Implementing Perioperative Care for Older Surgical Patients: Lessons from Real-World Practice

What Can Perioperative Interventions Teach Us?

In a comprehensive qualitative evaluation conducted at the University Medical Centre Hamburg-Eppendorf, researchers have assessed the implementation of a multicomponent perioperative intervention designed to reduce functional decline in geriatric surgical patients. The study, which included interviews with both healthcare professionals (HCPs) and patients, offers valuable insights into the barriers and facilitators affecting the adoption of evidence-based perioperative care practices in routine clinical settings.

With 7.1 million Germans undergoing surgery in 2019, and more than half of these patients being over 60 years of age, addressing the unique risks faced by geriatric surgical patients represents a significant healthcare priority. Older adults are particularly vulnerable to postoperative complications including neurocognitive disorders and delirium, which can significantly impact functional status and quality of life. The researchers implemented a multicomponent intervention targeting various risk factors throughout the perioperative journey, from preoperative assessment and prehabilitation to intraoperative management strategies. The implementation was evaluated using Proctor's Implementation Outcomes Framework, focusing on feasibility, adoption, appropriateness, acceptance, and sustainability.

How Was the Intervention Conducted and What Challenges Emerged?

The study involved 278 patients aged 65 and above with impending surgery, allocated to three groups: routine care (control), implementation phase (gradual introduction of interventions), and intervention phase (full implementation). The qualitative evaluation included interviews with seven patients and 15 healthcare professionals from various disciplines and work settings. The intervention components ranged from preoperative measures such as iron supplementation, protein nutritional support, and physical exercise regimens to intraoperative strategies including EEG-guided anesthesia administration and retention of orientation aids (glasses, hearing devices) until just before anesthesia induction.

The findings revealed complex implementation dynamics. Initially, many HCPs exhibited resistance to changes in established routines, particularly for interventions requiring significant procedural modifications. However, acceptance gradually increased with repeated education sessions and positive patient feedback. The researchers noted that ward nurses generally showed greater acceptance of interventions compared to other staff groups, possibly due to their closer patient interaction. The short interval between anesthesia consultation and surgery emerged as a major barrier to implementing preoperative interventions, limiting the effectiveness of medication adjustments and prehabilitation efforts. Resource constraints, including financial limitations, staffing shortages, and space restrictions, were consistently identified as significant implementation challenges.

Patient adherence to home-based prehabilitation was variable, with the researchers noting that frail patients who might benefit most from these interventions often had the poorest compliance. Interestingly, while healthcare professionals reported that patients appreciated the retention of orientation aids during the preoperative period, the interviewed patients themselves did not perceive this as significantly beneficial to their orientation. Such discrepancies highlight the importance of capturing diverse stakeholder perspectives when evaluating complex interventions.

Can Evidence-Based Practices Be Sustained in Clinical Routine?

The sustainability of the intervention components varied considerably. Intraoperative interventions were generally considered more feasible for routine implementation than preoperative components, which faced greater logistical and financial barriers. Healthcare professionals emphasized that ongoing training and updated standard operating procedures were essential for sustainable implementation, particularly given high staff turnover rates. They also highlighted the need for improved communication with general practitioners to enhance the effectiveness of preoperative interventions such as medication optimization and nutritional support.

This study distinguishes itself from previous research by evaluating a comprehensive perioperative intervention across multiple surgical contexts rather than focusing on specific components or patient populations. The findings underscore the challenges of implementing evidence-based practices in routine care settings and highlight potential strategies for overcoming these barriers. Future implementation efforts should address resource allocation, enhance interprofessional communication, strengthen links between hospital and primary care, and develop strategies to improve patient engagement and adherence.

A notable strength of this research is its implementation evaluation under real-life circumstances for various surgeries, providing valuable insights into the practical challenges of translating evidence into practice. The qualitative methodology enabled in-depth data collection of the implementation process and its components, capturing multidisciplinary experiences from patients and healthcare professionals from different workspaces and backgrounds. However, the researchers acknowledge limitations including potential selection bias due to the small number and non-random selection of interview partners, as well as the absence of long-term data on how sustainably the components could be integrated into clinical routine.

The study also revealed interesting interrelationships between implementation outcomes. All outcomes were highly interrelated, with sustainability dependent on all other outcomes but not significantly influencing them. The feasibility of interventions depended on estimates of appropriateness and acceptance by both HCPs and patients, while acceptance was influenced by feasibility and adoption. These complex interactions underscore the multifaceted nature of implementation processes in healthcare settings.

What Future Directions and Innovations Lie Ahead?

Could improved financial models that better account for the long-term benefits of perioperative optimization help overcome the resource constraints identified in this study? What strategies might healthcare systems employ to bridge the communication gap between hospital specialists and general practitioners? How might digital health technologies support patient engagement in preoperative prehabilitation, particularly for frail older adults? These questions merit consideration as healthcare systems work to implement evidence-based perioperative care pathways for vulnerable geriatric populations.

As healthcare systems worldwide face growing numbers of older surgical patients, studies like this one provide crucial guidance on how to translate evidence-based recommendations into practice. The findings suggest that successful implementation requires not only addressing logistical and resource constraints but also engaging stakeholders across disciplines and care settings to build acceptance and ensure sustainability of new care practices.

Summary

Researchers at the University Medical Centre Hamburg-Eppendorf conducted a comprehensive qualitative evaluation of a multicomponent perioperative intervention designed to reduce functional decline in geriatric surgical patients. The study, involving 278 patients aged 65 and above and interviews with healthcare professionals and patients, assessed implementation outcomes using Proctor's Implementation Outcomes Framework. With over half of Germany's 7.1 million annual surgical patients being over 60, addressing geriatric surgical risks represents a significant healthcare priority. The intervention included preoperative measures such as iron supplementation, protein support, and physical exercise, alongside intraoperative strategies like EEG-guided anesthesia and retention of orientation aids. Initial resistance from healthcare professionals gradually decreased with repeated education and positive patient feedback, though ward nurses showed greater acceptance than other staff groups. Major implementation barriers included short intervals between consultation and surgery, resource constraints, staffing shortages, and variable patient adherence to home-based prehabilitation, particularly among frail patients who would benefit most. Intraoperative interventions proved more feasible for routine implementation than preoperative components due to fewer logistical and financial barriers. The study revealed complex interrelationships between implementation outcomes, with sustainability dependent on feasibility, adoption, appropriateness, and acceptance. Healthcare professionals emphasized the need for ongoing training, improved communication with general practitioners, and enhanced interprofessional collaboration for sustainable implementation. The research provides valuable insights into translating evidence-based perioperative care into routine clinical practice for vulnerable geriatric populations facing postoperative complications including neurocognitive disorders and delirium.