In our October 18, 2011 Patient Safety Tip of the Week “High-Risk Surgical Patients” we discussed a recently released report from the Royal College of Surgeons of England (Royal College 2011) addressing high rates of mortality and morbidity in high-risk general surgery patients, especially patients undergoing emergency or unscheduled general surgery procedures. That report suggested use of tools such as the P-POSSUM scoring tool to estimate risk in patients undergoing surgery.
Mortality may be difficult to predict and most tools used to predict mortality have only modest accuracy, large variability across diseases and populations, and limited clinical utility (Siontis 2011).
But several studies have shown that much simpler tools may predict complications in elderly patients undergoing surgery. Those that include markers of frailty have been especially useful. In our June 2010 What’s New in the Patient Safety World column “The Frailty Index and Surgical Outcomes” we noted a study (Makary et al 2010) demonstrating use of the frailty index greatly improved the ability to predict post-surgical outcomes (post-op complications, LOS, and discharge to an SNF or assisted living setting) much better than existing methods. And in our August 9, 2011 Patient Safety Tip of the Week “Frailty and the Surgical Patient” we noted two studies by Robinson and colleagues (Robinson 2009, Robinson 2011) looked at outcomes in (mostly male) patients age 65 and older who were undergoing major elective surgical procedures in the VA medical system and correlated them with measures of frailty, disability, and comorbidity. Using a group of markers that were easy to use in a surgeon’s office setting they were able to predict 6-month postoperative mortality and post-discharge institutionalization.
That group has now expanded their study to a total of 223 subjects (Robinson 2011) and focused on discharge to an institutional setting. The burden of comorbidity was assessed using the Charlson index, the ASA score, the total number of medications taken, and anemia. Function was measured by the Katz ADL score and a timed up-and-go test. Nutrition was assessed by BMI, albumin level, and weight loss. Cognitive function was assessed by the Mini-Cog test and the Two-Question Depression Screen. And they added a measure of “geriatric syndromes” (eg. falls) and “extrinsic frailty” (eg. social isolation). Overall, 30% of patients were discharged to institutional settings and another 17% needed home care. The 3 variables most predictive of institutionalization were a timed up-and-go >15 seconds, Charlson score 3 or greater, and hematocrit <35%. Three or more frailty characteristics had a sensitivity of 82% and specificity of 84% for predicting institutionalization. Interestingly, age itself was not a predictor but rather the measures of frailty, function, and comorbidities were most important.
The timed up-and-go-test is a measure incorporated into several frailty indices. For those of you unfamiliar with the timed up-and-go test, you simply time a patient standing up from a chair, walking 10 feet, returning to the chair and sitting down. Now a new preliminary study suggests that the timed up-and-go test by itself is an excellent predictor of complications in elderly patients undergoing surgery (American College of Surgeons 2011). Daniel Wu, M.D. and colleagues at the University of Colorado, Denver studied 195 patients aged 65 and older who underwent cardiac or colorectal surgery. They stratified the patients into slow (>15 seconds), intermediate (11-14 serconds), and fast (less than 10 seconds) groups based on the timed get-up-and-go test. Compared to the fast group, the “slow” group was much more likely to be discharged to an institutional care facility and had longer hospital LOS. This applied to patients undergoing either cardiac or colorectal surgery. Though the authors state this was simply a “proof-of-concept” study and plan a multi-institutional trial to confirm their findings, this is exciting that a simple test that can be performed in the office may provide such important information. Note that the timed up-and-go test (>15 seconds) was one of 3 variables most predictive of institutionalization in the Robinson study noted earlier.
While we are waiting for more sophisticated risk prediction tools that are validated for the specific populations and procedures you are dealing with, it is helpful to know you can do at least this one simple test and get a pretty good idea of your patient’s surgical risk.
The Royal College of Surgeons of England / Department of Health. The Higher Risk General Surgical Patient: Towards Improved Care for a Forgotten Group. 2011
Siontis GCM, Tzoulaki I, Ioannidis JPA. Predicting Death. An Empirical Evaluation of Predictive Tools for Mortality. Arch Intern Med. 2011; 171(19): 1721-1726
Makary MA, Segeve DL, Pronovost PJ, et al. Frailty as a Predictor of Surgical Outcomes in Older Patients. Journal of the American College of Surgeons 2010;
Robinson TN, Eiseman B, Wallace JI, et al. Redefining Geriatric Preoperative Assessment Using Frailty, Disability and Co-Morbidity. Annals of Surgery 2009; 250(3): 449-455, September 2009
Robinson TN, Wallace JI, Wu DS, et al. Accumulated Frailty Characteristics Predict Postoperative Discharge Institutionalization in the Geriatric Patient. J Am Coll Surg 2011; 213(1): 37-42, July 2011
American College of Surgeons. Simple Timed Walking Test Is an Accurate Predictor of Adverse Outcomes for Older Surgical Patients. Newswise October 26, 2011