Annals of the Royal College of Surgeons of England (1991) vol. 73, 285-288
An audit very old
of
surgical emergencies in the
R Faruqi MB FRCS FRCSEd Surgical Registrar
R B Galland MD FRCS Consultant Surgeon
J M Williams MB BS House Surgeon
Department of Surgery, Royal Berkshire Hospital, Reading
Key words: Surgical emergencies; Elderly patients
The surgical emergency admissions of patients over the age of 80 years at the hospitals of the West Berkshire Health Authority during 1989 have been analysed. The results were then compared with those of 1976 and 1966 in an attempt to identify any changing trends. The total number of admissions increased by almost 37% from 248 in 1976 to 339 in 1989. There was a dramatic increase in those patients admitted with gastrointestinal problems. The average length of stay was less in 1989, being 9 days compared with 15 days in 1976; this was despite the fact that the average length of stay for all ages was comparable for the 2 years in question. The overali mortality rate has not appreciably altered being 21.8% in 1976 and 22.4% in 1989. Excluding terminal disease the mortality rates were 12.5% and 15.9% for 1976 and 1989 respectively. Despite the increased numbers of patients admitted the total beds occupied by the over 80s has actually fallen between 1976 and 1989, due to their shorter hospital stay. Figures for the year 2000 predict a continuing increase in the number of elderly patients in the community. It is unlikely that we will be able to reduce hospital stay much further and therefore the total number of beds occupied by the very old in the acute surgical ward will rise steadily.
The proportion of older patients in the community is steadily rising. From 1966 to 1976 Salem et al. (1) noted a trend in Reading of increasing surgical emergency admissions in those patients over 80 years of age. The aim of the present audit was to determine whether this trend continued into the 1980s. We also tried to identify whether there was a change in the nature of admissions and whether any tangible improvements in patient management could be identified.
Methods As part of a continuing audit the clinical details of all patients aged over 80 years admitted as surgical emergencies to the Royal Berkshire and Battle Hospitals, Reading, during 1989 were studied. In particular we analysed the reason for admission, management, mortality and duration of hospital stay. We then compared our results with those for 1966 and 1976 in the same health authority. Population figures for the West Berkshire Health Authority (WBHA) in 1989 were obtained from the Office of Population Censuses and Surveys. We also obtained projected figures for the year 2000 from the same source.
Results The population under the care of WBHA increased from 403 000 in 1976 to 460 410 in 1989 (an increase of 14.2%) (2). The number of people over the age of 80 years has increased by 54%, from 8060 to 12 426 during the same period. The relative proportion of those over 80 years of age has increased from 2% of the adult population in 1976 to 3.7% in 1989. During 1989 a total of 21 384 patients were admitted as an emergency to all specialties, 3792 (17.7%) were over the age of 80 years and 339 (8.9%) of these were surgical. The total surgical emergency admissions have increased steadily from 1966 to 1989 (Fig. 1). Emergency surgical admissions of the elderly have also increased from 122 in 1966 to 248 in 1976 and to 339 in 1989
(Fig. 2). Correspondence to: Mr R B Galland, Consultant Surgeon, Royal Berkshire Hospital, London Road, Reading RG1 SAN
The proportion of emergency to total surgical admissions
seems to be dropping (51.2% in 1966, 44.8% in 1976,
286
R Faruqi et al.
WI
Elective
Inpatient
11000
E Emergency
10000
After discharge
n pat!ents
9000.
Total swgoca soooadrslsions 7000
6000.
5000
4000n 3000 2000
10001966
1976
1989
> Bmths
29days 6112
Figure 1. Surgical admissions 1966, 1976, 1989 to the West
Figure 3. Timing of deaths.
Berkshire Health Authority.
Mode of discharge Of the 263 (77.5%) patients who were discharged, 229 (87%) went back to their own home and 34 (13%) went either to other hospitals or specialties or to nursing or convalescent homes. The comparative figures for 1976 were 78% and 22%, respectively.
350 300
250
Adrrssions
200 150 100
50 1968
1976
1989
Year
Figure 2. Emergency surgical admissions in patients aged over 80 years of age.
