ORIGINAL ARTICLE

ANZJSurg.com

Establishing a successful perioperative geriatric service

in an Australian acute surgical unit
Lauren Styan,*† Skyle Murphy ,*† Aisling Fleury,*† Brian McGowan* and Martin Wullschleger*†
*Division of Surgery, Logan Hospital, Brisbane, Queensland, Australia and
†Department of Medicine, Griffith University, Brisbane, Queensland, Australia

Key words Abstract

acute surgical unit, general surgery, geriatric,
perioperative.
Correspondence
Dr Skyle Murphy, Division of Surgery, Logan
Hospital, Cnr Loganlea and Armstrong Road,
Meadowbrook, QLD 4131, Australia. Email: skyle.
murphy@griffithuni.edu.au
L. Styan BMSc, MD; S. Murphy BSc (Hons), MD;
A. Fleury MB BCh BAO, FRACP; B. McGowan
MBBS, FRCSEd, FRACS; M. Wullschleger MD,
PhD, FRACS, FMH, EBSQ Trauma.
Accepted for publication 4 January 2018.
doi: 10.1111/ans.14411
Background: The purpose of this study was to assess the impact of a perioperative geriat-
ric service (PGS) in an acute surgical unit (ASU) on patient and organizational outcomes.
Methods: Single centre retrospective cohort study. Inclusion criteria were patients over the
age of 65 admitted to the ASU between January and June 2014 (pre-PGS) and 2015 (post-
PGS). Chart reviews were performed to identify outcomes of interest including in-hospital
morbidity and mortality, length of stay (LOS), 30-day representation and mortality.
Results: Geriatric admissions increased by 32% over the two study periods (154 pre-PGS
and 203 post-PGS). Surgical intervention increased by 11% (P = 0.01). Significantly more
medical complications (14% versus 33%, P < 0.001) were identified after the implementa-
tion of the PGS. Recognition of delirium in the over 80s also increased by 57%. Rate of sur-
gical complications was unchanged over the study (28% pre-PGS and 34% post-PGS,
P = 0.6). In-hospital (<1%, P = 0.5) and 30-day mortality (<1%, P = 0.6) remained low, as
did 30-day representation (10% versus 8%, P = 0.5). A trend towards decreased LOS of
1 day was identified after the implementation of the PGS (P = 0.07).
Conclusion: This study demonstrated successful implementation of a PGS into an ASU.
This multi-disciplinary approach has been effective in maintaining low numbers of surgical
complications, in-hospital mortality, LOS and patient representations despite an increased
number of medical complications. This likely reflects more timely recognition and interven-
tion of medically unwell patients with the PGS.

Multi-morbidity, polypharmacy and geriatric syndromes such as

Introduction
With an ageing population, surgeons are increasingly faced with
the challenging task of caring for geriatric patients aged 65 years
and older. Australia’s geriatric population is forecast to double to
25% over the next 40 years.1 Health expenditure for this group is
expected to increase sevenfold during the same period.2 Currently,
at least 60% of all general surgical procedures are performed on
patients over the age of 65.3 Projections from comparable health
services, suggest that the workload attributable to the geriatric pop-
ulation will increase up to a third by 2020.3
Caring for the geriatric population presents unique challenges for
surgeons. Older patients requiring acute general surgical admission
are being increasingly recognized as a population that benefits from
close consultation with aged care physicians.4 The pathophysiology
of ageing, including increased incidence of trauma and malignancy,
create a growing demand for surgical intervention in the elderly.3,5,6
dementia, delirium and frailty, often result in delayed and atypical
clinical presentations.1,7 Consequently, for each decade over
50 there is a stepwise increase in post-operative morbidity and mor-
tality, with the greatest burden on those over the age of 80.8 Nota-
bly, adverse events in the geriatric population are often the result of
medical complications, rather than surgical factors.8–13 Ortho-
geriatric models of care have been shown to be effective in decreas-
ing length of stay (LOS), in-hospital complications and mortality
following hip fracture.14 Such services have established positive
benefits of geriatrician input in the perioperative period. These
advantages include evaluation of premorbid function, recognition
of geriatric syndromes, preoperative risk assessment and optimiza-
tion, rehabilitation and coordination of a multi-disciplinary team.7
Despite recommendations by numerous international bodies includ-
ing the Royal College of Anaesthetists UK National Emergency
Laparotomy Audit, Association of Anaesthetists of Great Britain

© 2018 Royal Australasian College of Surgeons ANZ J Surg (2018)

