Are we referring the right patients? Aligning Care of the Elderly referrals for older surgical admissions: 2-cycle QIP

Background

Older adults admitted under General Surgery, particularly with head injury or rib fractures, commonly live with frailty and complex needs. Early Care of the Elderly (COTE) involvement enables comprehensive geriatric assessment and reduces avoidable harm, yet referrals are inconsistent and poorly targeted.

Aim

To assess and improve (1) referral of older general surgical inpatients who met locally agreed COTE criteria, and (2) alignment of referrals with those criteria.

Methods

Two retrospective audit cycles of General Surgery admissions aged ≥65 years at Tunbridge Wells Hospital were completed: Cycle 1 (November 2023) and Cycle 2 (March 2025). Locally agreed referral criteria, informed by Get It Right First Time and British Geriatrics Societyguidance, defined eligibility as any of: Clinical Frailty Scale (CFS) ≥6, National Emergency Laparotomy Audit (NELA) criteria, head injury, or rib fractures. Outcomes were (1) proportion of criteria-positive patients referred (capture) and (2) proportion of referrals meeting criteria (alignment). Following Cycle 1, a referral guide and targeted teaching for the surgical team were introduced. Local governance approval was obtained.

Results

In Cycle 1, 52/209 (24.8%) admissions met criteria; 14/52 were referred (26.9% capture; 6.7% overall). In Cycle 2, 67/202 (33.1%) met criteria; 30/67 were referred (44.8% capture; 14.8% overall). Capture improved significantly for CFS ≥6 (20.0% to 43.6%, p=0.045). Improvements were also observed for rib fractures (40.0% to 80.0%) and head injury (25.0% to 58.8%). NELA referrals remained low (0 to 1). Alignment improved from 71% (10/14) to 80% (24/30).

Conclusion

Simple, low-cost interventions, including a brief referral guide and targeted teaching, significantly improved frailty recognition and appropriate geriatric referral in General Surgery. Future work will focus on embedding frailty and NELA prompts in documentation and reinforcing referral criteria during staff induction and surgical workflows. This will support sustainability and earlier access to comprehensive geriatric assessment for high-risk patients.