33.4% in 1989) (Fig. 1). However, the corresponding elderly component of the emergency surgical workload (ie elderly to total emergency admissions), is increasing (6.2% in 1966, 8.4% in 1976, 9.90/o in 1989).
Age and sex distribution The median age of patients in our study was 85 years (range 80-102 years) and 59.8% (203) were women. The average age of patients who died was also 85 years. These figures are similar to those for 1966 and 1976.
Mortality The inpatient mortality rate was 22.4% (76/339) or 15.9% if terminal disease was excluded. These figures are slightly worse than those during 1976 of 21.8% and 12.5% respectively. A further 61 patients died after discharge. Thus 40% of patients died within 17 months of being admitted as a surgical emergency (Fig. 3). Of the 76 inpatient deaths, 33 (43.4%) died after an operation, providing a 30 day operative mortality of 16.8%.
Length of stay The median duration of stay was 9 days (range 1-98 days) irrespective of death. By contrast the median length of stay for non-geriatric patients was 5 days. Reasons for admission The breakdown into broad diagnostic categories is shown in Fig. 4. The most marked change from 1976 was the dramatic increase in patients presenting with gastrointestinal symptoms.
Gastrointestinal disease Of the 339 emergency admissions, 70 (20.6%) were due to intestinal obstruction, 47 (67%) underwent an operation with 14 deaths (29.8%). There were 21 (30%) with a malignant cause of obstruction, with all but two undergoing an operation. The mortality in this group was
Nuneer
80 70 60 l 50
1976
|
1989
Admissions 3 0
iL-
i i
l
2100 v
/h , s le, A
e
.
q.A.o .,f
oo jj.
.0
,
4
ct4
C* 0
.0
qsp
Figure 4. Diagnosis of patients admitted (1976-1989).
$.
-
Surgical emergencies in the elderly 47.6%. A total of 20 patients (28.5%) presented with incarcerated hernias, all but one had an emergency operation with two requiring bowel resections. There were no deaths. A total of 56 patients (45%) were admitted with evidence of localised or generalised peritonitis. Cholecystitis was the commonest cause accounting for 13 (23%) of admissions. All but three had urgent cholecystectomies, none of these patients died. The other causes of peritonitis were appendicitis (4), diverticulitis (10), perforated duodenal ulcers (11), pancreatitis (5) and mesenteric infarction (7). A further five patients were admitted with an acute abdomen of indeterminate cause but were too ill to undergo laparotomy. All five died, as did the patients with mesenteric infarction, only two of whom were fit enough to undergo an operation. All 11 patients with perforated duodenal ulcers went to theatre with an operative mortality of 18%. Of the 56 patients admitted with peritonitis 36 (64%) underwent an operation. The overall mortality was 32% with an operative mortality of 25%. There were 37 patients admitted with upper gastrointestinal haemorrhage; only three had an emergency opeation and two died. The overall mortality rate was 13.5% (five deaths).
Genitourinary problems Of 53 patients admitted, 17 (32%) underwent an operation. The commonest reason for admission was acute urinary retention. Of the 33 patients with retention 16 (48.5%) had prostatic resections during their admission. The rest either had successful trial without catheter or were discharged home with indwelling Silastic® catheters and leg bags. The mortality rate in this group of patients was 7.5% (four deaths), almost one-half of that in 1976.
Peripheral vascular disease (PVD) Admissions due to PVD continue to increase. Of the 26 admissions, three had ruptured abdominal aortic aneurysm, they were all moribund and operation was not considered. A total of 22 patients had occlusive disease and eight eventually underwent an amputation. Patients having amputations had a median bed occupancy of 21 days (46 days in 1976) compared with the overall bed occupancy, in this group of patients, of 10 days. The overall mortality was 38.5% (10 deaths), with an operative mortality of 28.5%.
