Title : Using respect forms peri-operatively, to document patient wishes in case of deterioration, for patients with a frailty score of 5 or more
Abstract:
Introduction: Frail individuals are making up an increasing proportion of our patients. Research shows that a clinical frailty score (CFS) of 5 or more greatly increases the risk of 90-day mortality post-operatively; with those with a CFS of 7 having nearly 25x the risk of those with a CFS of 1. Highlighting the importance of a clear escalation plan for this cohort of patients in the post-operative period. The Resuscitation Council UK and British Geriatric Society also provide guidance on the importance of care plans for these patients.
Method: An observational study across a period of 6 weeks. Collating data from clinical notes and electronic data sources. Data collected included: frailty score, age, operation performed, SORT score, ReSPECT form/discussion documentation, and complications that occurred in the 30 days post-operatively. Inclusion criteria: CFS of 5-7 and undergoing surgical intervention.
Results: A total of 46 patients met the criteria for inclusion within the timeframe, with only 12 (26%) of the patients having a valid ReSPECT form documented. 83% of the patients with a ReSPECT form were documented as DNACPR or ‘ward-based ceiling of care’. Whilst 21 patients (46%) experienced post-operative complications (including sepsis, ICU readmissions and death). 5 out of the 46 patients died within 2 weeks of their surgery, only 1 of which had a valid ReSPECT form; 3/5 of those patients underwent ‘simple’ hernia repairs without bowel resection, none of which had a valid ReSPECT form in place.
Conclusions: Patients with a CFS of 5 or above are increasingly vulnerable to sudden postoperative deterioration, regardless of the surgical risk or high standard of care they receive. 83% of the patients with a ReSPECT form in place were not suitable for, or did not wish for, CPR. We can therefore infer this would likely be the case for many of our patients. Thus, we can use this study to implement changes to practice, such as ensuring our patients at risk of deterioration are given the chance to voice their wishes. We can introduce this as part of the routine consent process for our frail patients, improving their care, preventing unnecessary/unwanted CPR and ensuring clear communication to our staff (especially those working out of hours with limited knowledge of our patients). A secondary outcome was also identified in this project; the mortality rates for seemingly low-risk operations were higher than expected (namely hernia repairs). This suggests that we may be underestimating the risk of these procedures in frail patients and has highlighted this as an area for future projects to investigate.
