1. Early results from implementation of a novel perioperative geriatric service in an acute surgical unit Dr Lauren Styan, Dr Skyle Murphy, Dr Aisling Fleury, Dr Brian McGowan, A/Prof Martin Wullschleger Division of Surgery, Logan Hospital AMA QLD Junior Doctors Conference

2. Introduction Australia has an ageing population Geriatric population forecast to double Health expenditure to increase 7x General surgery workload to increase 31% by 2020 1 1. Etzioni et al. Annals of Surgery 2003.

3. Introduction Complex management challenges Age related physiological changes Multiple medical comorbidities Polypharmacy Geriatric syndromes Increased in-hospital complications and mortality independent of surgical factors 2 2. McVeigh et al. International Journal of Surgery 2013

4. Introduction Geriatricians are experts in managing elderly patients Ortho-geriatric models effective in decreasing LOS, in- hospital morbidity and mortality following hip fracture 3 American College of Surgeons and the Royal College of Surgeons of England recommendations Novel perioperative geriatric service implemented Logan Hospital Surgical Unit in Oct 2014 3. Grigorvan et al. Journal of Orthopaedic Trauma 2014

5. Purpose To determine if the implementation of a novel perioperative geriatric service (PGS) into an acute surgical unit improves patient and organizational outcomes

6. Methodology Single center, retrospective cohort study Patients ages 65 years and over Admitted to acute general surgical unit 1 May 2014 – 31 July 2014 (Pre-PGS) 1 Jan 2015 – 30 March 2015 (Post-PGS) Primary outcomes included the number and outcome of medical consults, length of stay, in-hospital mortality and discharge destination Statistical analysis significance level P<0.05 Metro-south HREC approval (Reference no: HREC/15/QPAH/352)

7. Pre-PGSPost-PGS Patients admitted to ASU 84100 Operative management16 (19%)30 (30%) Non-operative management 68 (81%)70 (70%) Age (average and range) 73.6 (65-94)74.5 (65-96) M:F47 (56%) :37 (44%)48 (48%) : 52 (52%) Results - Demographics

8. PGS reviewed 36% of patients, resulting in a change to management in 75% of those reviewed. PGS review

9. Pre-PGSPost-PGSSignificance Number of specialist consults 35 (41.6%)28 (28%)P = 0.06 Intervention following specialist consult 29 (82.8%)26 (92.8%)P = 0.28 Complications (Medical and Surgical) 9 (10%) 18 (18%)P = 0.16 ICU admissions4 (4.76%)5 (5%)P = 0.6 In-hospital mortality01 (1%) Length of stay (average)3.984.05P=0.9 Discharge to previous residence 79 (94%)93 (93%)P=0.5 Results – Primary Outcomes

10. Pre-PGSPost-PGSSignificance Patients managed operatively 1630 Patients requiring 1+ specialist consults 3 (19%)4 (13%)P = 0.68 ComplicationsMedical – 2 (13%) Surgical – 2 (13%) Medical – 8 (27%) Surgical – 5 (17%) P = 0.45 P = 1 ICU admissions1 (6%)5 (17%)P = 0.65 In-hospital mortality00 Length of stay (median) 63P = 0.45 Discharge to previous residence 15 (93%)28 (93%)P = 1 Results – Subset analysis of operative management

11. Hospital wide acceptance of a perioperative geriatric service Trends towards improved utilization of hospital resources Decreased specialist consultations and increased interventions from specialist consults Similar in-hospital patient outcomes Reduced length of stay in sub-analysis of operative management Cost of admission to ASU per day $1200-1400 Future directions Large scale review with greater statistical power Long term outcomes Conclusions

12. Questions?

13. AIHW 2013. Australia's welfare 2013. Australia's welfare no. 11. Cat. no. AUS 174. Canberra: AIHW. Treasury (The Treasury) 2010. Australia to 2050: future challenges. Intergenerational report series no. 3. Canberra: Treasury Etzioni DA, Liu JH, Maggard MA, et al. The aging population and its impact on the surgery workforce. Ann Surg 2003;238:170–7. McVeigh TP, Al-Azawi D, O’Donoghue GT et al. Assessing the impact of an ageing population on complication rates and in-patient length of stay. International Journal of Surgery. 2013:11(9);872-875 Grigorvan KV, Javedan H, Ruldolph JL. Ortho-Geriatric Care Models and Outcomes in Hip Fracture Patients: A Systematic Review and Meta-Analysis. J Orthop Trauma. 2014 Mar;28(3):e49-55 American college of Surgeons National Surgical Quality Improvement Program United Kingdom National Emergency Laparotomy Audit References