287
Surgical care of the elderly is associated with many problems and this is borile out by the high mortality in these patients (3-6). Our figures show no improvement in mortality from 1966 to 1989. Difficulty in diagnosis and the presence of co-existing disease are major contributors to the poor outcome in the elderly. Bosch et al. (7) showed that 52% of patients over the age of 60 years, who underwent an operation, had concomitant disease. While the CEPOD audit considered all age groups, 79% of deaths were in patients over the age of 65 years and intercurrent disease was thought to have contributed to death in between 44% and 52% of cases (8). The elderly patient is much more prone to sepsis, cardiovascular and respiratory complications, as well as to deep vein thrombosis with its attendant sequelae (9). Cardiorespiratory problems are the commonest cause of death in these patients (10). Indeed, it has been shown that 45.6% of patients over the age of 80 years have objective evidence of cardiac disease (11). Our figures show a dramatic increase in the number of patients admitted with gastrointestinal disease, typified by the 212% increase in the incidence of bowel obstruction compared with the 1976 figures. Excluding the patients with widespread malignancy, patients with PVD had the highest mortality (38.5%). This coincides with figures from Hobler and Howlett's study (9). Of note, however, is the fact that their patients had a mean length of stay of 20 days, which was almost twice that of ours. The average stay of our patients undergoing amputation was 21 days, less than half of that in 1976. Although the number of very old patients admitted has increased between 1976 and 1989, since they are staying in hospital for a shorter time the total number of beds occupied by these patients has actually fallen. However, it is difficult to see how the hospital stay can be shortened further. As the number of elderly patients increases and with cutbacks reducing the number of available beds, acute surgical beds are in danger of being overwhelmed by emergency surgical cases in this group of patients. Health care of the elderly is expensive. With the rapidly growing elderly population this problem will worsen. These patients should be carefully assessed and, in particular, pre-admission quality of life and the wishes of the patient and their families should be taken into account before embarking upon a policy of aggressive management. We would like to thank the members of the Division of Surgery of the Royal Berkshire and Battle Hospitals for allowing us to study patients admitted under their care.
Discussion Projected figures for the year 2000 show that while the population of the WBHA will increase by 8.8%, with an increase in hospital admissions of 11%, the corresponding increase in the 'over 75' age group will be 16.8% and 19.7% respectively (2).
References I Salem R, Devitt P, Johnson J, Firmin R. Emergency geriatric surgical admissions. Br Med J 1978;2:416-17. 2 Figures from the Office of Population Censuses and Surveys.
288
R Faruqi et al.
3 Carp L. Mortality in geriatric surgery. Br Med J 1950;2: 1198-1201. 4 Seymour DG. Medical aspects of surgery in the elderly patient. Baillieres Clin Obstet Gynaecol 1988;2:269-87. 5 Keller SM, Markovitz LJ, Wilder JR, Aufses AH Jr. Emergency and elective surgery in patients over age 70. Am Surg 1987;53:636-40. 6 Bonus RL, Dorsey JM. Major surgery in the aged patient. A continuation study. Arch Surg 1965;90:95-6. 7 Bosch DT, Islami A, Tan CTC, Beling CA. The elderly surgical patient. An analysis of five hundred consecutive cases of patients sixty years of age or older. Arch Surg 1952;64:269-77.
8 Buck N, Devlin HB, Lunn JN. The Report of a Confidential Enquiry into Perioperative Deaths. London: The King's Fund, 1987. 9 Hobler KE, Howlett PA. Surgery in the very elderly. QRB 1985;11:339-41. 10 Seymour DG, Vaz FG. Aspects of surgery in the elderly: preoperative medical assessment. Br J Hosp Med 1987; 37:102-4, 106, 108 passim. 1I Mithoefer J, Mithoefer JC. Studies of the aged. Arch Surg 1954;69:58-65.
