Pre-operative
Evaluation of the Elderly
Authors:
Maurice Brygel, General Surgeon, Lesley Pocock, Medical Educator
Author detail:
Maurice Brygel - Surgeon
Lecturer Melbourne University, Monash University,
Melbourne Hernia Clinic, Sir John Monash Hospital, Masada Hospital
mbrygel@netspace.net.au
Lesley Pocock - Accredited Education
Provider
medi+WORLD International
lesleypocock@mediworld.com.au
| Keywords: Adverse events,
informed consent, risk management, evaluation |
Most countries
are introducing risk management and quality assurance programs
for surgical patients. High levels of adverse events affect
surgery in most large hospitals around the world, and to date,
few preventive or control measures on an organizational basis,
have been implemented to avoid such occurrences.
A Canadian Study (1) reports that the
Adverse Event occurrence rate is 7.5 per 100 hospital patients.
Of these 36.9% involved something preventable occurring and
20.8% resulted in death.
The Canadian data showed that the overall incidence rate of
adverse events of 7.5% suggests that, of the almost 2.5 million
annual hospital admissions in Canada, about 185,000 are associated
with an adverse event and close to 70,000 of these are potentially
preventable.
Although men and women experienced equal rates of adverse events,
generally patients who had adverse events were significantly
older than the norm - (mean age [and standard deviation] 64.9
[16.7] v. 62.0 [18.4] years; p = 0.016). (1)
This means that it is even more important to evaluate the elderly
patient when considering surgery.
Similar reports globally have led to
the development of quality assurance programs aimed at review
of adverse events, prior to surgical admissions, across a range
of healthcare issues aimed at better patient outcomes, improved
communications and reporting, less morbidity and mortality and
consequent saving of health spending.
Areas covered by these programs, ideally
include: adverse event management, clinical/practice audits,
informed consent, patient communication and satisfaction, management
of serious illness, complaints management, emergency management,
infection control, patient documentation, practice medication
management, reminder systems, sharps management, waste management.
Coupled with these general issues, are
specific issues related to each individual patient.
This paper looks specifically at issues
concerning elderly surgical admissions, and these include: general
health, language issues, informed consent, family support, pain
management and follow up. It is also important to provide discharge
summaries to the patient's family and referring doctor as many
elderly patients are on multiple medication and have concomitant
illness. It is also incumbent on the surgeon to ensure that
he/she has a full patient history from the referring doctor.
A full history of course should be taken on first presentation
to the surgeon as well.
The following quality assurance checklist
can be used as part of the evaluation of elderly patients, for
surgery:
Review prior adverse events associated
with this type of surgery in your practice. Identify the type
and cause of adverse event and ensure a system is in place to
prevent a reoccurrence.
Take full medical history including
full medication history. If a prescription is written as part
of post-operative management, discharge summaries must be sent
to the referring doctor or the patient's family doctor.
Patient is to be informed of all of
the risks of any treatment . Discuss pros and cons and if the
patient is considered not to be capable of making an informed
decision, family members or carers accompanying the patient
should be fully informed.
Provide clear, concise, written information
if possible.
Obtain written consent for all invasive
surgical procedures. Consent includes warnings about driving,
and signing and witnessing documents.
Full contact details including next
of kin should be sought.
Enquire as to availability of patient
support and home help immediately after dismissal..
If a patient refuses a recommendation
for treatment this is to be documented in the patient's medical
record.
Advise patients of potential drug reactions
or other medical complications.
Have procedures in place for patients
with communication or language needs.
Diagnosis and treatment options need
to be discussed directly with the patient in a clear and comprehensible
fashion.
Encourage patients to ask questions
and discuss any areas of concern.
If the patient has any of the following
serious illnesses, symptoms and treatment must be known:
Asthma, cancers, diabetes, heart disease, HIV/AIDs, meningitis,
meningococcal, mental illness.
Investigations regarding the possibility of these in patients
who are at risk of such, should be managed proactively.
Applying informed consent and risk
management to elderly hernia patients
As a general surgeon, with a focus on hernia surgery, I
provide my own audit as a way of introducing risk management
and improving the quality of informed consent. In Victoria,
Australia, where I practice occurrences of harm to patients
undergoing surgical procedures is on the rise. Figures just
released show that of 340,000 cases of medical errors and mishaps,
in the previous year, 218,000 of these occurred after patients
underwent surgery. This was an increase of 20,000 occurrences,
compared to the previous year. Most of these 'adverse events'
were in public hospitals.(4)
In our clinic, our age break up shows
that in the 70-80 year old group - 49% of hernia operations
are performed as day surgery and even in the 80+ year old group
over 50% are performed as day cases (under local anaesthetic
infiltration).
