Better post-operative care for Australia’s rapidly growing older population

More than 900,000 patients over the age of 65
are admitted for surgery each year in Australia. Many have other medical
problems such as dementia, kidney problems or heart disease. Now a new model of
post-operative care for older people has the potential to ensure a far larger
number of these patients return to good health quickly following surgery.

“For decades we’ve known that when geriatricians
and orthopaedic surgeons work collaboratively, we get better outcomes in terms
of reduction in pneumonia, pressure sores and other complications, as well as
lower mortality,” says Professor Jacqueline Close, a consultant in orthogeriatrics
at the Prince of Wales Hospital in Sydney and the clinical director of the
Falls, Balance and Injury Research Centre of Neuroscience Research Australia.

Orthopaedic surgeons treat bone injuries and geriatricians specialise in
the care of older patients. But increasing levels of collaboration between
doctors responsible for care of older people and other surgical specialties has
been found to offer numerous benefits for the patient, she says.

This was the finding of a recently completed, 16-month study of 580 older
surgical patients at the Prince of Wales Hospital led by Professor Close and staff
specialist geriatrician Dr Christina Norris. The study was funded through the
NSW Health Translational Research Grants Scheme.  

“We were able to demonstrate a reduction in complications, physiotherapists
were getting patients up and about much earlier, the length of stay was a
little shorter and the rate of falls was reduced,” Professor Close says.

The improvement in outcomes is down to the fact that geriatricians are
responsible for the entire holistic care of patients and can provide important
insights to surgeons, who historically have been mostly focused on the operation
to hand.

For example, if an older patient comes to hospital for surgery on a
perforated bowel, the surgeon will concentrate on that, but there might be
other complications such as heart failure, chest infections, clots in the legs,
dehydration, kidney problems and malnutrition.

“While the surgeon focusses on repairing the perforated bowel, the
geriatrician works on all those areas to prevent other things that might go
wrong,” Professor Close explains.

Dr Norris says that an example of a typical patient she sees is perhaps
82 or 83 and comes in with a bowel that is twisted and obstructed. A surgeon
has decided they need emergency surgery, but the patient might also have
dementia and heart problems and following surgery may be confused and have
difficulty walking and caring for themselves. 

“It’s not just a simple problem with a bowel
blockage, it becomes a number of different problems that require comprehensive
care,” she says. “So rather than just focussing on the bowel, we ensure that
whatever other medical problems are going on receive appropriate care.”

This might also involve making sure they have their glasses and hearing
aids, and ensuring that their physiotherapists and families are involved, Dr
Norris adds. “That comprehensive, multi-disciplinary type of care, really does
seem to deliver better outcomes.”

For example, over the course of their study, the pair saw a 50%
reduction in patients requiring help to get out of bed three days after surgery,
as well a 60% reduction in heart failure.

Furthermore, Dr Norris says the approach had a beneficial impact on
entire wards, as nursing staff and other doctors also applied a holistic
approach to their own patients.

Australia’s ageing population is resulting in more operations being
performed, but advances in anaesthetics and surgery have also made it safer and
easier for older people to undergo surgery, which is resulting in even larger
numbers requiring post-operative care.

Surgeons have long realised that if it was possible to be more proactive
and preventative in the care of older patients, rather than being reactive
after problems occur, that outcomes might be improved – so a study like this
has been much sought after.

The model has been so successful at the Prince of Wales Hospital and the
Nepean Hospital in the Blue Mountains, that they will both continue it, says
Professor Close. She and Dr Norris will now publish papers “so other hospitals across
Australia and the world can see the potential benefits of this approach to care.”

By John Pickrell