Received 16 January 1991
Assessor's comment Most surgeons have a strong impression that an increasing proportion of their emergency admissions are among the elderly, infirm population. This paper reinforces that impression with hard data drawn from a prospective audit of this group which has been carried out over a long period. As expected, the mortality is high. It is particularly so in those patients admitted with disease in the aortic, mesenteric and lower limb vasculature, emphasising the widespread nature of occlusive vascular disease. While the significance of concomitant disease is referred to as a significant contributor to mortality, no data is presented in this study. Perhaps future studies will include such data which might enable 'outcome indi-
cators' (similar to the APACHE scoring for ill patients) to be derived for this group of patients. Together with the pre-admission quality of life (often difficult to assess) and patient/family wishes, such indicators may assist in making decisions about management. Clearly, accurate data will continue to be needed if planning is to be realistic for this growing and resource-expensive group of patients. T J DUFFY FRCS Consultant Surgeon City General Hospital Stoke-on-Trent
An audit very old
of
surgical emergencies in the
R Faruqi MB FRCS FRCSEd Surgical Registrar
R B Galland MD FRCS Consultant Surgeon
J M Williams MB BS House Surgeon
Department of Surgery, Royal Berkshire Hospital, Reading
Key words: Surgical emergencies; Elderly patients
The surgical emergency admissions of patients over the age of 80 years at the hospitals of the West Berkshire Health Authority during 1989 have been analysed. The results were then compared with those of 1976 and 1966 in an attempt to identify any changing trends. The total number of admissions increased by almost 37% from 248 in 1976 to 339 in 1989. There was a dramatic increase in those patients admitted with gastrointestinal problems. The average length of stay was less in 1989, being 9 days compared with 15 days in 1976; this was despite the fact that the average length of stay for all ages was comparable for the 2 years in question. The overali mortality rate has not appreciably altered being 21.8% in 1976 and 22.4% in 1989. Excluding terminal disease the mortality rates were 12.5% and 15.9% for 1976 and 1989 respectively. Despite the increased numbers of patients admitted the total beds occupied by the over 80s has actually fallen between 1976 and 1989, due to their shorter hospital stay. Figures for the year 2000 predict a continuing increase in the number of elderly patients in the community. It is unlikely that we will be able to reduce hospital stay much further and therefore the total number of beds occupied by the very old in the acute surgical ward will rise steadily.
The proportion of older patients in the community is steadily rising. From 1966 to 1976 Salem et al. (1) noted a trend in Reading of increasing surgical emergency admissions in those patients over 80 years of age. The aim of the present audit was to determine whether this trend continued into the 1980s. We also tried to identify whether there was a change in the nature of admissions and whether any tangible improvements in patient management could be identified.
Methods As part of a continuing audit the clinical details of all patients aged over 80 years admitted as surgical emergencies to the Royal Berkshire and Battle Hospitals, Reading, during 1989 were studied. In particular we analysed the reason for admission, management, mortality and duration of hospital stay. We then compared our results with those for 1966 and 1976 in the same health authority. Population figures for the West Berkshire Health Authority (WBHA) in 1989 were obtained from the Office of Population Censuses and Surveys. We also obtained projected figures for the year 2000 from the same source.
Results The population under the care of WBHA increased from 403 000 in 1976 to 460 410 in 1989 (an increase of 14.2%) (2). The number of people over the age of 80 years has increased by 54%, from 8060 to 12 426 during the same period. The relative proportion of those over 80 years of age has increased from 2% of the adult population in 1976 to 3.7% in 1989. During 1989 a total of 21 384 patients were admitted as an emergency to all specialties, 3792 (17.7%) were over the age of 80 years and 339 (8.9%) of these were surgical. The total surgical emergency admissions have increased steadily from 1966 to 1989 (Fig. 1). Emergency surgical admissions of the elderly have also increased from 122 in 1966 to 248 in 1976 and to 339 in 1989
(Fig. 2). Correspondence to: Mr R B Galland, Consultant Surgeon, Royal Berkshire Hospital, London Road, Reading RG1 SAN
The proportion of emergency to total surgical admissions
seems to be dropping (51.2% in 1966, 44.8% in 1976,
286
R Faruqi et al.
WI
Elective
Inpatient
11000
E Emergency
10000
After discharge
n pat!ents
9000.
Total swgoca soooadrslsions 7000
6000.
5000
4000n 3000 2000
10001966
1976
1989
> Bmths
29days 6112
Figure 1. Surgical admissions 1966, 1976, 1989 to the West
Figure 3. Timing of deaths.
Berkshire Health Authority.
Mode of discharge Of the 263 (77.5%) patients who were discharged, 229 (87%) went back to their own home and 34 (13%) went either to other hospitals or specialties or to nursing or convalescent homes. The comparative figures for 1976 were 78% and 22%, respectively.
350 300
250
Adrrssions
200 150 100
50 1968
1976
1989
Year
Figure 2. Emergency surgical admissions in patients aged over 80 years of age.
33.4% in 1989) (Fig. 1). However, the corresponding elderly component of the emergency surgical workload (ie elderly to total emergency admissions), is increasing (6.2% in 1966, 8.4% in 1976, 9.90/o in 1989).
