Dr Hairil Rizal, Senior Consultant, Department of Anaesthesiology, SGH, shares with us his award winning program that aims for Preoperative Optimisation of Frail Patients Undergoing Major Abdominal Surgery.
Frailty is a state of reduced physiological reserve predisposing one to adverse outcomes when exposed to stressors such as surgery. It is one of the strongest predictors of postoperative complications in a recent meta-analysis (Watt et al, 2018).
As such, the PeriopeRativE ProgrAm foR Elderly (PREPARE) program designed by Hairil Rizal and his team in SGH aims to implement a frailty assessment tool to identify frail elderlies during preoperative assessment and provide a one-stop prehabilitation program to frail patients to minimize need for multiple hospitals visions for preoperative optimization, and to reduce postoperative complications and improve postoperative outcomes.
The PREPARE program was recently awarded the Best Practice Medal in Care Redesign at the National Healthcare Innovation and Productivity (NHIP) awards 2020. The annual NHIP was launched in 2016 by the Ministry of Health to inspire and celebrate healthcare professionals who have pushed the boundaries with breakthrough ideas. In this issue of the ANAES ACP newsletter, we take a closer look this award winning program:
The team believes the PREPARE program has the potential to be scaled to a nation-wide program, to maximize postoperative outcomes for frail patients.
Implementation of PREPARE
The PREPARE program was implemented in January 2019 and comprises of a multi-disciplinary team of anaesthetists, Internal Medicine (IM) physicians, nurses, physiotherapists, dieticians and administrators. The program was implemented in multiple phases:
Phase 1: Validation of the use of Edmonton Frailty Scale (EFS) for frailty assessment
We conducted a prospective observational study of 134 elderlies aged 70 years and above who attended PAC at SGH prior to major abdominal surgery from Dec 2017 –Sep 2018. They were screened for frailty by the PAC nurses using the Edmonton Frail Scale. Postoperative outcomes such as complications and hospital length of stay were measured.
EFS was feasible as a screening tool in a fast-paced outpatient clinic setting such as PAC. The average time taken to complete EFS was 3.75 minutes, and there was high inter-rater correlation of scores between 2 nurses assessing the same patient.
Higher EFS score was a significant predictor of postoperative complications and longer lengths of stay after adjusting for confounders including age, gender, race, surgical disciplines and surgical technique (open or laparoscopic surgery).
Phase 2: Formation of a multi-disciplinary PREPARE team to facilitate seamless screening, referral and preoperative optimization
Frailty screening is performed by PAC nurses using the EFS upon arrival. Patients scheduled for major abdominal surgery and identified as frail on the EFS would have a preoperative optimisation strategy drawn up by their reviewing anaesthetist. This strategy is made in consultation with relevant members of the PREPARE team.
Interventions include preoperative physiotherapy education, inspiratory muscle training and/or preoperative exercise programs conducted by physiotherapists; nutritional supplementation/education by dieticians and optimization of chronic medical problems by the IM physicians, often within the same visit at the PAC. Where appropriate, the PREPARE team would also follow-up on these patients postoperatively during their hospitalization to ensure continuity of care.
To maximise patient convenience and minimize multiple hospital visits, the PREPARE team was embedded in the PAC, so that every elderly patient aged ≥ 65 years would receive mandatory screening in their elective surgical journey at SGH.
Phase 3: Engaging primary surgeons to improve PREPARE take-up rate
Word-of-mouth was used to spread awareness of this project to primary surgeons, to gain their support of PREPARE. Increasingly, more and more surgeons started referring patients whom they suspected to be frail for earlier review by the PREPARE team, so that the team would have a longer period to optimize patients prior to their surgery.
Phase 4: Improving take-up rate for PREPARE by Plan-Do-Study-Act cycle
The team had regular process meetings to monitor patients recruited for PREPARE. Through the PDSA cycle, we have improved the take-up rate for PREPARE. This was done by (1) Repeat reminders to junior doctors on the availability of this programme (2) Pasting laminated copies of referral criteria in prominent areas of the consult room and (3) Expanding the referral criteria to include all patients with poor baseline functional scores so that they could also benefit from preoperative optimisation. This resulted in an improvement in take-up rate from 9% between Jan to Jun 2019, to 18% between Jul 2019 to Dec 2019.
Results
With the institution of a centralized approach to screen and optimize frail patients going for elective surgery, the program has seen a decrease in the median hospital length of stay (days) in vulnerable-frail patients by 2-3 days, as well as an increase in the average proportion of vulnerable-frail patients with no complications by 24%. Average bill size post-intervention for anterior resection surgeries decreased by 21% and for colectomy, a decreas in 7% of the bill size was seen. The team believes the PREPARE program has the potential to be scaled to a nation-wide program, to maximize postoperative outcomes for frail patients.
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