2 Styan et al.
and Ireland4 and the American College of Surgeons National Surgi-
cal Quality Improvement Program;14 there is little evidence to sup-
port geriatric models of care for acute general surgical patients.
The purpose of this study was to assess the impact of a perioper-
ative geriatric service (PGS) in an acute surgical unit (ASU) on
patient and organizational outcomes.
Methods
Perioperative geriatric medical service
A PGS was established in the acute general surgical unit at Logan
Hospital (Brisbane, Queensland, Australia) in October of 2014.
Logan Hospital is a busy 448 bed outer-metropolitan hospital,
which manages over 75 000 emergency presentations and
14 000 ASU admissions per annum. The ASU is a consultant-led
weekday model consisting of two ASU consultants and six regis-
trars, with elective consultant cover on nights and weekends. The
unit is supported by a PGS, which consists of two specialist geria-
tricians (1.2 full time equiv.) and a medical registrar. Weekday
chart reviews were performed for all acute general surgical patients
aged 65 years and over. Comprehensive assessment within 24 h of
admission on weekdays occurred for patients with significant medi-
cal comorbidities, functional deficits, those at high risk of deteriora-
tion during admission and at the request of the surgical team. There
was no scope within the service for review outside of office hours.
The PGS was involved in the assessment of patients receiving both
operative and non-operative management. Other functions of the
service include preoperative optimisation of medical comorbidities,
facilitation of early rehabilitation and discharge planning and sup-
porting ceiling of care and end of life decision making.
Study design and participants
Participants were retrospectively recruited using the hospital’s elec-
tronic clinical record database. Inclusion criteria were patients aged
65 years and over admitted to the acute general surgical unit at
Logan Hospital over two 6-month study periods. The first from
1 January 2014 to 31 July 2014 preceded the implementation of the
PGS. An establishment phase for the service was excluded from
analysis. The second recruitment period was from 1 January 2015
to 31 July 2015. This analysis was limited to two 6-month study
periods as changes to the structuring of the ASU and the PGS
occurred before and after this period. Patients admitted from the
hospital’s emergency department and inter-hospital transfers from
peripheral hospitals were included in the study. As were patients
managed both operatively and non-operatively. Individuals under
the primary care of a physician or orthopaedic surgeon were
excluded. Ethics exemption was sought and obtained from the gov-
erning Human Research Ethics Committee (HREC/15/QPAH/352).
Data collection and analysis
Chart reviews were performed to identify primary outcomes of
interest including in-hospital morbidity and mortality, LOS and 30-
day readmission and mortality. Patients undergoing operative man-
agement were subdivided by surgical technique employed, into
laparoscopy, laparotomy and other (e.g. abscess incision and drain-
age, wound debridement and open hernia repairs not requiring entry
to the peritoneal cavity). Percutaneous drainage and endoscopic
procedures were classified as non-operative management. In
instances when multiple procedures were performed during the
same surgery (e.g. appendectomy and umbilical hernia repair), the
primary operation was recorded.
For analysis, participants were divided into cohorts based on
decade of life after age 65. In addition, comparison was made
between the 65 and 79 years age group and the over 80 years age
group, as the literature suggests that patients aged over 80 years
have the greatest morbidity and mortality during surgical
admissions.8
The secondary outcome of this study was to identify the prevalence
of delirium in geriatric patients admitted to the ASU. This analysis
focused on patients over 80 years of age. A specialist geriatrician ret-
rospectively reviewed patient charts including all notes made by
multi-disciplinary team members, to identify symptoms consistent
with delirium during their admission, including fluctuating confusion
and impaired attention. These findings were then compared with the
documented rates of delirium in the two study periods.
Statistical analysis was performed electronically using GraphPad
Prism software (GraphPad Prism version 7.0 for Mac; GraphPad
Software, La Jolla, CA, USA). Descriptive statics are reported for
all sample characteristics. Fisher’s exact test (P < 0.05) was used to
examine the significance of the association for outcomes of interest
using categorical data. Unpaired T-test (P < 0.05) was used to com-
pare mean LOS between the two groups.
Results
A total of 357 patients were included in the study (Table 1). The
number of acute surgical geriatric admissions increased by 32%
across the two study periods (154 pre-PGS and 203 post-PGS
implementation). This represents a disproportionate increase in
geriatric admission when compared to the total increase in ASU
admissions by 9.5% (681 pre-PGS and 746 post-PGS) over the
same period. Patient sex (56% female pre- and post-PGS) and age
(average 75 years; range 65–98 years pre- and post-PGS) were
comparable between groups. In both study periods, the majority of
admissions were patients aged 65–79 years (73% and 72%
respectively).
Table 1 Participant characteristics
Pre-perioperative Post-perioperative
service, n (%) service, n (%)
Admissions (n) 154 203
65–69 44 (29) 72 (35)
70–79 69 (45) 75 (37)
80–89 31 (20) 48 (24)
90–99 10 (7) 8 (4)
Average age (range) 75 (65–98) 75 (65–98)
Sex, n (%)
Male 68 (44) 89 (44)
Female 86 (56) 114 (56)
© 2018 Royal Australasian College of Surgeons
Establishing a successful perioperative geriatric service 3

