Priming elderly patients for surgery - the development of a pre-operative service for frail elderly patients

Purpose

The Peri-operative Review Informing Management of the Elderly (PRIME) Clinic was developed in response to the increasingly frail population undergoing complex major surgery. Due to this, it was recognised that clinicians with advanced skills were required to manage and optimise this patient group pre-operatively, which led to the formation of a multi-disciplinary team consisting of consultant geriatricians, consultant anaesthetists, a senior physiotherapist and a senior occupational therapist. The aim of the team was to optimise patients from a medical, physical and social viewpoint.

The focus of physiotherapy input was to increase physical activity pre-operatively, improve respiratory function and identify falls risks in order to contribute to a reduction in post -op length of stay and improve patient function.

This service evaluation demonstrates the benefit of a highly specialised MDT model with frail elderly elective surgery patients.

Patient experience questionnaires
generated a respondent rate of 62.7%.
100% of patients
reported they understood the advice provided in the PRIME Clinic...
98.2% of patients
Were either “very satisfied” or “satisfied” with their PRIME appointment
...with 72.8% of patients
reporting they would make “most” or “some” of the lifestyle adjustments suggested e.g. exercise, smoking cessation.

Approach

A business case secured funding for anaesthetic and geriatrician time, as well as the formulation of new part-time permanent posts for a physiotherapist and occupational therapist. The multidisciplinary team conducts comprehensive geriatric assessments with patients identified as frail during pre-operative nursing assessment, or by their surgeon.

Patients who are over 65 and score 4 or more on the Rockwood Clinical Frailty Scale are appropriate for referral to the PRIME Clinic. Patient satisfaction was measured on a patient experience questionnaire conducted over an 8-week period in 2018. We present a retrospective service evaluation on this new service model.

Outcomes

A comparison between pre-PRIME data and the 2016 data set (n = 640), demonstrated a statistically significant reduction length of stay in frail patients undergoing intermediate or high risk surgery who had been to a PRIME Clinic(OR 0.83, p = 0.03).

Patient numbers have grown each year, increasing from 290 in 2015 to 493 in 2019. In total, over 2000 patients have attended the PRIME Clinic. Performance has remained steady in terms of complications rates and delirium.

Data for 2019 shows the median age of patients is 79 [IQR 74 -84], and 41.8% are frail. Further analysis indicates that frailty does not imply a longer LOS following PRIME review. A positive shift in the percentage of patients achieving expected LOS was observed in Dec 2018 – Jan 2019, with 68% of patients now achieving expected LOS, or shorter. Frailty has also been shown not to increase the risk of complications following PRIME assessment.

As a result of shared decision making, surgical cancellations have halved, whilst pre-operative patient-led cancellations have increased to 35.2% in 2019 from 27.7% in 2017.

Patient experience questionnaires generated a respondent rate of 62.7%. Overall, 98.2% of patients were either “very satisfied” or “satisfied” with their PRIME appointment. Encouragingly, 100% of patients reported they understood the advice provided in the PRIME Clinic, with 72.8% of patients reporting they would make “most” or “some” of the lifestyle adjustments suggested e.g. exercise, smoking cessation.

Cost and savings

Clinically, the PRIME Clinic has shown improved independence and activity pre-operatively, through the provision of walking aids, advice and exercise programmes.

The PRIME Clinic costs approx. £750 per patient appointment, excluding any tests or investigations requests, however a reduction in post-op length of stay across specialities and rate of cancellations across the surgical specialities have been demonstrated, but not quantified.

The PRIME Clinic has received overwhelmingly positive patient experience in recent patient experience feedback, which will be repeated every 6 months.

Implications

Increased investment has allowed a third clinic to be held, increasing capacity by approximately 150 patients per year. With the demonstrated success of the PRIME Clinic, development of a post-operative service is being investigated, including links with community services to book post-operative care packages; however this has challenges in terms of funding, logistics and staffing which require consideration.

The team are also developing pre-operative interventions for patients, as part of a doctoral research project.

Top three learning points

  1. The importance of multidisciplinary teams – utilising all the skills of all those in the team in shared decision making.
  2. The importance of giving our patients time – time to discuss concerns, ask questions, receive advice and the opportunity to have face to face contact with senior members of the team.
  3. Skills and knowledge from working closely with anaesthetic and geriatric medicine colleagues.

Fund acknowledgements

No funding to undertake this review work.

Additional notes

This work was presented at Physiotherapy UK 2019. 

The author would like to thank Dr Romit Samanta and the extended PRIME team for their contribution to this project.

Please see the attached Innovations poster below. 

 

For further information about this work please contact Amanda Saunders.    

More information can be found on the PRIME Service pages on the official CUH website: www.cuh.nhs.uk and on Twitter @CUH_PeriOps