This avoids a general anaesthetic, which
is not well tolerated in these age groups.
Mesh is used in all operations apart
from two cases where it was refused by the patient (after informed
consent as to the merits of its use)
The percentage of day cases at our clinic is high, the remainder
of the patients mostly stay for one night only and it is rare
to have a patient stay more than one night. .
Patients who are immobile with Parkinsons
or have no carers at home are the longest stayers, with admissions
of 3-4 days.
I prefer hospitals with the availability
of coronary care or other emergency facilities. While these
were not needed in our patients, many of the patients had had
previous coronary surgery or cardiac conditions so felt more
at ease at such a facility.
Counselling is given regarding pain
relief post operatively.
All patients are given information on
herniae to read prior to surgery.
After the paper work has been completed
and surgery arranged - at the same first visit usually - the
patient is seen to explain the procedure further. The risks
of surgery are explained and a sample of the Prolene meshes,
we use, are shown to the patient.
These patients
require careful assessment to decide whether surgery is indicated
and if the surgery is feasible in a day surgical setting. More
so in the elderly because these patients may not have Private
Insurance. An increasing number of non-insured patients elect
to have their hernia surgery in a non-public (private Day Surgery
Centre). The cost in a private Day Surgery Centre is significantly
less than in a full hospital for the non-insured.
As with any other surgery careful pre-operative
evaluation, skilled technique and proper follow up are mandatory.
It is the pre-operative evaluation and proper planning which
allows the skilled surgeon to be successful with proper planning
reduced post operative problems. Eighty per cent of all patients
are treated as a day case. Fifteen per cent of hernia patients
are bilateral hernias and ten per cent of the total number of
hernias carried out, are for recurrent hernia operations. Fifteen
percent of patients are non-insured and are treated at the day
surgery only facility (SJMPH). The majority of bilateral inguinal
hernia repairs are also treated as a day case.
The most common age group for surgery
is in the 50 - 60 year old.
It has been noted in the pre-operative
assessment of these patients that some were infirm, or had Alzheimer's
disease or Parkinson's, making the post-operative management
more difficult. Other factors might have been multiple medications
together with a lack of home facilities and in some cases the
need to have anti-coagulants supervised.
It is noted in comparing our practice
audits that there is from year to year an increasing number
of cases done as a day case and an increasing number of elderly
patients.
A thorough history and examination often
detects unsuspected abnormalities such as co-existent carcinomas
or bleeding tendencies. These problems are more common in the
elderly.
Elderly patients often need to be brought
back for a second consultation after assessing all of the relevant
factors before deciding finally on surgery. This gives time
to communicate with relatives and other health professionals
about the possible risks as well. Surprisingly in hernia repair
in my practice, with the elderly, very serious adverse events
are rare.
As hernia surgery is not always mandatory
the pros and cons of surgery must be weighed up before deciding
upon proceeding. In a large number of cases the patient will
not come to any harm just leaving the surgery. However the elderly
patient often experiences discomfort and is concerned about
the possible need for emergency surgery at a later stage when
they are more fragile. This risk of strangulation versus the
risk of not operating needs to be considered. Due consideration
must be given to the elderly patient respecting their decision
making. Discomfort which can be inhibiting their joyful activities
does lead them to request surgery.
This involves identifying problems,
which might occur prior to the surgery, during the surgery,
the immediate post-operative period of the first 24 to 48 hours
and then longer-term issues, that is, review of adverse events.
The main pre-operative consideration
may be the need for emergency or urgent surgery. The patient
who has a painful hernia, or a hernia which appears to run the
risk of strangulation, should be warned of this.
An assessment of the fitness for surgery
is carried out and this involves assessment of many systems.
We believe in the elderly especially,
that the procedure should be carried out under Local Anaesthetic
and light sedation. A mesh reinforcement is routinely used.
For this technique one needs to take into account whether the
patient can lie comfortably on the operating table - emphysema,
Alzheimer's, cardiac disease and shortness of breath and even
arthritis may make it difficult for the patient to lie comfortably
during the procedure. This needs to be evaluated.
As well factors, which may lead to bleeding
during the procedure or other difficulties, should be considered.
A careful check is required of the patient's medication. Aspirin
is commonly routinely used in the elderly. Anti-platelet medication
for patients with a past history of stroke or cardiac disease
is increasingly common and there are many patients with a past
history of cardiac valve or deep venous thrombosis who are on
Warfarin. These must all be fully assessed and a decision made
in consultation with other treating specialists as to the best
approach. The Surgeon does need to understand the principles
of the management.
