Perceptions and practices surrounding the perioperative management of frail emergency surgery patients: a WSES-endorsed cross-sectional qualitative survey

Demographics

We had 168 respondents, out of 1000 active WSES members. Table 1 shows respondents’ characteristics. Most of our respondents were European (83.3%, n = 140), with a small proportion from Asia (7.7%, n = 13). General surgery was the most common specialty (86.9%, n = 146). Most respondents held consultant roles: 51.2% (n = 86) were senior consultants, 31.5% (n = 53) were junior consultants. A minority (14.9%, n = 25) of our respondents were trainees. 63.7% (n = 107) of respondents worked in an academic hospital.

Table 1 Respondent demographicsRisk stratification practices

33.3% (n = 56) of participants said they did not risk score all patients using a validated Risk stratification tool (RST) prior to emergency surgery. Figure 1 shows which RSTs respondents used: the most used RSTs included ASA-PS, NELA and POSSUM. These did not vary by type of hospital (Additional file 1: Figure S1).

Fig. 1figure 1

RSTs used by respondents. List of unabbreviated RSTs in Additional file 1

POPS model and frailty

61.3% (n = 103) of our respondents were unaware of the POPS model and CGA, and this did not vary depending on whether they were in an academic hospital (60.4%) or not (62.3%). There was no meaningful variance by country (Additional file 1: Figure S2).

Figure 2 shows how strongly respondents agreed that they understood the term “frailty” and if they believed it influences outcomes in surgery. 86.9% (n = 146) agreed or strongly agreed that they understood frailty. 98.2% (n = 165) of respondents believed that the presence of frailty influences outcomes in emergency surgery patients.

Fig. 2figure 2

Likert scale questions on Frailty (1 = strongly disagree, 3 = neutral, 5 = strongly agree)

Frailty assessment

Figure 3 shows which pre-surgical assessments are routinely carried out by respondents during an emergency surgical admission. Comorbidity management and pain assessment were most regularly done. 4.8% (n = 8) did none of the assessments routinely. Only 1 respondent routinely frailty scored, and 4 respondents (2.3%) used CGA through a geriatric liaison.

Fig. 3figure 3

Routine pre-assessments conducted during emergency surgical admissions

There was a mixture of answers when asked whether respondents routinely frailty scored (Fig. 4), with the majority neither agreeing nor disagreeing with the statement. However, almost half (47.6%, n = 80) said the use of a formal scoring tool was not applicable and 3 participants reported they base it on general “eyeballing” (Fig. 5). Clinical Frailty Score (CFS) was the most commonly used frailty tool, followed by the modified frailty index (MFI) (Fig. 5). When asked whose responsibility scoring is, participants responded that frailty scoring is mostly conducted by surgical trainees (44%, n = 74), followed by surgical nurses and consultants (29.8%, n = 50 and 28%, n = 47, respectively). Only 15.5% (n = 26) of respondents said geriatricians reviewed patients.

Fig. 4figure 4

Likert scale of frailty scoring by patients (1 = strongly disagree, 3 = neutral, 5 = strongly agree)

Fig. 5figure 5

Clinical frailty scales used by respondents

Barriers to frailty assessment

We allowed participants to select from multiple common reasons why frailty was not assessed and had a free text option to suggest others. Thematic analysis revealed that lack of knowledge and training regarding clinical frailty scoring were key barriers. Participants reported not knowing about frailty scoring tools or why scoring is important. Other themes included not having enough time and being unsure whose responsibility scoring was. Only 8.3% (n = 14) of respondents stated lack of funding as being a barrier to scoring. Figure 6 shows the complete list of responses.

Fig. 6figure 6

Common reasons why frailty was not assessed

Current perioperative care practices

Over half of our respondents had poor awareness of the term “perioperative physician” (mean Likert score 3.03). Anaesthesia was the specialty respondents most associated with that term (69.5%, n = 117), followed by surgery (53.6%, n = 90) and geriatrics (42.3%, n = 71). Only 12% (n = 20) of responses associated it with GP and 1 respondent put “all specialties” as a free text answer.

60.7% (n = 102) of respondents said that other specialties in their hospital have physician or geriatrician input, although only 25.6% (n = 43) said geriatrician input is routinely asked for in frail emergency surgery patients. Most (40.5%, n = 68) said they only seek physician/geriatrician review post-surgery to facilitate discharge, and 28% (n = 47) said that the surgical team manages all issues. A common theme seen is that physician review is only requested in select patients with complications or co-morbidities, but not routinely. When an input is requested, 81.5% (n = 97) of respondents said it was delivered on demand of the surgical team, and only 19.3% (n = 23) of respondents said it was delivered during routine ward rounds. Only 10.1% (n = 12) of respondents said geriatricians were embedded in the surgical team.

Amidst respondents who do ask for physician input (n = 118), three main themes emerged. The first was managing medical problems such as hypertension or pulmonary oedema (78.3%, n = 94), and medication review (56.7%, n = 68). Another theme was facilitating holistic patient care by discussing shared decision-making (33.3%, n = 40), “do not attempt resuscitation” (DNAR) forms (20.8%, n = 25), goals and expectation of care (40%, n = 48), and arranging rehab (48.3%, n = 58) or discharge (75.8%, n = 91). The third theme was seeking advice regarding issues of the elderly such as management of the frailty syndrome (51.7%, n = 65) and delirium (50.8%, n = 61).

Of those who reported that they did not seek physician input, lack of staff availability was cited as the key reason in both academic and non-academic hospitals (Fig. 7). Lack of knowledge about the role of physicians in perioperative medicine was the second-most common barrier in non-academic hospitals, whilst in academic hospitals more participants felt that all issues could be handled by the surgical team.

Fig. 7figure 7

Pie chart showing reasons why participants did not seek geriatrician input in academic versus non-academic hospitals

This survey successfully generated interest in perioperative medicine as 84.5% (n = 142) of participants agreed that they would consider reviewing relevant literature to find out more about the topic.

留言 (0)

沒有登入
gif