From left: Geriatric Surgery Nurse Ms Phyllis Tan, Dr Rodis, Geriatric Surgery Nurse Ms Lynn Tan, Dr Priscilla Ng from Geriatric Medicine, Dr Tan Kok Yang
My Singapore Experiences by Dr Belinda Rodis
Dr Rodis is a qualified Geriatric Physician from Vancouver, Canada who was attached to Khoo Teck Puat Hospital for a 1-month fellowship on Perioperative Care of the Elderly, from 12 March to 8 April 2018.
As a Canadian geriatrician interested in perioperative care of the elderly, I recently had the wonderful opportunity to spend a month working with the Geriatric Surgery Service (GSS) in Khoo Teck Puat Hospital (KTPH). During that time, I had the pleasure of working with the transdisciplinary geriatric surgery team, the general surgeons, the geriatricians, the integrated hip fracture unit, the dementia programme and the community outreach programmes.
Most of my time was spent with the geriatric surgery service, a vibrant group that has been built up over years by passionate and driven people with a shared vision. Coordinated by the surgeons, it truly is a transdisciplinary model of care, where multiple health specialties and disciplines work together to achieve patient goals.
They call it the Start to Finish (STF) programme for a reason. I followed patients through the process from their perspective, and could see that they were at the centre of care throughout. The first key step was the surgeons making sure they truly understood the patients' goals and values. Then, based on that, the geriatric surgery service could be activated by the surgeons to help guide decisions about feasibility of these goals in the setting of their overall health status as well as to work on optimizing recovery. Postoperatively, they were seen again by the dietician and physiotherapist to enhance recovery.
This concept of ownership is one that is truly well considered within the team, and, in fact, throughout the numerous services I worked with at KTPH. Within the geriatric surgery service, I saw that each specialist is responsible for and accountable for their share of the patient's care while still knowing what the other team members do. This allows them to see patients quickly and
Communicate effectively with each other. They truly are a team; I had the opportunity to meet each of them and the comraderie is palpable.
One of the most unique experiences I had there was seeing the prehabilitation programme in place for frail patients. The physiotherapists work one on one with the patients and come up with an individualized exercise program that is supervised and focuses on goal-directed, functional movements. Their important patient-related outcomes – such as functional recovery to baseline – have shown quite impressive results since the onset of the STF programme.
I went to Singapore figuring that I'd get to see what it was like. I left inspired, with a new dream to start a similar program in Vancouver. Coincidentally, my colleague in Vancouver who connected me with the team in the first place ended up being there at the same time. We bonded over the shared experience of eating far too much laksa at family dinners with our gracious and kind host while planning how to bring the dream back to Vancouver.
From exploring the great sights of Singapore in the deadly heat (which I am told I complained about on an unusually cool day) to becoming a part of the team, this was an experience that I'll never forget and I'll always be grateful for.
One of the key lessons I took home from this experience is how to establish sustainability. A transdisciplinary care model where each discipline has a champion who takes ownership over their role is important. I only hope to have the fortune of working with people who are such dedicated champions back home.
PEERS team photo
The Peers Programme
An article contributed by Dr Sharmini Su Sivarajah and A/Prof Chew Min Hoe from Sengkang Hospital.
It is projected that 20-25% of Singapore’s population will be above 65 years old by 2030. With an aging population and a longer life expectancy, the average age of the surgical patient is expected to increase. Frailty is a common condition among the elderly. This has immense health care implications as frail individuals do not just experience increased morbidity and mortality after surgical intervention; they are also likely to require nursing home and long term care facilities after surgery. Needless to say, these individuals can pose a significant healthcare financial and societal burden for the nation. There is evidence in medical literature that frailty can be reversed with
appropriate prehabilitation and nutritional therapy. Thus, there exists a window of opportunity for surgeons to optimise frail individuals prior to
elective surgery in the hope of achieving outcomes similar to that of non-frail individuals.
