A dream on fire – perioperative geriatrics across the world
Belinda Rodis is a geriatrician from Canada who had the fortune of observing three perioperative geriatrics programs in the United Kingdom, Singapore, and the United States. This is her opinion from her experiences. She tweets @belindarodis
It starts with a dream – in each case, someone thinking that we need to do something to provide better care for older people undergoing surgery. I recently had the fortune of doing clinical observerships and experiencing what perioperative geriatrics is like in three different places. Over the last six months, I spent a month with the Proactive care of Older Persons undergoing Surgery (POPS) programme at Guy’s and St Thomas’ Hospital in London, a month with the Start to Finish (STF) programme at Khoo Teck Puat hospital in Singapore, and two months with the Perioperative Optimization of Senior Health (POSH) program at Duke University Hospital in the United States. Each service is based around the idea that care is too fragmented for older adults. One problem, three solutions.
POPS was the first and has chosen to solve this problem by becoming the quarterback – the geriatricians coordinate the care and communicate with other providers to avoid having to send patients to see other specialists. STF was next and solved this by introducing a transdisciplinary service with stellar communication between multiple specialist champions (both physicians and allied health). Last but not least, POSH chose to bring the specialists to the patient and now sees the patients in concert with anaesthesia in the clinic.
While the goal for each of them is the same – to provide better care for older adults going through surgery, the way that each programme approaches this is different. POPS has the broadest scope of the programmes, seeing as many complex adults as possible whilst being visible and integrating themselves on many different surgical wards. STF, on the other hand, specializes in carefully selecting and seeing the frailest patients who will benefit the most from their interventions. These patients are with utmost care followed by the same specialists through the entire process from surgical decision-making to re-integration and socialization back into the community. POSH chooses the middle ground – bundled care counselling is the key, and geriatricians spend long visits with the patients taking care to empower the patients through discussion of delirium risk, nutrition, and mobility. Postoperatively, a dedicated nurse practitioner for the POSH team will see patients when needed.
Each program has something about it that is unique and astounding to me. For POPS, it was the sheer breadth. Driven by geriatricians, they have huge volumes of patients, dedicated trainees to the programme, multidisciplinary meetings with a presence on almost every ward, and a focus on research. POPS is truly systemic. For STF, it was the dedication to care. This programme is unique in that it is the only program primarily run by surgeons, who provide deep and meaningful holistic care. With much smaller volumes, the clinicians here dedicate time on top of their clinical work to see the carefully selected patients. Anticipatory care is key, based on shared decision-making between the patients, their families, and the team. Prehabilitation is a core component – both physical and nutritional; frail patients build up strength and reserve prior to surgery to have the best possible outcome. For POSH, it was the dedication to giving the patients the tools they need to help themselves. The geriatricians spend time carefully optimizing and working through barriers to give personalized advice. Patients and families here learn how to protect their mind and mobility.
All very different, and yet all very similar. They’ve each taught me lessons that I’ve taken home with me to Canada. And they all work – each of them has shown improved meaningful patient outcomes. Each of the programmes has built a partnership between surgeons and geriatricians. Though they all started off small, they have all grown while keeping their focus all about the patients. You would not believe the number of patients who have mentioned at the end of the visits what a wonderful experience they had and how they wish this type of care was everywhere. A dream on fire – it’s time to spread across the world.