Age and sex distribution The median age of patients in our study was 85 years (range 80-102 years) and 59.8% (203) were women. The average age of patients who died was also 85 years. These figures are similar to those for 1966 and 1976.
Mortality The inpatient mortality rate was 22.4% (76/339) or 15.9% if terminal disease was excluded. These figures are slightly worse than those during 1976 of 21.8% and 12.5% respectively. A further 61 patients died after discharge. Thus 40% of patients died within 17 months of being admitted as a surgical emergency (Fig. 3). Of the 76 inpatient deaths, 33 (43.4%) died after an operation, providing a 30 day operative mortality of 16.8%.
Length of stay The median duration of stay was 9 days (range 1-98 days) irrespective of death. By contrast the median length of stay for non-geriatric patients was 5 days. Reasons for admission The breakdown into broad diagnostic categories is shown in Fig. 4. The most marked change from 1976 was the dramatic increase in patients presenting with gastrointestinal symptoms.
Gastrointestinal disease Of the 339 emergency admissions, 70 (20.6%) were due to intestinal obstruction, 47 (67%) underwent an operation with 14 deaths (29.8%). There were 21 (30%) with a malignant cause of obstruction, with all but two undergoing an operation. The mortality in this group was
Nuneer
80 70 60 l 50
1976
|
1989
Admissions 3 0
iL-
i i
l
2100 v
/h , s le, A
e
.
q.A.o .,f
oo jj.
.0
,
4
ct4
C* 0
.0
qsp
Figure 4. Diagnosis of patients admitted (1976-1989).
$.
-
Surgical emergencies in the elderly 47.6%. A total of 20 patients (28.5%) presented with incarcerated hernias, all but one had an emergency operation with two requiring bowel resections. There were no deaths. A total of 56 patients (45%) were admitted with evidence of localised or generalised peritonitis. Cholecystitis was the commonest cause accounting for 13 (23%) of admissions. All but three had urgent cholecystectomies, none of these patients died. The other causes of peritonitis were appendicitis (4), diverticulitis (10), perforated duodenal ulcers (11), pancreatitis (5) and mesenteric infarction (7). A further five patients were admitted with an acute abdomen of indeterminate cause but were too ill to undergo laparotomy. All five died, as did the patients with mesenteric infarction, only two of whom were fit enough to undergo an operation. All 11 patients with perforated duodenal ulcers went to theatre with an operative mortality of 18%. Of the 56 patients admitted with peritonitis 36 (64%) underwent an operation. The overall mortality was 32% with an operative mortality of 25%. There were 37 patients admitted with upper gastrointestinal haemorrhage; only three had an emergency opeation and two died. The overall mortality rate was 13.5% (five deaths).
Genitourinary problems Of 53 patients admitted, 17 (32%) underwent an operation. The commonest reason for admission was acute urinary retention. Of the 33 patients with retention 16 (48.5%) had prostatic resections during their admission. The rest either had successful trial without catheter or were discharged home with indwelling Silastic® catheters and leg bags. The mortality rate in this group of patients was 7.5% (four deaths), almost one-half of that in 1976.
Peripheral vascular disease (PVD) Admissions due to PVD continue to increase. Of the 26 admissions, three had ruptured abdominal aortic aneurysm, they were all moribund and operation was not considered. A total of 22 patients had occlusive disease and eight eventually underwent an amputation. Patients having amputations had a median bed occupancy of 21 days (46 days in 1976) compared with the overall bed occupancy, in this group of patients, of 10 days. The overall mortality was 38.5% (10 deaths), with an operative mortality of 28.5%.
