Summary of included studies
| Study | Study type; inclusion and exclusion criteria | Outcomes measured | No. of patients | Interventions | Results |
|---|---|---|---|---|---|
| Braude et al., 2017 (12)* | Phase quality improvement project with stepwise interventions Patients undergoing urology surgery aged > 65 yr and meeting 1 of the following criteria (130 patients): 1. Referred to POPS team 2. Emergency admission 3. Acute medical problem 4. Discharge-related problem 5. Length of stay > 7 d | Length of inpatient stay Medical or surgical postoperative complications 30-d readmission rate 30-d mortality Cancellation of surgery | Control: 112 (32 emergency) Intervention: 130 (41 emergency) | Phase 1: before-and-after study with initiation of daily board rounds, weekly multidisciplinary meetings, and twice-weekly targeted geriatrician-led ward rounds. Involved services: urology junior doctor, staff nurse, ward physiotherapy, and occupational therapy. Phase 2: Plan-do-study-act cycles and qualitative staff surveys to create a geriatric surgical checklist that helps to standardize the board rounds, identify geriatric syndromes and facilitate targeted interventions, improve teamwork and equity of care, and reduce duplication of handovers. Initially did not screen for frailty but in phase 2 through working groups created a checklist to identify those with geriatric syndrome risk factors. This was then embedded into routine clinical care using quality improvement. | Phase 1: Length of stay ↓ 19% (4.9 [n = 124] v. 4.0 [n = 101]; p = 0.01) Total postoperative complications decreased (24% [n = 101] v. 6% [n = 124] risk ratio 0.24, p = 0.001) Fewer cancellations of surgery (10% [n = 112] v. 5% [n = 130]; p = 0.12) due to avoidance of medical problems as opposed to administrative reasons. Subgroup analysis demonstrates no difference whether elective or emergency (p > 0.5). 30-d readmission (8% [n = 112] × 3% [n = 130]; p = 0.07) Phase 2: Staff understood their roles better in multidisciplinary meetings, had improved confidence with raising issues, reduced duplication of handovers and standardized identification of geriatric issues. Five daily meetings were eliminated between nurses, disposition coordinators and allied health and as more people were joining the board rounds. Board rounds remained at 30 min despite maintained POPS referrals, but cases changed to also include patients aged < 65 yr with more functional-related issues. |
| Koebrugge, et al., 2010 (13)* | Prospective study using high-standard delirium protocol No preintervention group; compared with existing literature Patients aged > 65 yr undergoing elective and emergency aortoiliac surgery (24/110 emergency patients) Excluded patients with Alzheimer disease or dementia | Postoperative delirium Length of ICU stay Length of hospital stay Postoperative complications Mortality | Control: none Intervention (n = 107, 22 emergency) | Providing hearing aids or glasses for those impaired. Photographs of relatives. Calendars in every room. Install familiar key points near all patients. No preoperative pharmacologic treatment. Does not screen for frailty. Instead uses Delirium Observation Scale of verbal and nonverbal behaviour 3 times daily. Geriatric consults for scores > 3. If deemed delirious after consultation, they would follow while in hospital and give advice to the surgical team daily, in addition to delirium work-up. No standardized or specific pathway. This study does not have emergency literature values to compare with, so not clear whether improved. But they did see improvements in the elective setting compared with previously published literature. | Patients with delirium were older (p = 0.01), had higher ASA scores (p = 0.01), lower diastolic blood pressure measurements (p = 0.03), and higher preoperative urea measurements (p = 0.02). They underwent longer operations (p = 0.01) and more often showed hemodynamic instability and blood loss (p < 0.01). Previous literature values are in the 20%–30% range and include only elective patients. Mortality rate 27.3% (emergency patients n = 22), and higher in patients developing delirium (p = 0.03). 59% of patients developed delirium after emergency surgery (n = 22), especially after laparotomy (compared with endovascular surgery) (p = 0.01). Delirious patients had longer ICU stay (p = 0.01), had longer length of stay (p < 0.01), and developed more complications (p < 0.01). Relative risk factors for delirium: advanced age and emergency surgery. |
| Bakker et al., 2014 (14)* | Before–after study Elective and emergency surgery Patients > 70 yr and frail with expected length of stay > 48 h Were able to begin intervening at least 48 h before admission Excluded: delirium at admission, refusal, logistic issues | Primary: Incidence of delirium Cognitive decline, and decline in ADLs during hospital stay Secondary: ADL performance at 3 mo postdischarge Readmission caregiver burden | Control: 191 (120 surgical, 13% emergency) Intervention: 195 (121 surgical, 22% emergency) | CareWell in Hospital program: Frailty review by a nurse, geriatric nurse, and then geriatrician (medication review and patient/family interviews), followed by comprehensive geriatric assessment and CareWell team verbal and written recommendations to the medical team, carefully categorized for clarity. The patient is followed closely while in hospital as part of a comprehensive geriatric assessment. Dynamic patient care via weekly multidisciplinary meetings with the entire health care team. Various stimulating activities with volunteers. Educational sessions to the nurses and physicians, and provision of continuous coaching. Screening for frailty but unclear how and if standardized. CareWell program: proactive and intensive support by CareWell geriatrics team for older, frail patients and increased awareness among nurses and physicians + team of volunteers to offer cognitively and physically stimulating activities. | Delirium and functional decline were highest among the surgical patients, but this was not statistically significant between before and after intervention groups. Significant improvement in ADLs at 3 mo and significant decrease in burden of care felt by informal caregivers. Surgical v. medical, not elective v. emergency. Surgical patients: Delirium: 13% (n = 120) v. 12% (n = 121), p = 0.828 Cognitive decline: 19% (n = 84) v. 14% (n = 96), p = 0.316 Physical decline: 41% (n = 80) v. 61% (n = 98), p = 0.008 ADLs at 3 mo: 7.9% (n = 62) v. 9.5% (n = 81), p = 0.035 Readmission < 1 mo: 11% (n = 120) v. 14% (n = 121), p = 0.464 Caregiver burden of care: 3.1% (n = 19) v. 1.9% (n = 26), p = 0.126) |