Geriatric patients admitted to the ASU were predominantly man- Table 2 Medical complications, emergency team calls and intensive care
aged conservatively across the study. However, the number of admissions by age

emergency surgical procedures performed on geriatric patients Pre-perioperative Post-perioperative P-value

increased by 11% in the second study period (P = 0.01). Analysis service, n (%) service, n (%)
of surgical management by patient age (Fig. 1) showed that the Medical complications
number of patients having operations tended to decrease with 60–69 6 (14) 20 (28) 0.1
increasing patient age, with the exception of patients aged 70–79 10 (14) 28 (37) 0.002
80–89 13 (42) 20 (42) 1
80–89 years. Laparoscopies, including laparoscopic cholecystec- 90–99 5 (50) 3 (38) 0.66
tomy and appendicectomy, were most commonly performed on Total 34 (22) 71 (35) <0.001
younger patients (those aged 65–79 years old). The oldest patients ICU admissions
60–69 1 (2) 3 (4) 1
were more likely to need emergency laparotomy, most commonly 70–79 1 (1) 12 (16) 0.002
for bowel obstruction. 80–89 5 (16) 5 (10) 0.5
Since its implementation, the PGS has been actively involved in 90–99 0 (0) 0 (0) 1
Total 7 (5) 20 (10) 0.07
the management of 39% of all patients over the age of 65 years MET calls
admitted to the ASU. The greatest contribution was to patients aged 60–69 1 (2) 2 (3) 1
80–89 years, with the PGS performing comprehensive reviews of 70–79 2 (3) 2 (3) 1
80–89 3 (10) 6 (13) 1
more than half during their admission. 93% of patients who under- 90–99 1 (10) 0 (0) 1
went laparotomy (14/15) had PGS input. Total 7 (5) 10 (5) 1
Of the 90 patients aged over 65 who were operatively managed, ICU, intensive care unit; MET, medical emergency team.
approximately one third had one or more post-operative complica-
tion during the study (28% pre-PGS and 34% post-PGS, P = 0.6).
Patients aged 80–89 years had the greatest number of post-
in both groups (78% pre-PGS and 67% post-PGS, P = 0.84). The
operative complications (45% pre-PGS and 50% post-PGS). The
number of medical emergency team calls for acute deterioration of
most common post-operative complications were arrhythmias
patients on the ward was equivalent between the two periods (5%,
requiring pharmacological intervention (total of 10), post-operative
P = 1). Intensive care unit (ICU) admissions increased by 50% (5%
ileus (total six) and urinary tract infection (total six). Less than
versus 10%, P = 0.07) across the study groups. However, 90% were
0.05% of surgical complications were Dindo–Clavien Classification
planned post-operative admissions (as compared to 42% pre-PGS).
III or IV. In both periods, one patient had a retained ductal stone
Retrospective specialist geriatrician review identified that more
following cholecystectomy requiring endoscopic retrograde cholan-
than one fifth of patients aged over 80 years admitted to the ASU
giopancreatography. Four patients (one pre-PGS and three post-
had symptoms consistent with delirium. This was consistent across
PGS) required unplanned reoperation for intra-abdominal
the duration of the study (20% pre-PGS and 23% post-PGS,
collections.
P = 0.8). Notably, the recognition of delirium by the treating team
The number of patients with one of more documented medical
increased by 57% following the implementation of the PGS.
complication during their admission (Table 2) was significantly
A trend towards a decreased LOS by 1 day was identified after
higher after the implementation of the PGS (22% versus 35%,
the implementation of the perioperative service, however this failed
P < 0.001). Specifically, patients aged 65–79 years with identified
to reach statistical significance (4.5 days versus 3.5 days,
medical complications during their admission increased twofold
P = 0.07). In the post-PGS group, LOS was an average of 6.5 days
since the implementation of the perioperative service (14% versus
for patients who experienced medical complications as compared to
33%, P < 0.001). Over two thirds of patients over the age of
2 days for those without. Representation within 30 days of dis-
80 years experienced medical complications during their admission
charge was 10% pre- and 8% post-implementation of the PGS
(P = 0.5). In-hospital (<1%, P = 0.5) and 30-day mortality (<1%,
Surgical management of geriatric patients by age.
250 P = 0.6) was low across both study periods.