287
Surgical care of the elderly is associated with many problems and this is borile out by the high mortality in these patients (3-6). Our figures show no improvement in mortality from 1966 to 1989. Difficulty in diagnosis and the presence of co-existing disease are major contributors to the poor outcome in the elderly. Bosch et al. (7) showed that 52% of patients over the age of 60 years, who underwent an operation, had concomitant disease. While the CEPOD audit considered all age groups, 79% of deaths were in patients over the age of 65 years and intercurrent disease was thought to have contributed to death in between 44% and 52% of cases (8). The elderly patient is much more prone to sepsis, cardiovascular and respiratory complications, as well as to deep vein thrombosis with its attendant sequelae (9). Cardiorespiratory problems are the commonest cause of death in these patients (10). Indeed, it has been shown that 45.6% of patients over the age of 80 years have objective evidence of cardiac disease (11). Our figures show a dramatic increase in the number of patients admitted with gastrointestinal disease, typified by the 212% increase in the incidence of bowel obstruction compared with the 1976 figures. Excluding the patients with widespread malignancy, patients with PVD had the highest mortality (38.5%). This coincides with figures from Hobler and Howlett's study (9). Of note, however, is the fact that their patients had a mean length of stay of 20 days, which was almost twice that of ours. The average stay of our patients undergoing amputation was 21 days, less than half of that in 1976. Although the number of very old patients admitted has increased between 1976 and 1989, since they are staying in hospital for a shorter time the total number of beds occupied by these patients has actually fallen. However, it is difficult to see how the hospital stay can be shortened further. As the number of elderly patients increases and with cutbacks reducing the number of available beds, acute surgical beds are in danger of being overwhelmed by emergency surgical cases in this group of patients. Health care of the elderly is expensive. With the rapidly growing elderly population this problem will worsen. These patients should be carefully assessed and, in particular, pre-admission quality of life and the wishes of the patient and their families should be taken into account before embarking upon a policy of aggressive management. We would like to thank the members of the Division of Surgery of the Royal Berkshire and Battle Hospitals for allowing us to study patients admitted under their care.
Discussion Projected figures for the year 2000 show that while the population of the WBHA will increase by 8.8%, with an increase in hospital admissions of 11%, the corresponding increase in the 'over 75' age group will be 16.8% and 19.7% respectively (2).
References I Salem R, Devitt P, Johnson J, Firmin R. Emergency geriatric surgical admissions. Br Med J 1978;2:416-17. 2 Figures from the Office of Population Censuses and Surveys.
288
R Faruqi et al.
3 Carp L. Mortality in geriatric surgery. Br Med J 1950;2: 1198-1201. 4 Seymour DG. Medical aspects of surgery in the elderly patient. Baillieres Clin Obstet Gynaecol 1988;2:269-87. 5 Keller SM, Markovitz LJ, Wilder JR, Aufses AH Jr. Emergency and elective surgery in patients over age 70. Am Surg 1987;53:636-40. 6 Bonus RL, Dorsey JM. Major surgery in the aged patient. A continuation study. Arch Surg 1965;90:95-6. 7 Bosch DT, Islami A, Tan CTC, Beling CA. The elderly surgical patient. An analysis of five hundred consecutive cases of patients sixty years of age or older. Arch Surg 1952;64:269-77.
8 Buck N, Devlin HB, Lunn JN. The Report of a Confidential Enquiry into Perioperative Deaths. London: The King's Fund, 1987. 9 Hobler KE, Howlett PA. Surgery in the very elderly. QRB 1985;11:339-41. 10 Seymour DG, Vaz FG. Aspects of surgery in the elderly: preoperative medical assessment. Br J Hosp Med 1987; 37:102-4, 106, 108 passim. 1I Mithoefer J, Mithoefer JC. Studies of the aged. Arch Surg 1954;69:58-65.
Received 16 January 1991
Assessor's comment Most surgeons have a strong impression that an increasing proportion of their emergency admissions are among the elderly, infirm population. This paper reinforces that impression with hard data drawn from a prospective audit of this group which has been carried out over a long period. As expected, the mortality is high. It is particularly so in those patients admitted with disease in the aortic, mesenteric and lower limb vasculature, emphasising the widespread nature of occlusive vascular disease. While the significance of concomitant disease is referred to as a significant contributor to mortality, no data is presented in this study. Perhaps future studies will include such data which might enable 'outcome indi-
cators' (similar to the APACHE scoring for ill patients) to be derived for this group of patients. Together with the pre-admission quality of life (often difficult to assess) and patient/family wishes, such indicators may assist in making decisions about management. Clearly, accurate data will continue to be needed if planning is to be realistic for this growing and resource-expensive group of patients. T J DUFFY FRCS Consultant Surgeon City General Hospital Stoke-on-Trent
