March 4, 2021
As the world’s population ages, older people are increasingly presenting to the hospital with surgical problems that require assessment and management. Older patients face different challenges than their younger counterparts, including an increased risk of complications, death, and functional decline.1,2 The presence of frailty, cognitive impairment, and multiple comorbidities also contributes to poorer postoperative outcomes and necessitates holistic and comprehensive care.1,3,4
Collaboration between surgeons and geriatricians is known to improve outcomes for older patients with hip fracture.5 Evidence is emerging for similar models of care in other surgical populations—including patients with vascular and gastrointestinal conditions.6-8 Furthermore, a recent study demonstrated the benefit of geriatrician review in reducing mortality of older people undergoing emergency laparotomy.9 Nonetheless, translation into clinical practice has been slow.10-12 Whether a similar model of care would improve outcomes for patients in the acute general surgery setting is less clear.
Prince of Wales Hospital, Sydney, Australia—a 450-bed metropolitan teaching hospital and tertiary referral center—has a long history of collaborative care for older patients with orthopaedic and vascular surgical problems. Patients admitted with general surgery conditions were noted to have a high rate of hospital-acquired complications with significant levels of functional dependency and unplanned readmission. This problem is particularly common among older patients undergoing emergency laparotomy.10 Given the success of the established models of collaborative care, the departments of general surgery and geriatric medicine sought to determine whether similar benefits could be achieved in the emergency general surgery population, with a view toward improving their outcomes.
Prince of Wales Hospital has a well-established department of geriatric medicine that operates a shared model of care for older orthopaedic trauma and vascular surgery patients. Input into other surgical specialties was otherwise provided on an individual consult basis.
Over the course of a year, approximately 500 older (75-plus years old) patients are admitted to the general surgery service for emergency care. Less was known about these patients until a 2016 observational cohort study (n = 303) was undertaken, which demonstrated that many (41 percent) patients experienced complications during admission, with the most common complication being delirium (18 percent). A significant proportion (26 percent) of patients also experienced decline in mobility and function during their stay.
Armed with the information from the observational cohort study, literature demonstrating how collaborative care can improve outcomes, and a shared desire to improve care for older general surgery patients, senior members of both departments agreed to pilot a new model of care. We decided to focus on older emergency general surgery patients because this population appeared vulnerable, experiencing a high rate of complications.
Before proceeding, funding had to be secured with an understanding that the work would be time-limited and if it failed to add value, the service would cease. Likewise, success would then necessitate ongoing financial support.
Discussions took place with key stakeholders, and grant funding for innovation and translational research grants was sought from the local Health District and State Department of Health, respectively.
This study follows several international initiatives and guidelines for older surgical patients. In the U.K., geriatrician review is considered a standard of care for older people undergoing emergency laparotomy and is known to improve outcomes for this population.9,13 Similarly, the perioperative medicine model of care for older people undergoing surgery has been well described in the literature, with evidence of increasing uptake of similar collaborative models of care between surgeons and geriatricians across the U.K.12,14
In the U.S., the American Geriatrics Society, American Society of Anesthesiology, American College of Surgeons, and the Society for Perioperative Assessment and Quality Improvement have produced guidelines for older surgical patients. These standards include a recommendation that high-risk, older surgical patients receive geriatrician review, with comprehensive geriatric assessment considered the gold standard for managing frailty.15-18
To address identified opportunities to improve care, we decided to use a collaborative model of care with each patient receiving shared care from a general surgeon and a geriatrician. The model was introduced September 19, 2016, and was delivered to patients ages 75 and older admitted to a general surgical specialty on an emergent basis, with a planned period for the pilot to run until January 31, 2018.
Continued commitment at senior levels and ongoing support from clinical champions to ensure that a collegial and collaborative environment was maintained, along with communication with key stakeholders, including nursing staff and allied health, assisted with successful implementation.
In addition to shared care, all patients received physiotherapy from extra hours resourced by the grant. Patients underwent comprehensive geriatric assessment on admission and were reviewed daily, Monday through Friday, by an aged care fellow who worked closely with nursing and allied health staff on the ward to ensure the delivery of coordinated care and facilitate early discharge planning.
The Care of Older People in Surgery (COPS) service includes a geriatrician (0.2 full-time equivalent [FTE]), geriatric registrar (0.6 FTE), and physiotherapist (0.5 FTE). This service operates collaboratively and in tandem with the usual surgical services, which include an acute surgical unit for emergency general surgical admissions that is composed of a general surgeon, a surgical registrar, senior resident, and clinical nurse consultant. Funding was sought through two grant initiatives, including an innovation grant locally via the South Eastern Sydney Local Health District as well as at the state level with a translational research grant through New South Wales Health. The cost of this initiative totaled $284,000 (AUD) over 18 months.
After initial discussions, the model of care was introduced. Throughout implementation multiple problems were encountered. These ranged from a high volume of allied health referrals, beyond that generated directly by the COPS service; lack of experience among nursing staff in caring for patients with delirium; and access to food immediately upon upgrade of diet.