| Engelhardt et al., 2018 (15)* | Before–after study Patients aged > 65 yr who screened positive for frailty and emergency and nonoperative general surgery/trauma patients | Length of stay, loss of independence (decline in function or mobility, increased care needs at home, or discharge to nonhome destination), 30-d readmission rates | Control: 11 emergency surgical Intervention: 59 emergency surgical | Assessed frailty using trauma-specific and emergency general surgery–specific frailty indices. Discussions with the team, patient, and family about length of stay and disposition goals were held and documented. Early hospitalist consultation used to address complex medical needs. Expedited allied health involvement if increased risk of falls and difficulty with ADLs. Created geriatric-specific admission order sets. Standardized multitiered postdischarge follow-up schedule. | Length of stay: 9–6 d (p = 0.4) Readmissions decreased: 36.4%–10.2% (p = 0.02) Loss of independence: 100%–60% (p = 0.01) By prioritizing frail patients, other nonfrail geriatric patients may have had delays in their evaluation and thus worsened length of stay, loss of independence, or readmissions. However, these outcomes were not significantly different before or after the intervention. |
| Mudge et al., 2020 (16)† | Before–after study Patients aged > 65 yr undergoing emergency, elective, nonoperative vascular surgery More than half were urgent operations | Primary: Length of stay Discharge to usual residence Mortality data Delirium and functional decline Secondary: Serious medical complications, discharge destination, total hospital length of stay (definitive discharge) | Control: 112 (59 emergency) Intervention: 123 (68 emergency) | A medical doctor available 5 d/wk to review the patients and prioritize them for daily discussion with the surgical and nursing team. They would provide advice and support to junior doctors, help coordinate other consultations, supported daily huddles and weekly discharge planning meetings with the multidisciplinary team and assisted after-hours handover. The medical team conducted twice weekly joint rounds with surgeons. Eat Walk Engage program: created a monthly working group to identify care practices for older patients (focus on early mobility, nutrition, hydration, and meaningful cognitive activities). Availability of allied health assistant. | Functional decline: 39.7% v. 20.6% (p = 0.02) Delirium: 35.6% v. 16.2% (p = 0.01) Length of stay: 12.6 v. 9.3 d (p = 0.02) Patients discharged home or to usual care: 54.2%–67.6% (p = 0.12) |
| Khadaroo et al., 2020 (17)‡ | Before–after study, prospective, nonrandomized Patients aged > 65 yr undergoing emergency general surgery Excluded elective surgery/trauma patients, transfers, palliative, and nursing home residents | Proportion of patients who experienced a major postoperative in-hospital complication or death Death or readmission within 30 d and 6 mo of initial discharge, minor in-hospital complications, length of hospital stay, and requirement for alternative level of care at discharge | Preintervention 153 Postintervention 140 | Integration of a geriatric assessment team, optimization of evidence-based elder-friendly practices through a standardized order set, promotion of patient-oriented rehabilitation (BE-FIT program), and early discharge planning (identify estimated discharge date at time of admission). Co-locating older patients to a single unit for better coordination of care. “Comfort rounds” and delirium screening by nursing staff. Proactive mobilization. Early removal of tubes and lines. Elderly-friendly appropriate medication use. | Increase in geriatric consultations from 6.5% (n = 153) v. 58.1% (n = 136) (p < 0.001) Decrease in use in urinary catheters (76.5% [n = 153] v. 63.6% [n = 140]), total parenteral nutrition (27.5% [n = 153] v. 13.6% [n = 140]), and quick to postoperative mobilization (46.4 v. 29.1 h, p < 0.05) Delirium reduced by half (25.5% [n = 153] v. 12.9% [n = 140], p = 0.006) Decrease in major postoperative complications or death by 19% (p < 0.001) and decrease in all complications by 19% (p < 0.001) at the intervention site (n = 153 v. n = 140) Median length of stay decreased by 3 d (10 v. 7, p = 0.001) Requirement for alternative level of care decreased by half (39.9% [n = 153] v. 20.7% [n = 140], p < 0.001) Death or readmission at 30 d and 6 mo were unchanged |
ADLs = activities of daily living; ASA = American Society of Anesthesiologists; BE-FIT = Bedside Reconditioning for Functional Improvements; ICU = intensive care unit; POPS = Proactive Care of Older People Undergoing Surgery.
↵* From initial literature search.
↵† Thillainadesan J, Yumol MF, Suen M, et al. Enhanced recovery after surgery in older adults undergoing colorectal surgery: a systematic review and meta-analysis of randomized controlled trials. Dis Colon Rectum 2021;64:1020–1028.
↵‡ Ellis G, Gardner M, Tsiachristas A, et al. Comprehensive geriatric assessment for older adults admitted to hospital. Cochrane Database Syst Rev 2017;9:CD006211.