Search

Older adults constitute a large proportion of patients undergoing surgery and present with complexity, predisposing them to adverse postoperative outcomes. Inequalities exist in the provision of surgical care across the United Kingdom evidenced by increased waiting times in areas of social deprivation, a disparity in the provision of surgical care across geographic locations as well as a variation in the medical management of comorbidities in surgical patients. Addressing inequalities in the delivery of perioperative care for older adults necessitates a multi-faceted approach. It requires implementation of an evidence-based approach to optimisation of older surgical adults using Comprehensive Geriatric Assessment and optimisation methodology at scale, development of an age-attuned, flexible, transdisciplinary workforce, a restructuring of funding to commission services addressing the needs of the older surgical population and a change in culture and professional and public understanding of the needs of the older surgical patient. [ABSTRACT FROM AUTHOR]

Background: This is Part 2 of the first consensus guidelines for optimal care of patients undergoing emergency laparotomy (EL) using an Enhanced Recovery After Surgery (ERAS) approach. This paper addresses intra- and postoperative aspects of care. Methods: Experts in aspects of management of high-risk and emergency general surgical patients were invited to contribute by the International ERAS® Society. PubMed, Cochrane, Embase, and Medline database searches were performed for ERAS elements and relevant specific topics. Studies on each item were selected with particular attention to randomized clinical trials, systematic reviews, meta-analyses, and large cohort studies and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Recommendations were made on the best level of evidence, or extrapolation from studies on elective patients when appropriate. A modified Delphi method was used to validate final recommendations. Some ERAS® components covered in other guideline papers are outlined only briefly, with the bulk of the text focusing on key areas pertaining specifically to EL. Results: Twenty-three components of intraoperative and postoperative care were defined. Consensus was reached after three rounds of a modified Delphi Process. Conclusions: These guidelines are based on best available evidence for an ERAS® approach to patients undergoing EL. These guidelines are not exhaustive but pull together evidence on important components of care for this high-risk patient population. As much of the evidence is extrapolated from elective surgery or emergency general surgery (not specifically laparotomy), many of the components need further evaluation in future studies. [ABSTRACT FROM AUTHOR]

Frailty is common in the older population and is a predictor of adverse outcomes following emergency and elective surgery. Identification of frailty is key to enable targeted intervention throughout the perioperative pathway from contemplation of surgery to recovery. Despite evidence on how to identify and modify frailty, such interventions are not yet routine perioperative care. To address this implementation gap, a guideline was published in 2021 by the Centre for Perioperative Care and the British Geriatrics Society, working with patient representatives and all stakeholders involved in the perioperative care of patients with frailty undergoing surgery. The guideline covers all aspects of perioperative care relevant to adults living with frailty undergoing elective and emergency surgery. It is written for healthcare professionals, as well as for patients and their carers, managers and commissioners. Implementation of the guideline will require collaboration between all stakeholders, underpinned by an implementation strategy, workforce development with supporting education and training resources, and evaluation through national audit and research. The guideline is an important step in improving perioperative outcomes for people living with frailty and quality of healthcare services. This commentary provides a summary and discussion of the evidence informing the standards and recommendations in the published guideline. [ABSTRACT FROM AUTHOR]

Objective To assess the impact of introducing and embedding a structured geriatric liaison service, Proactive care of Older People undergoing Surgery ( POPS)-Urology, using comprehensive geriatric assessment methodology, on an inpatient urology ward. Patients and Methods A phased quality improvement project was undertaken using stepwise interventions. Phase 1 was a before-and-after study with initiation of a daily board round, weekly multidisciplinary meeting, and targeted geriatrician-led ward rounds for elective and emergency urology patients aged ≥65 years admitted over two 1-month periods. Outcomes were recorded from medical records and discharge documentation, including length of inpatient stay, medical and surgical complications, and 30-day readmission and mortality rates. Phase 2 was a quality improvement project involving Plan-Do-Study-Act cycles and qualitative staff surveys in order to create a Geriatric Surgical Checklist ( GSCL) to standardize the intervention in Phase 1, improve equity of care by extending it to all ages, improve team-working and streamline handovers for multidisciplinary staff. Results Phase 1 included 112 patients in the control month and 130 in the intervention month. The length of inpatient stay was reduced by 19% (mean 4.9 vs 4.0 days; P = 0.01), total postoperative complications were lower (risk ratio 0.24 [95% confidence interval 0.10, 0.54]; P = 0.001). A non-significant trend was seen towards fewer cancellations of surgery (10 vs 5%; P = 0.12) and 30-day readmissions (8 vs 3%; P = 0.07). In Phase 2, the GSCL was created and incrementally improved. Questionnaires repeated at intervals showed that the GSCL helped staff to understand their role better in multidisciplinary meetings, improved their confidence to raise issues, reduced duplication of handovers and standardized identification of geriatric issues. Equity of care was improved by providing the intervention to patients of all ages, despite which the time taken for the daily board round did not lengthen. Conclusion This is the first known paper describing the benefits of daily proactive geriatric intervention in elective and emergency urological surgery. The results suggest that using a multidisciplinary team board round helps to facilitate collaborative working between surgical and geriatric medicine teams. The GSCL enables systematic identification of patients who require a focused comprehensive geriatric assessment. There is potential to transfer the GSCL package to other surgical specialties and hospitals to improve postoperative outcomes. [ABSTRACT FROM AUTHOR]

Background Delirium is a common clinical syndrome with significant associated mortality, morbidity and financial cost. Less is understood about the experience of delirium for the patient, their family and staff involved in their care. Objective This synthesis draws on qualitative and quantitative literature examining different populations (patients, relatives and staff) in different clinical settings (intensive care units, surgery and hospice care) to provide a clinical summary of the delirium experience from the perspective of patients, relatives and staff. Design A literature search was conducted in Ovid, MEDLINE, Embase, PsychINFO, British Nursing Index and Archive and PubMed between 1980 and 2011 using the terms 'delirium' combined with 'distress', 'recall', 'anxiety', 'depression', 'PTSD', 'experience' and 'patient education'. Articles were restricted to English language only. Results Evidence suggests that some patients recall delirium and that recollections are generally distressing. Distress may be greater in relatives witnessing delirium and is also reported in professional staff. This distress may result in longer-term psychological sequelae. Remedial action, such as explanatory information to patients and their families, may reduce distress and psychological morbidity. Conclusions A better understanding of the experience and psychological consequences of delirium will inform the development of appropriate methods of providing support and information to those at risk of delirium and their families or carers. Copyright © 2012 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Presents a reply by J. K. Dhesi, C. Moniz, J. C. T. Close and S. H. D. Jackson to a letter to the editor about their study "A Rationale for Vitamin D Prescribing in a Falls Clinic Population," published in the 2002 issue of the journal "Age and Ageing."