In addition many patients require an
antibiotic cover for the procedure. The appropriate antibiotic
needs to be chosen in consultation with the treating Physician.
This minimises the risk of infection of prostheses or valves
particularly when a cardiac murmur is present. Manu orthopaedic
replacements are advised to have an antibiotic cover.
Unusual complications have to be assessed
in light of the patient's history. For example especially in
the elderly there may be urinary problems and there is the small
risk of retention of urine occurring following surgery. This
risk needs to be explained and the possibility that this may
lead to surgical intervention in itself.
Other rare risks such as damage to the
testis - particularly when there is only a unilateral testis
present, must be mentioned, particularly when the hernia being
operated upon is a recurrent hernia.
Thus potential risks of surgery must
be explained - including deep venous thrombosis and pulmonary
embolisms.
We believe that surgery under local
anaesthetic with light sedation reduces these risks to the elderly.
There are specific other issues related
directly to the surgery, these are the risk of intra-operative
and post-operative haemorrhage which may require re-exploration.
These are minor degrees of this such as severe bruising or swelling
of the scrotum.
The risk of infection - less than 1%
and the management of this if it were to occur, needs to be
explained. Seroma formation should be explained to the patient
prior to the procedure as with epigastric hernia or umbilical
hernia, this occurs more commonly. Some discussion is required
regarding the mesh that is to be used. Whilst the need to remove
the mesh because of infection or other problems is rare, there
are occasionally problems associated with a mesh. It should
be explained to the patient that the majority of Surgeons believe
that mesh reduces the incidence of recurrence of the hernia
significantly, but it does carry its own risks, as it is a foreign
body, which can become infected and may require removal. The
mesh is often fixed into position with staples. Non-ferrous
staples are used and these have no problems for magnetic resonance
imaging.
Thus it can be seen that there are many
issues to be discussed with all hernia patients, all surgical
patients, and specifically with the elderly patient. The elderly
patient is more prone to falling in particular.
| Explanation of the Post -Operative
Course |
This must be detailed to the patient
prior to the operation and after the operation, and to the relatives.
For day surgery the patient is usually
able to be discharged home within an hour or two of the surgery
and must be accompanied by a responsible person on the way home
and for the first night.
Advice about analgesia is given - together
with some mention of the possible side effects such as constipation,
abdominal pain, ringing in the ears etc.
The patient is warned that they can
feel faint on the day of surgery or the following day and should
be accompanied.
It is our practise to have the patient
ring myself personally the day following surgery to let me know
how they are.
They often need reassurance about the
small amount of blood on the dressing, the management of pain,
the management of dizziness and their bowels.
One factor taken into account in auditing
day surgery hernia repair is the need for readmission on the
night or the night following surgery. The incidence of this
is extremely low but does occasionally lead to issues. Bleeding
is rarely a problem. Occasionally fainting with extra systoles
or brachycardia or vasovagal reaction can be a problem and cause
alarm leading to the patient representing to hospital. The patient
should be advised about what to do under these circumstances.
Return to normal activity is an issue
that patients want to hear more about. They want to know how
much they can do, how much they can lift. This can be best explained
at the first post-operative visit when their recovery has been
assessed.
I explain to all patients that despite
doing thousands of operation in exactly the same way, the individual
response is different. I explain about the standard deviation
curve, and also pain, which usually gradually gets better but
there can be spikes of pain with activity or for no reason.
Continuing post-operative pain following
hernia surgery has been mentioned as a problem because of nerve
damage, tension, haematoma formation, or for unknown reasons.
The subject of meshoma with the mesh forming a painful mass
has been broached.
It should be explained to all patients
that surgery does not always give perfect results.
We have surveyed the analgesia requirements
following hernia surgery - a significant number of patients
- 41 out of 310 patients, required no painkillers. 47 required
painkillers for only one day. 20 patients required painkillers
for more than four days. Many patients say that pain is not
a problem.
The average time in theatre for a single
sided inguinal hernia repair is 35 minutes. More and more patients
are overweight and this adds to the technical difficulty of
surgery and occasionally the need to convert the Local Anaesthetic
technique to a General Anaesthetic. The Local Anaesthetic technique
has been successful even for obese patients or the extremely
anxious. In fact now with obese patients we advise weight loss
prior to the surgery and often call in an Endocrine Consultant
to manage this for a few weeks prior to surgery. This would
be for the over 100 kilogram patients of short stature.
