Supporting Patients Undergoing Surgery

Perioperative medicine is a transdisciplinary field meant to care for patients throughout their surgical journey. Preoperative medical assessments help patients with complex medical histories understand their personal risk of surgery, which is critical for informed consent. After surgery, perioperative medical consults can help surgeons manage or avoid postoperative complications.

In most American and Canadian centres, cardiologists and anesthesiologists are responsible for most 
perioperative medical care. Because of this, the majority of perioperative guidelines and research focus on preventing, identifying, and treating cardiac complications of surgery, which account for about 50% of perioperative deaths. However, the increasing age and medical complexity of the surgical population calls for a more comprehensive approach to perioperative medical care.

Calgary stands out for its involvement of general internists and geriatricians in anticipating, preventing, and managing medical complications before, during, and after surgery – including risks specific to older adults like delirium and loss of independence. This approach allows patients to consider additional risks from their surgery beyond mortality when deciding between surgery and conservative approaches.

Beyond the clinical advantages to have general internists and geriatricians involved in perioperative care, this holistic approach has expanded research in perioperative medicine. Perioperative research in the Department of Medicine now includes collaboration with other Canadian centers on international clinical trials, quality improvement work on perioperative glycemic management, and health systems research on managing surgical risk in older adults.  

Clinical Focus

Patients may visit both the Preadmission Clinic and the Geriatric Medicine Preoperative clinic in varying timelines. For example, a family medicine physician, specialist or surgeon can refer to the Geriatric Medicine Preoperative clinic after seeing them in their office or in the Preadmission clinic. Patients can also be seen by the Geriatric Medicine Pre-Operative Clinic if they are contemplating having surgery and without a surgical date. 

GIM Preadmission Clinic (PAC) 

In a preadmission clinic, general internists play a crucial role in preparing patients medically for surgery. Their primary focus is to optimize a patient's medical status, assess surgical risk, and ensure that all relevant medical issues are identified and managed beforehand. This will generally be accomplished by performing a thorough medical assessment including a functional assessment, medication review and review of the patient’s comorbidities and management by other specialties.

Risk stratification is undertaken using several validated tools such as the revised cardiac index score (RCRI) or the NSQIP score. Medications are managed with instructions given to patients about the immediate preoperative changes required and advice given to the surgical teams about perioperative medication management. This includes complex medication management of medications such as insulin and anticoagulants in the perioperative period. Other activities include the ordering and review of needed perioperative investigations including bloodwork and when appropriate, cardiac investigations. Optimization of chronic health conditions is required prior to surgery and may include treatment of anemia, improvement of glycemic control and assessment of chronic cardiac/respiratory diseases as needed prior to undergoing surgery.

General Internists work as a team with the preadmission clinic Nurses, Pharmacists, Anesthetists and Surgeons to prepare patients for surgery and ensure that there is a comprehensive perioperative medicine plan documented for patients with complex chronic disease. 

Geriatric Perioperative Clinic 

The Geriatric Medicine Preoperative Clinic supports older adults preparing for major elective surgery, with suspected or established geriatric syndromes, including frailty, cognitive impairment (e.g. mild cognitive impairment or dementia), polypharmacy, and functional decline.

Patients initially receive a pre-visit RN phone call and then are assessed by a geriatrician and nurse at the Seniors Health Clinic at Rockyview General Hospital in person or virtually. In-clinic evaluations include medical and functional assessments, frailty and cognitive screening and staging, deprescribing potentially high risk or inappropriate medications, and identification of nutritional deficits and postoperative discharge needs. The team then discusses surgical risks and benefits, focusing on cognitive and functional outcomes, in the context of the patient’s overall health trajectory and values, supporting informed decision-making.

Counselling focuses on delirium prevention education and engaging families in early delirium identification and support. Advance care planning, including creation of personal directives, and goals of care designations are also reviewed.

This clinic functions independently but complementary to Anesthesiology or General Internal Medicine preoperative assessments. If surgery proceeds, the clinical nurse specialist in geriatrics at the acute care sit provides post-operative support such as implementation of delirium prevention interventions and coordination of further geriatric care as needed, aiming to improve surgical outcomes and support patient-centered care.

Research Spotlight: Dr. Krista Reich

Dr. Krista Reich is an early career researcher with a clinical and research focus on improving perioperative and acute care for older adults. She is committed to advancing the care for older adults, highlighting knowledge user values in research and bringing diverse interdisciplinary and cross-specialty relationships together to provide a holistic approach to older adult care.

She is leading knowledge translation initiatives aimed at implementing and optimizing the Geriatric Medicine Pre-operative Clinic to improve surgical care for older adults. Supported by UCalgary and the MSI Foundation, her research is identifying and working to address key barriers to the integration of comprehensive geriatric assessments (CGAs) into preoperative workflows. This includes the co-development and application of evidence-based tools to enhance the feasibility, efficiency, and clinical utility of CGAs in surgical settings, including guideline recommended frailty screening.

In parallel, Dr. Reich conducts health services research using administrative data to explore the impact of surgery on patient-centered outcomes, including the risk of incident dementia, and to understand utilization of specialized geriatric inpatient services. These findings inform broader system-level improvements in geriatric perioperative care. She has also conducted prioritization work to identify outcomes that are meaningful to older adults, their care partners, and interdisciplinary surgical teams, ensuring that future evaluation efforts are grounded in patient-centered outcomes

She has a strong research interest in enhancing perioperative risk communication, particularly in the context of frailty. Her goal is to support clinicians in delivering individualized, value-sensitive discussions about surgical risk that align with the health goals and vulnerabilities of older adults living with frailty. Her work contributes to advancing person-centered, evidence-based perioperative care for aging populations.

Research Spotlight: Dr. Shannon Ruzycki 

The Perioperative Glycemic Management Project (PGMP) received a $1.3 million PRIHS-6 grant from Alberta Innovates in 2021 to address gaps in measurement of blood sugars and treatment of hyperglycemia in the perioperative period.

This work demonstrated that 1 in 5 patients with diabetes does not have any glucose measurements on the day of their surgery and that most patients who have high blood sugars do not receive insulin. Interviews with surgeons, nurses, anesthesiologists and patients outlined the barriers to improved glucose management. The PRIHS research team worked with healthcare teams to steadily address these barriers.

In the past 4 years, the PGMP has been implemented in seven hospitals and one First Nations Health Department in Alberta. Mid-implementation evaluation has demonstrated improvements in glucose measurement and treatment of hyperglycemia, and early decreases in postoperative infections. Ongoing work includes a health economics evaluation and a full analysis of the effects of improved glucose management on patient outcomes.