the top Mutual understanding, trust and respect

INTENSIVE PHYSIO PROGRAM MULTIDISCIPLINARY CARE COORDINATION FRAIL OR UNDERGOING SURGERY COMPREHENSIVE GERIATRIC ASSESSMENT 1 2 3 4 5 6 7 8 9 FIT VULNERABLE FRAIL END OF LIFE Clinical Frailty Scale

Nepean Hospital - Partners

799 patients seen over the study period Analysis in progress

Key Process and Outcome Measures Clinical Outcomes PROMs and PREMS Process Measures Complications Mortality Functional Status Experience Satisfaction LOS Cost of Care

Reduction in complications since the introduction of the COPS service 60% Reduction in Complications 50% 40% 30% 20% 10% 0% PRECOPS POSTCOPS

LOS 7.6 days to 6.9 days

Rate of Falls Reduced

Better Documentation - Nepean 80 Co-Morbidities 70 60 50 % 40 Pre-COPS Post-COPS 30 20 10 0 HT AF IHD Cog Imp Depression COPD

Reduced Medical Complications - Nepean 14 Complication 12 10 % 8 6 Pre-COPS Post-COPS 4 2 0 HAP AKI Arrhythmias ACS CCF Delirium

Patient and Staff experiences

3 words to describe COPS Service

Conclusions Orthopaedic care model well established altho still room to improve delivery / outcomes Evidence in other surgical specialties emerging Geriatric medicine needs to be clear who is its target population Do we need large RCTs?