Elder-Friendly Emergency Surgery Care Can Improve Outcomes

By Marilynn Larkin

February 22, 2020

NEW YORK (Reuters Health) - Adopting the EASE (Elder-Friendly Approaches to the Surgical Environment) model in an emergency general surgical setting led to a reduction in complications and deaths, in a nonrandomized controlled study.

"The aging population and extended lifespans mean a growing number of emergency surgeries are being performed on older and frailer patients," Dr. Rachel Khadaroo of the University of Alberta told Reuters Health by email. "Some suggest such patients should not be eligible for emergency surgery because of the increased risks, but I believe a better approach is to introduce standardized screening for frailty and improved post-surgical care for vulnerable patients."

"A patient's age alone should not determine appropriateness for surgery," she said.

Dr. Khadaroo and colleagues at two hospitals reviewed data on 684 elderly patients who underwent emergency abdominal general surgery procedures (mean age, 76; close to half, women), including 139 (20.3%) who were frail. One hospital provided only usual care. At the other hospital, researchers implemented the intervention and conducted a before-and-after analysis.

Most patients were living independently in the community.

Overall, between April 2014 and March 2017, 544 patients received standard care, including 153 at the intervention site before implementation of EASE in September 2015; 140 patients received EASE. Palliative care and trauma cases were excluded.

As reported in JAMA Surgery, the intervention included integration of a geriatric assessment team, optimization of evidence-based elder-friendly practices, promotion of patient-oriented rehabilitation, and early discharge planning.

At the intervention site, in-hospital major complications or death decreased by 19% with EASE (33.3% vs. 13.6% pre-EASE) and the mean Comprehensive Complication Index decreased by 12.2 points, according to the report.

Minor complications also decreased significantly, whereas they increased at the control site (35.3% to 27.1% vs. 32% to 49.5%).

A comparison of pre- and post-EASE findings showed statistically significant decreases in the use of urinary catheters (76.5% to 63.6%) and total parenteral nutrition (27.5% to 13.6%), and participants were mobilized more quickly after surgery (mean time, 46.4 hours to 29.1 hours).

The median length of stay decreased by three days (10 days vs. 7) with EASE compared to no change at the control site, and fewer patients required an alternative level of care at discharge (39.9% vs. 20.7%).

Further, 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,

Dr. Khadaroo said, "The interventions we took through this study are relatively low-cost, due to savings related to fewer complications and readmissions and shorter hospital stays. We anticipate that EASE interventions can be adapted to fit many surgical centers to benefit older patients."

"Following an operation, it improves the chances a patient will return home healthy," she noted. "We can get the patient better with fewer complications and a shorter hospital stay if we have a coordinated elder-friendly team approach."

Dr. Shelley McDonald of Duke University Medical Center in Durham, coauthor of a related editorial, commented by email, "The physiological complexities of older age can be medically challenging to care for and (patients') social circumstances even more so, because basic information such as who they live with or how they manage their daily affairs often is not recorded in the medical record."

"Older adults have usually overcome many circumstances in life to get where they are and deserve to have the time and attention paid to what is really most important to them about their medical care," she noted. "Until we have multidisciplinary, interprofessional teams working together, it is incumbent on each provider to take a little extra time to connect and have a conversation with your older patients about these things and to also document their preference in the medical record."

"Performing this kind of 'whole person' evaluation creates an opportunity to recognize hidden risks and provide earlier interventions - often at lower costs - to more effectively treat someone when urgent needs, like surgery, arise," she said. "This will require continued change in our healthcare system toward policies and payment that emphasize team-oriented, person-centered, value-based care."

SOURCE: http://bit.ly/2T0mhz9 and http://bit.ly/2T0awsB JAMA Surgery, online February 12, 2020.