Patient Safety Tip of the Week Archive

What’s New in the Patient Safety World

April 2020

Emergency Surgery in the Elderly: Easy with EASE

In our April 10, 2018 Patient Safety Tip of the Week “Prepping the Geriatric Patient for Surgery” we discussed many things to do before surgery on geriatric patients. Most of those presume you have some time prior to the surgery. But what about those elderly patients who need emergency surgery? They, too, can benefit from a comprehensive, integrative approach according to a new Canadian study.

Khadaroo et al. developed and implemented the Elder-Friendly Approaches to the Surgical Environment (EASE) model in an emergency surgical setting in Alberta, Canada. EASE study initiatives include: co-locating patients over the age of 65 years to a single unit; having an interdisciplinary care team that includes a Geriatrician; initiating confusion prevention strategies; getting patients moving earlier in their recovery; and optimizing nutrition. Also included (Khadaroo 2020) were use of a standardized order set (including intentional “comfort” rounds and delirium screening by nursing staff; proactive mobilization; early withdrawal of tubes, lines, urethral catheters, and drains; and elder-friendly appropriate medication use); promoting patient-orientated rehabilitation activities with the BE FIT (Bedside Reconditioning for Functional Improvements) program; and early discharge planning, which encouraged the team to identify the day of discharge at time of admission with the involvement of the care coordinator.

Results were recently reported (Khadaroo 2020). The study was conducted at 2 tertiary hospitals and included patients age 65 and older who underwent emergency general surgery. It was a nonrandomized before/after study that compared patients receiving the EASE protocol to those managed in usual ways. Just over 20% of patients met criteria for frailty. The most frequent diagnoses included cholecystitis (25.9%), intestinal obstruction (18.7%), hernia (14.5%), and appendicitis (12.0%).

In the pre-EASE and post-EASE comparison at the intervention site, a statistically significant 19% decrease occurred in a composite primary outcome of in-hospital major complication or death and a 19% decrease in all complications. There was also a statistically significant decrease in the mean Comprehensive Complication Index. They also noted a significant decrease in minor complications at the intervention site, compared with an increase at the control site. Notably, the incidence of delirium was reduced by half (25.5% to 12.9%) with EASE, whereas no significant change was found at the control site.

At the intervention site, the median length of stay decreased by 3 days, whereas there was no change at the control site. And the number of participants requiring an alternative level of care at discharge decreased by almost half at the intervention site, compared with no change at the control site. Death or readmission was unchanged at 30 days.

Note that transfers from other medical services, patients undergoing elective surgery or with trauma, and nursing home residents were excluded.

Most of you will recognize that EASE draws heavily on concepts from HELP, the Hospital Elder Life Program (Inouye 1999). We’ve discussed many of those concepts in prior columns (September 2011 “Modified HELP Helps Outcomes in Elderly Undergoing Abdominal Surgery”, April 10, 2018 “Prepping the Geriatric Patient for Surgery”, September 17, 2019 “American College of Surgeons Geriatric Surgery Verification Program”).

The Khadaroo study adds to our understanding of the usefulness of comprehensive approaches to management of older patients, particularly those with frailty.

Some of our prior columns on preoperative assessment and frailty:

March 31, 2009 “Screening Patients for Risk of Delirium”
January 26, 2010 “Preventing Postoperative Delirium”
June 2010 “The Frailty Index and Surgical Outcomes”
August 17, 2010 “Preoperative Consultation – Time to Change”
August 31, 2010 “Postoperative Delirium”
August 9, 2011 “Frailty and the Surgical Patient”
September 2011 “Modified HELP Helps Outcomes in Elderly Undergoing Abdominal Surgery”)
October 18, 2011 “High Risk Surgical Patients”
November 2011 “Timed Up-and-Go Test and Surgical Outcomes”
April 3, 2012 “New Risk for Postoperative Delirium: Obstructive Sleep Apnea”
August 7, 2012 “Cognition, Post-Op Delirium, and Post-Op Outcomes”
August 14, 2012 “Gait Speed: A New Vital Sign?”
September 25, 2012 “Preoperative Assessment for Geriatric Patients”
September 3, 2013 “Predicting Perioperative Complications: Slow and Simple”
November 2013 “Predicting Perioperative Complications: Even Simpler!”
June 2014 “Another Study Linking Frailty to Surgical Complications”
September 2, 2014 “Frailty and the Trauma Patient”
February 17, 2015 “Functional Impairment and Hospital Readmission, Surgical Outcomes”
June 2015 “Get a Grip on It!”
January 26, 2016 “More on Frailty and Surgical Morbidity and Mortality”
May 2016 “Guidelines for Perioperative Geriatric Care”
May 31, 2016 “More Frailty Measures That Predict Surgical Outcomes”
May 16, 2017 “Are Surgeons Finally Ready to Screen for Frailty?”
February 2018 “Global Sensory Impairment and Patient Safety”
April 10, 2018 “Prepping the Geriatric Patient for Surgery”
January 15, 2019 “Another Plus for Prehabilitation”
September 17, 2019 “American College of Surgeons Geriatric Surgery Verification Program”

References:

EASE. Alberta’s Strategic Clinical Networks. Elder-friendly Approaches to the Surgical Environment (EASE).

https://www.albertahealthservices.ca/assets/about/scn/ahs-scn-sb-seniors-ease.pdf

Khadaroo RG, Warkentin LM, Wagg AS, et al. Clinical Effectiveness of the Elder-Friendly Approaches to the Surgical Environment Initiative in Emergency General Surgery. JAMA Surg 2020; Published online February 12, 2020

https://jamanetwork.com/journals/jamasurgery/article-abstract/2760955?resultClick=3

Inouye SK, Bogardus ST, Charpentier PA, Leo-Summers L, Acampora D, Holford TR, Cooney LM. A Multicomponent Intervention to Prevent Delirium in Hospitalized Older Patients. NEJM 1999; 340: 669-676

https://www.nejm.org/doi/full/10.1056/NEJM199903043400901

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