Considering the Possibility of Outcomes Worse than Death
By Amanda Decimo, MSN, MPH, CRNA, from the IARS, AUA and SOCCA 2019 Annual Meetings*
As the IARS 2019 Annual Meeting came to a close on Monday, May 20, the presenters in the review course lecture, Emergency General Surgery, the Elderly, and Non-Beneficial Surgery: The Problems, Solutions, and Outcome, examined a persistent question that arises in anesthesia: Should we really be doing this procedure? The presentation was given by Nial Quiney, MBBS, FRCA, and Geeta Aggarwal, MBBS, FRCA, from the Royal Surrey County Hospital Anaesthetics.
What do emergency surgery, the elderly, and non-beneficial surgery all have in common? These clinical scenarios place anesthesiologists at the crossroads of making cost-effective and high-quality clinical decisions.
Emergency General Surgery
In the U.S., 8% of patients admitted to the hospital undergo general surgery. Emergency general surgery, which makes up only a small number of these patients, carries 80% of the burden for surgical death.
After reviewing the literature, Dr. Quiney and colleagues found that emergency surgeries have higher mortality and increased length of hospital stay. Their South England institution decided to take action. They developed a care bundle that included simple interventions to improve outcomes in emergency surgeries:
- Collect lactate levels
- Initiate antibiotics for suspected infections
- Fast track emergency procedures to the OR, minimize delays
- Guided fluid resuscitation
- Get a senior clinician consult involved throughout their care
- Admit to the ICU
The intervention started in four hospitals but expanded to 28 hospitals. The care bundle decreased mortality and improved outcomes. Limited resources were not the biggest hurdle, it was changing staff attitudes. Through this program, they found that standardization of basic care is key to improving outcomes. Change happens with regular performance feedback conversations at the staff level at least every three months.
There is a tidal wave of elderly patients coming our way in healthcare. In North America, the population of individuals aged greater than 60 is growing faster than all other groups. Over the past 10 years, this group has increased by 35%. The 85+ population is projected to triple in the next 20 years. The World Health Organization (WHO) reports that the world is on the brink of a demographic milestone. There are more centenarians than ever before. Adding those extra years to life sounds great, but only if accompanied by good health.
It’s the over-65 age group that is having the most surgery. How can we improve outcomes for elective surgery in this population? Frailty is a multi-system decline where patients gradually lose their reserves. It can help predict poor outcomes. Preparing these patients for emergency surgery presents a special challenge. These patients are busy with preoperative scans, consults, and bloodwork. They have higher rates of morbidity and mortality, yet there is little time for optimization.
The comprehensive geriatric assessment (CGA) is the cornerstone of modern geriatric care. It identifies patients at risk of complications and poor outcomes. It utilizes a multidisciplinary team to determine domains of risk. The core team includes a geriatrician, social worker, and a nurse. It allows for more holistic care of the elderly. Use of the CGA reduces mortality, functional decline, and improves cognitive function.
The ELCOOP study examined patients over 70 requiring laparotomies to see whether implementing the CGA improved outcomes would prove effective. Implementing the CGA, decreased the length of stay by four days, but did not improve mortality. They found that leaving the hospital early resulted in a faster return to better quality of life.
Quantity of life and quality of life are two entirely different concepts. Quality is challenging to measure and should be measured in health-related terms. Several different scoring systems are available. The EQ5D is a questionnaire that evaluates quality of life. A quality-adjusted life year (QALY) is a utility score that measures time spent in a healthy state, weighted by the length of time. One QALY=one year of perfect health.
QALYs lack sensitivity. The cost for 1 QALY is controversial and possibly unethical, yet the UK uses it to allocate resources. The EQ5D survey does not take into account emotional and mental health issues or impact on careers. While these indicators have their limitations, they should be considered for studies evaluating quality of life outcomes, particularly in the elderly.
An interesting phenomenon is often reported where patients “code” from the Emergency Department en route to emergency surgery. Dr. Quiney and colleagues examined a registry of postoperative deaths following emergency surgery. They found 70% of those deaths occurred in the first 24 hours. They wanted to investigate if these procedures were futile.
These patients looked different physiologically, they were: older, had higher lactate levels, higher ASA scores, elevated creatinine, higher heart rate, and lower blood pressures. The surgical indications were often perforated large intestine or ischemic small bowel. They often were not moving fast enough from the emergency room to the operating room. Physiological status and procedure indications tell us which patients are likely to experience early death after emergency surgery.
An enlightening JAMA article titled, “States Worse than Death Among Hospitalized Patients” was referenced. Clinicians are pulling out all the stops to save lives, but it may be time to stop and listen to our patients, the presenters explained. Many patients express that needing a “breathing machine,” a feeding tube, being incontinent, or going to a nursing home are outcomes worse than death. Patients need to have a more active part of the decision-making process after emergency surgeries.
Decision-making improvements are needed in this phase of care. Four solutions include:
- Advance planning with awareness of patients’ wishes in end-of-life care scenarios.
- Education for clinicians about outcomes of emergency procedures.
- Take the decision away from the surgeon; other clinicians should also be involved.
- Improve discussions with patients about death and complications after emergency surgery via structured formats and coaching.
Talking to patients at 2-, 4-, and 6-months will enlighten us about their quality of life after emergency procedures. No outcomes research is currently available in this area.
A lively Q & A session grappled with what these recommendations look like in daily practice. How do we effectively speed patients through the ED to the OR for emergency surgeries? Dr. Quiney says it’s about ownership and getting senior decision-makers to own the responsibility for these patients. He also recommends discussing all patient deaths, as this offers valuable insight and increased familiarity with these topics.
The presenters concluded the session with a moving video clip from AgeUK that reminds us to respect and honor our elderly patients.
*Coverage from the Review Course Lecture: Emergency General Surgery, the Elderly, and Non-Beneficial Surgery: The Problems, Solutions, and Outcome during the IARS 2019 Annual Meeting