Dr Paul Dalley presented on the comprehensive high-risk surgical patient pathway (CHRISP) being trialed at Capital & Coast DHB at the Choosing Wisely forum in May 2019.
The CHRISP process is patient-centred, and nurse-led and coordinated. It is used to find out more about high-risk older patients referred for surgery, including what matters to them. As a result, some patients may choose less invasive or aggressive treatment options.
'The research is quite sobering,' Dr Dalley says. 'If you look at those in New Zealand and Australia over the age of 70 having major surgery, 20 percent will have a major complication within five days of surgery, 10 percent of them will need to go to the intensive care unit and five percent of those will have died within a month of major surgery.'
He says as the age of our population increases, we are seeing a tsunami of frailty and polypharmacy.
'Mortality review committee data shows that the most deprived segment of the community is over-represented in their need for surgery and when they do have surgery, they do worse.
'We regularly see people coming to surgery taking 8, 10, 12 different regular prescribed medications and there’s also an increasing burden of mild cognitive impairment among the elderly patients coming into surgery. It’s evident that we are consistently under-identifying frailty and cognitive impairment, and missing important co-morbid health conditions.'
Dr Dalley says frailty and cognitive impairment are strong predictors of bad outcomes in older patients.
'They predict major complications, prolonged hospital stay, failure to go home after major surgery, failure to survive complications that other patients would survive, new disability and death.
'We find that some elderly patients coming in for major surgery are quite philosophical about accepting death as an outcome, but surviving with new significant disability, or surviving but not getting back to their previous independent quality of life are unacceptable outcomes. We clearly need to do better about picking strong risk factors for those outcomes.'
He says evidence shows a comprehensive multidisciplinary pre-operative approach helps identify truly high-risk patients.
Dr Dalley brought together a multidisciplinary team with representation from consumers, anaesthesia, geriatrics, palliative care, ICU, multiple surgery disciplines, nursing, management, allied specialities, whānau support and general practice.
'When we convened the team, everyone was really quickly onboard with this process – those probably most quickly on board were the surgeons. Surgeons often really agonise over what to do with high-risk patients. A lot of the time they felt they didn’t have options other than going ahead with surgery.'
He says that, in simple terms, CHRISP is a ‘red light, orange light, green light’ system.
- Green: If a patient is clearly low risk and surgery straight forward, they would continue through the standard process and get their operation.
- Red: If the case is clearly high-risk and complex, the patient would be referred to the CHRISP nurse who would come to the clinic and undertake further screening to assess risk. As a result, the patient and their care team might opt to go ahead with surgery, or to have less invasive or aggressive treatment.
- Orange: For patients where there is some ambivalence, nurses and surgeons use risk-scoring tools. These tools help identify red flags for patients over 65 in five domains – frailty, medical comorbidity, polypharmacy, possibility of cognitive disfunction, and complex social or cultural needs. Once further information is available, patients are allocated into the low-risk or high-risk category and go through the relevant process.
When CHRISP nurses assess a patient, they focus on learning more about them – what is their home situation, what does their GP think about the operation, have they talked to their family, do they need any cultural support, are there any issues related to getting to hospital or financial support?
Dr Dalley says once there is a fuller picture of who the patient is and what the issues are, the nurse will organise to bring them to an appropriate clinic.
'Most of the time this will be a combined anaesthesia and geriatrics clinic. But we may bring in additional people – for example, palliative care, intensive care, our colleagues from whānau support, or Pacific health services.
Dr Dalley gave the example of a patient in her eighties who had been diagnosed with renal pelvis cancer.
'Before we saw her in the pre-surgery clinic, we went back to the surgeon and talked about the options. The surgeon said the definitive thing to do would be to remove her kidney, but it would be a high-risk operation.
'When we talked with the patient we found that she thought her only option was to have surgery. What she was most worried about was her future living arrangements. She just wanted her kidney out so she could focus on sorting that out.
'We asked her, was it more important to her to live a long time or to live well? She said she was not really interested in how long she lived, she just wanted to maintain as much quality of life as she could. And she wouldn’t accept any treatment that could make her health significantly worse.
'Once we’d had that discussion it was clear that the best thing for her was to have embolisation of her kidney and not to have surgery. The geriatrician also organised a package of community-based care for her, to put in the extra support she needed and to make decisions about their living arrangements.
'We knew we’d done a good job because at the end of it she was crying and she hugged all of us.”
Dr Dalley says with more information, more time for discussion and better, more detailed risk analysis, a lot of patients will choose alternative treatment options. These options will typically be less invasive and less aggressive.
We think we can provide greater support for patients and reduce perioperative complications and length of stay by two-to-three days in elderly patients having major surgery. And while this isn’t about saving money, we estimate potential savings of about $4400 per patient.
'Patients who shouldn’t come to theatre and patients who do come for surgery should be better prepared beforehand, and better prepared for discharge, with more patients going home independently afterwards.'