Anaesthetists have become more experienced
with the Local Anaesthetic and sedation technique. The majority
of them including my two main Anaesthetists, prefer to have
the patient sedated enough at the initial injection of Local
Anaesthetic, so that the patient does not experience any needles
going in. The patient then slowly arouses and is able to wiggle
his toes around or cough or strain during the procedure as required.
Many of the patients enjoy the conversation with the staff during
the procedure. Many of the patients have no recollection of
the event despite having talked voluminously during the procedure.
Patients usually go home within one
to two hours following the procedure with written and explained
instructions about such things as pain relief and the dressing.
All patients are seen in the week following
surgery
We have surveyed the amount of analgesia
required following hernia surgery:
A significant number of patients (11%) require no pain killers
with most of the remainder on pain killers for only one day.
4% required pain killer for more than 4 days.
While there seems to be more pain after
bilateral inguinal hernia repair this does not appear to have
affected the number who can be treated by day surgery.
We have seen significant infections
post operatively, where drainage and antibiotics were instituted.
There were additonal patients (a few) with erythema which quickly
settled down on use of antibiotics
The risk of infection seems higher for
umbilical and epigastric hernias . The seromas were aspirated
without incidence. Occasionally the seroma persisted for two
to three weeks causing anxiety.
Fainting following procedures is rare
but can be a bother the following day when the patient goes
to the toilet. Incidence of this has decreased and day surgery
is not contraindicated because of this. But it is mandatory
with day surgery, that the patient has a responsible person
with them the night of release from day surgery., who should
also be present the following day.
We have had one case of coronary embolism,
which was severe. The patient made a full recovery but required
drainage of the haematoma due to the anticoagulation for the
embolism. This patient had a deep venous thrombosis some ten
years previously and was asymptomatic. The embolism was two
days after the operation. Another patient required readmission
for acute retention of urine, which led eventually to a TUR.
Deep venous thrombosis and acute retention of urine are rare
following day surgery hernia repair under Local Anaesthesia.
In my years of auditing hernia results,
the incidence of DVT - let alone pulmonary embolism - is rare,
possibly one in the last eight years. In a similar way urinary
problems after repair under Local Anaesthetic is also rare.
Other uncommon problems were that one
patient had pain and a lump following repair of a strangulated
epigastric hernia and the mesh was removed successfully and
the patient was able to return to work soon after without problems.
Another patient complained of neuropathic type pain persistently.
This was re-explored and a staple had been found to be clipped
around the genital division of the genitofemoral nerve. Removal
of this clip removed the pain.
We believe that hernia repair under
Local Anaesthetic and light sedation is the safest technique
for repairing hernias. The incidence of general complications
is low and the wound infection rate is in keeping or better
with many other series.
We are pleased that so many patients
are able to be treated as a day case, which has specific advantages.
We found that we were able to treat many patients with multiple
problems, as a day case or one night stay. We believe that the
technique of Local Anaesthetic has contributed to these figures.
The use of mesh has become standard
for many surgeons. There are numerous types of mesh in all forms
and shapes. During the year I visited other clinics where different
techniques were used and have adopted some of these as required
for individual cases. I believe one should be able to use different
techniques to repair a hernia as required by the circumstances.
There has been considerable debate regarding
laparoscopic (keyhole) surgery for hernia repair versus the
open technique. One advantage of keyhole surgery has been stated
to be a quicker recovery. In my opinion, the figures, which
I have on post-operative analgesia and return to work, are better
than many laparoscopic series. In addition I believe the open
technique is safer with less risk of major complications. The
recurrence rate in experienced hands is probably not much different.
There has been considerable debate about
the use of mesh causing increased local pain due to nerve irritation.
This has not been my experience.
Thus, after reviewing the figures I
am particularly pleased with the results. Wound infection, when
it does occur, is a problem. Other unexpected complications
are also a concern - such as pulmonary embolism or acute retention.
My auditing over the years shows that these rates are very low
and I believe are much lower for those patients who have a General
Anaesthetic.
This audit has highlighted some areas
where problems could occur and we are taking whatever measures
we can to avoid this.
However we must highlight that
no surgery was without risks and there needs to be bounds in
the decision making as to whether or not to operate on hernias
in the elderly and infirmed. Certainly the safest method should
be chosen. Particular care is required with the pre-operative
assessment.
Dr Brygel invites readers to send any
questions related to hernia surgery and he will answer all.
Send letters to: mbrygel@netspace.net.au
