Perioperative medicine: we’ve come a long way but there is still a long road ahead
Andrea Joughin is an ST6 geriatric medicine trainee with a subspecialty interest in perioperative medicine. She co-authored the recent Age and Ageing paper, “Where are we now in perioperative medicine? Results from a repeated survey of geriatric medicine delivered services for older people” which she discusses here.
As the population ages, increasing numbers of older people are presenting for elective and / or emergency surgical intervention. This group is at higher risk of adverse postoperative outcome, likely due to underlying comorbidity and frailty, increasing vulnerability to decompensation after surgery. Over the past decade national reports have highlighted deficiencies in pathways of surgical care for older patients and have described the urgent need for increased collaboration between surgeons, anaesthetists and geriatricians and the need for new models of care attuned to the older surgical patient.
Back in 2013, a survey published in Age and Ageing showed that less than a third of NHS trusts in the UK had established geriatrician led perioperative services in specialties other than hip fracture. Since then a number of initiatives have been established; a research programme examining the impact of CGA in perioperative medicine, education and training opportunities for geriatricians interested in perioperative medicine and a network of perioperative medicine services for older people to facilitate establishment of new services.
Reassuringly, our repeat survey shows that the picture is changing. Half of respondents now provide specialist geriatric medicine services to perioperative patients across a broad range of specialties in both emergency and elective settings. It also demonstrates increased cross specialty collaboration between geriatricians, surgeons and anaesthetists through joint meetings and guideline development.
With continued enthusiasm from geriatricians to further develop services (60% reported this to be a high priority), and an increase in training opportunities available to trainees encouraging a subspecialty interest in perioperative medicine, the future looks promising.
However, there is still work to be done. The survey shows significant heterogeneity in the availability and structure of services across the UK. Now, the challenge is to translate the evidence base into clinical practice with fidelity and measurement. To achieve this, we should learn lessons from our work in hip fracture where CGA has been successfully embedded into clinical practice through collaborative guideline development, national audit and financial incentives such as the best practice tariff.
If you are interested in participating in this work do get in touch through the BGS and join the POPS (Perioperative medicine for Older People undergoing Surgery) Specialist Interest Group.