200

150
100
50
0 ing for the most rapid growth (37% increase in admissions). This
2014 60-69 70-79 80-89 90-99 Total 2015 60-69 70-79 80-89 90-99 Total
Fig. 1. Surgical management of geriatric patients by age. ( ) Conserva-
tive, ( ) laparoscopic, ( ) laparotomy, ( ) other (includes abscess incision
and drainage, wound debridement and open hernia repairs not requiring
entry to the peritoneal cavity).
Discussion
As demonstrated in this study, the rate of emergency general surgi-
cal admissions for patients aged 65 years and older is expanding
rapidly. Geriatric admissions increased by a third over the 12-
month study duration, with older participants (>80 years) account-
increase in geriatric acute surgical admissions was greater than
anticipated, however we postulate that it is secondary to a combina-
tion of an observed increase in all acute surgical admissions and an
ageing population. These findings are comparable to a contempo-
rary population study by Mclean et al.,7 who identified a

© 2018 Royal Australasian College of Surgeons

4 Styan et al.
disproportionate increase in emergency general surgical admissions
in the UK for patients over 80 years.
The UK National Emergency Laparotomy Audit4 recommends
that all patients over the age of 70 years undergoing an emergency
laparotomy should be assessed for multi-morbidity, frailty and cog-
nition and have routine post-operative review by a geriatric consul-
tant. Interestingly, at 12-month follow up only 10% of patients
aged over 70 years and 18% of patients over 90 years undergoing
emergency laparotomy were assessed by a geriatrician in the post-
operative period.15 This is despite elderly medicine specialists
being available at 98% of participating hospitals. In our study
uptake of the geriatric services was significantly greater, with
elderly medicine consultants actively involved in the management
of 39% of patients over 65 years and 55% over 80 years. All but
one patient aged over the age of 70 years who underwent emer-
gency laparotomy had PGS input (90%).
There is a paucity of literature describing how elderly patients
are managed in an acute surgical setting. Despite a predominantly
conservative approach, we identified a significant increase in surgi-
cal intervention for geriatric individuals, from 18% pre- to 30.5%
post-implementation of the PGS. This observed rise in the number
of emergency geriatric procedures is expected to continue, owing to
increasing life expectancies in Australia,16 together with a greater
prevalence of general surgical pathology with increasing age, fewer
elective procedures, improved anaesthetic techniques and increas-
ing use of minimally invasive surgical techniques.17
In addition, our study also identified a significant increase in
medical complications and delirium following the implementation
of the PGS. We believe that this represents an improvement in the
recognition of complications with routine geriatrician input. This is
an important finding as in-hospital complications lead to a cascade
of events for older individuals, including increasing LOS, loss of
independence, functional decline, decreased quality of life and
institutionalization.12 When more closely examined it is likely this
rise in medical complications is related to a more acutely unwell
population in the post-PGS group, with a greater proportion of
patients requiring acute surgical management and a twofold
increase in elective ICU admissions in this group. Despite this
observed increase in medical complications and a likely more
unwell population there was no significant change in in-hospital
mortality, representation or LOS.
In our study, post-operative surgical complications increased
with age, with up to half of over 80s experiencing an adverse sur-
gery related event. A number of contemporary studies have failed
to identify age as an independent risk factor for surgical complica-
tions;9,12 however, as multi-morbidity, cognitive impairment and
frailty increase with age, it would be folly to ignore age as a risk.
Inclusion of elective patients and differences in the surgical compli-
cation classification systems likely account for this discrepancy.
ASU models of care have been gaining increasing acceptance as
a consultant-led service whose promoted benefits including
increased preoperative imaging, timely access to operating theatres
and decreased post-operative complications and shorter LOS.18 To
our knowledge, this is one of two studies that examine outcomes
for all geriatric patients admitted to an ASU, including those man-
aged conservatively.8
The greatest limitation of this study is its retrospective design.
This prevented the use of validated tools for assessing the presence
of geriatric syndromes such as frailty. Frailty is a syndrome of
decreased functional reserve and resistance to stressors which is
independently associated with increased disability following surgi-
cal hospital admission.19 Commonly used markers of frailty such as
grip strength are not routinely employed or documented at our hos-
pital, and no consistent criterion was utilized to assess fitness for
surgery or ICU admission. In addition, the increased recognition of
delirium in the post-PGS group, identified on retrospective chart
review by a geriatrician, may be influenced by observer bias.
Another limiting factor of this study is the short, 6-month study
periods, with a consequently small sample size and reduced power.
Overall this study demonstrates the successful implementation of
a PGS into an ASU. This multi-disciplinary approach has been
effective in maintaining low numbers of surgical complications, in-
hospital mortality, LOS and patient representations despite an
increased number of medical complications. This likely reflects
more timely recognition and intervention of medically unwell
patients with the PGS. While this study did not collect information
regarding the qualitative benefits of the PGS service, we have found
a number of positive benefits including improved communication,
timely access to medical opinions, greater support for decision-
making, including fitness for surgery and end of life decisions and
routine post-operative medical follow up.
Conflicts of interest
None declared.
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