The PEERS (Programme for Enhanced Elderly Recovery @ SKH) is a pilot programme to develop and validate a prehabilitation service for the frail and elderly. It is a 2-3 week programme which aims to intervene on frail individuals by optimising their nutritional and physical function before surgery. The patients are then provided with an individualised multi-disciplinary prehabilitation protocol targeted at their identified needs. Any intervention which can reverse or attenuate the frail state prior to surgery will improve patient outcomes with potential cost savings.
18 frail and elderly patients underwent the PEERS programme in Alexandra Hospital between 2017 and early 2018. The median age of the patients recruited was 79 years (i.q.r. 75 – 84 years). In this cohort, there was equal sex distribution (9 male: 9 female). 13 patients (72.2%) had either Stage 1 or Stage 2 disease. All patients developed improvement in their functional status post-prehab prior to surgery. There was no mortality reported and the morbidity rate was only 5.6% (1 out of 18 patients). The mean and median length of stay was 6.7 and 8 days respectively. All patients were discharged back to their own homes. 92.9% (13 out of 14 patients) professed equal or higher quality of life (QoL) scores at 3 months after surgery compared to QoL scores taken before surgery.
The outcomes for all these patients have been very favourable with low acceptable morbidity rates. There is improvement in functional status pre-surgery, reduced length of stay post-surgery, and rapid improvement back to baseline status after surgery. Our early pilot has validated the need for a pre-habilitation intervention programme for major surgery which in the long term helps to not only reduce the financial strain in managing an ageing population, but also increases the confidence in family members and patients to a successful positive outcome after major surgery.
With these encouraging results, we hope to recruit a larger sample of frail patients, so as to demonstrate significant cost effectiveness, a reduction of morbidity rates as well as an increase in quality of life in these patients. This in turn will drive the medical frontier to change how medical practitioners manage these frail patients, especially those who undergo major surgery in the future.
Professor Dale Avers
Learning Points from Dr. Dale Avers
This is a write-up on learning points of rehabilitating the frail by Ms Heng, a Senior Physiotherapist at Khoo Teck Puat Hospital, based on some suggestions from Visiting Expert Professor Dale Avers from USA. Professor Avers is a Professor of the Department of Physical Therapy Education at Upstate Medical University, Syracuse New York.
Khoo Teck Puat Hospital, Tan Tock Seng Hospital, together with Renci Hospital, hosted HMDP (Health Manpower Development Plan) visiting Expert
Professor Dale Avers (USA) in Singapore from 5th – 9th March 2018. During this coordinated visit, Professor Dale Avers was invited to deliver
teachings on the topic of Frailty. She discussed various issues and learnings relating to frailty in our older population. During her visit, she also had the opportunity to gain understanding of the local healthcare context and played a role in helping us identify challenges, possible suggestions as well as potential points of concern to help us direct better care for our clients.
Some of the recommendations that targets frailty care, as suggested by Professor Dale, include encouraging healthcare workers to reflect on:
1. Paternalistic and “Safety” Culture in healthcare, including institutional care (e.g. in acute and community hospitals) where it has an ongoing detrimental impact on the older person’s physical health with the amount of bed rest. Frequent barriers to exercise introduced include cultural influences such as families promoting dependency, use of domestic helpers that worked at cross purposes to activity goals, general lack of physical activity and exercise amongst all Singaporeans. These cultural factors while valid, need to be addressed, as they do present significant barriers to mobility.
2. To promote a culture of genuine listening with desires to deeply understand patient’s and families’ concerns, values, and desire. While time may be a constraint, simple methods of obtaining patient values and desires should be promoted among all healthcare professionals, across disciplines. This should aim to become a norm for all patient encounters as the alignment of patient’s goals provides a platform for patient advocacy at all levels and reduce the presence of paternalism in healthcare.
3. Culturism, similar to ageism, may a barrier that implies that nothing can be done an excuse.
4. There is a lack of cross talk among disciplines and healthcare professionals within and across healthcare organisations. Sharing of information is not just to inform the end- users but to meaningfully involve them for collaboration and encourage ownership of care.
Professor Dale applauded the local healthcare system on the standards of our physical facilities and the presence of caring healthcare providers who are actively working towards improving care for our population. She observed an active shift of healthcare towards community services and agreed that this is a timely move.