For each problem encountered, “plan, do, study, act” cycles were used to identify the root cause and appropriate solutions. Following are solutions that have been implemented:
More broadly, although an overarching goal was to improve collaboration between the general surgery and geriatric departments, not all staff bought in to the model from day one. Concerted efforts to meet with consultants and senior staff semi-regularly, continued support at an executive level, and promotion of communication at all levels within the team with their surgical counterparts allowed for the development of professional relationships. By the end of the implementation period, communication occurred freely, allowing for better medical and surgical decision-making, as well as more efficient discharge planning.
TABLE 1. PATIENT OUTCOMES BEFORE AND AFTER COPS INTRODUCTION
This initiative was evaluated using a mixed methods approach. First, the impact of COPS on clinical outcomes was evaluated through a retrospective, case-matched cohort study with patients matched before and after implementation of the model of care. Patients were matched using age, gender, and Australian Refined Diagnosis Related Group (AR-DRG). The primary outcome measure was the rate of hospital-acquired complications (HACs) with secondary outcomes measures, including specific complications such as delirium, 30-day mortality, length of stay (LOS), and unplanned readmission. Data were extracted directly from patient files using a range of pre-defined criteria for specific HACs. The local Human Research Ethics Committee granted approval for this patient data extraction.
Although there was a clear interest in a collaborative model of care between the departments of general surgery and geriatric medicine, the results of the observational cohort study provided much-needed data to demonstrate both an opportunity for improvement and the basis for change.
The analysis included 352 patients. Only a quarter of patients underwent surgical intervention with similar rates of surgical intervention between groups. Patients in the intervention group were significantly less likely than the control group to experience complications odds ration (OR) 0.69 (95 percent confidence interval (CI) 0.53–0.89, p = 0.004). Patients also were less likely to experience specific complications such as delirium OR 0.64 (95 percent CI 0.44–0.92, p = 0.017) and hospital-acquired infection OR 0.58 (95 percent CI 0.34–0.99, p = 0.045). Patients experienced lower rates of functional decline and unplanned readmission. There was no significant difference in LOS (median total LOS 4.1 versus 3.9 days).
Second, a qualitative study was undertaken to explore patient and staff experience with the model of care. Although this feedback was overwhelmingly positive, it was evident that opportunities for further improvement remain. Staff reported that they would like the service to be expanded to patients younger than 75 years of age, patients admitted electively, and patients admitted to other surgical specialties. Staff also were asked to offer three words that reflected their experience with working with the COPS service. For a word cloud representing this feedback, see Figure 1.
FIGURE 1. WORD CLOUD BASED ON STAFF FEEDBACK ON WORKING WITH THE COPS SERVICE
Third, system-level data were used to determine whether the model of care provided any benefit in terms of coding and cost. Patients with gastrointestinal or hepatobiliary AR-DRG diagnoses from two 16-month periods before and after the intervention were compared. A total of 894 patients were analyzed, with 415 admitted before the intervention and 479 after. Patients in the intervention group were found to have significantly higher rates of major or intermediate coded complexity, resulting in a higher mean total National Weight Average Unit (NWAU) (2.31 versus 1.88, independent t test p = 0.036). For the 2017–2018 fiscal year, these data equate to a difference of 0.43 total NWAU per patient, or $2,111.30 (AUD) based on the national efficient price at the time of $4,910 (AUD) per unit.
For this cohort of 479 patients, this cost difference reflects additional reimbursement of $1,011,312.70 (AUD) during the intervention period compared with the total outlay for staffing of $284,000 (AUD) for the same time period.
Despite the success of the service and clear evidence demonstrating benefit, securing long-term funding was difficult. At the end of the implementation period, many surgeons, nurses, and allied health care professionals asked to continue the program; in fact, we received requests for expansion. Only after many discussions and continued advocacy from the department of surgery was funding provided. As a result, the COPS service has been sustained with a part-time geriatrician, full-time geriatric registrar, and part-time physiotherapist, and plans are under way to expand the program to additional surgical specialties.
Although there was a clear interest in a collaborative model of care between the departments of general surgery and geriatric medicine, the results of the observational cohort study provided much-needed data to demonstrate both an opportunity for improvement and the basis for change. Similarly, the data also provided a means of comparison to demonstrate whether the intervention succeeded. The decision to pilot the model over a defined period of time provided a clear signal that if success was not achieved, the model would stop. Similarly, when success was achieved, the knowledge that the model of care would stop indefinitely without funding provided an impetus for securing permanent funding to prevent the cessation of the service.
At the end of the implementation period, many surgeons, nurses, and allied health care professionals asked to continue the program; in fact, we received requests for expansion.
The success of this intervention—like any novel model of care—also can be attributed to buy-in from key stakeholders and leadership. Continued commitment at senior levels and ongoing support from clinical champions to ensure that a collegial and collaborative environment was maintained, along with communication with key stakeholders, including nursing staff and allied health, assisted with successful implementation.
The COPS team similarly sought to ensure staff felt comfortable being approached to discuss patients or other aspects of care. These measures facilitated implementation and created a model of care that was responsive to the needs of patients within the environment it was being delivered in, while being flexible and adaptable to challenges as they arose.