Older adults, who represent the majority of emergency general surgery (EGS) patients, have high rates of morbidity and mortality associated with surgical admission. In an effort to improve outcomes and quality of care for these older patients, Brigham and Women’s Hospital launched a geriatric surgical service for EGS patients in 2020.
A paper published in the Journal of the American Geriatrics Society in August 2022 details the care of older EGS patients seen by the geriatric surgical service along with the value that geriatricians bring in serving this vulnerable patient population. “With older adults making up an increasing proportion of surgical cases, and our patients thus becoming more complex, it will be critical to have geriatric expertise moving forward,” says co-author Frances Y. Hu, MD, a resident in the Brigham’s Department of Surgery.
Integrating Geriatric and Palliative Expertise Into Surgical Care
The geriatric surgical service’s goals are to integrate geriatric and palliative expertise into surgical care to mitigate the risks of hospitalization most hazardous to older patients while also identifying interventions most relevant to EGS patients. The founders are trauma and acute care surgeon Zara Cooper, MD, MSc, and geriatrician Rachelle E. Bernacki, MD, co-directors of the Center for Geriatric Surgery, and geriatrician Samir R. Tulebaev, MD, of the Division of Aging.
“The care of these older adults should be multidisciplinary in nature, and having geriatrician input, especially for the more complex patients, is really useful,” Dr. Hu says. “The geriatric team can evaluate and then take action or make recommendations on geriatric syndromes that a surgical team might not otherwise discuss in the routine care of surgical patients.”
“With continued multidisciplinary care on a routine basis,” she adds, “our hope is that surgical teams will gain the fund of knowledge to manage day-to-day geriatric syndromes in older surgical patients but also know when to reach out to their geriatric colleagues for assistance.”
Mitigating the Risk of Delirium in Older Surgical Patients
The paper’s authors identified patients aged 75 years and older admitted to the EGS service and screened positive for frailty or cognitive impairment. Each patient received a geriatric consultation that typically involved frailty assessment, comprehensive geriatric assessment (including review of functional and cognitive status and mobility), and medication reconciliation.
Dr. Hu notes that delirium is a major risk for any older adult being hospitalized—and can be exacerbated by having an acute illness, undergoing surgery, or receiving certain medications. Accordingly, delirium prevention/management was the most frequently performed intervention (66%) by the service. The next two most common interventions were facilitation of serious illness conversations (58%) and consideration of swallowing function (52%).
“One thing we found particularly interesting was the frequency with which the geriatric team engaged in serious illness conversations with patients and their families, oftentimes in conjunction with the surgical team,” Dr. Hu says. “That really highlighted the role of the geriatric team in providing an additional perspective to help patients and families interpret the acute surgical episode, which presented emergently, in the larger context of their overall health.”
Consideration of swallowing function is an example of taking a step back to evaluate a patient’s (and family’s) post-hospitalization goals. As Dr. Hu explains, EGS presentations often bring a change in the patient’s functional status. Often, the patient may not be able to return to their baseline level of function or may be frailer than previously assumed.
“As we discuss recovery from the acute episode, patients and families may need to reconsider long-term living arrangements or consider the addition of caregivers in the home,” she says. “There may need to be a long-term change, and the geriatric team can help by facilitating these conversations as well as assisting with planning for discharge and transitioning home from the hospital.”
A Growing Role for Geriatric Consultations Among Surgical Patients
Dr. Hu and her colleagues will continue to evaluate the geriatric team’s interventions for the EGS service and other surgical specialties. They hope to collect more quantitative data on clinical outcomes, such as delirium rates, length of hospital stay, readmission, and discharge to a non-home destination. Their plans also include expanding the availability of geriatric consults to surgical patients at the Brigham.
“Right now, the geriatric consults are available to our general surgery, orthopedic, and neurosurgery spine patients,” Dr. Hu says. “Our eventual goal is to have geriatric consult availability across all surgical specialties. It will be interesting to see how geriatric interventions vary or have parallels across different surgical services.”