Proactive care of Older People undergoing Surgery (POPS)
Jude Partridge is a Clinical Research Fellow and Jugdeep Dhesi is a Consultant Geriatrician and Clinical Lead at Guy’s and St Thomas’ NHS Foundation Trust. They have recently reported on a UK survey of geriatric medicine delivered services in surgery in Age and Ageing journal. The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) has published another thorough and methodologically robust report, Lower Limb Amputation: Working Together. On this occasion they examined the care of the non-traumatic amputee across the UK and concluded that “only 229/519 (44.1%) of patients were receiving a standard of care with which the advisors would be happy for themselves or their family and friends. In other words, clinical management could have been better in half of the patients included in the study”. Unsurprisingly, the majority of cases reviewed in this report were older, multimorbid and due to the lower limb amputation, at a transition point in terms of functional status. This older, multimorbid population were inadequately prepared for surgery (only two fifths of elective patients had preassessment) and commonly required medical input from a physician postoperatively (60%). So, did NCEPOD miss an opportunity to link past reports with this current review? An Age Old Problem advocated the structured, daily input of geriatricians into the care of older surgical patients; a recommendation that was echoed in a joint Royal College Surgeons – Age UK report Access all Ages. In ‘Lower Limb Amputation: Working Together’, NCEPOD has failed to reiterate the role of geriatricians despite multiple references to complex multimorbidity and difficulty in discharging patients from hospital. Although rightly, NCEPOD emphasise the need for rehabilitation consultant input into the care of those undergoing lower limb amputation, perhaps what is also needed is consistent geriatrician input during the surgical pathway from preoperative assessment and optimisation through to discharge planning and ongoing rehabilitation. Maybe this link wasn’t made because there was no geriatric medicine representation on the advisory panel? Since the 2010 NCEPOD report ‘An Age Old Problem’ it’s been great to see a growing interest in surgical liaison for older patients from geriatricians, but as the results of a recent survey show, this has so far failed to translate into clinical services across the UK. The survey found geriatric medicine liaison services for older surgical patients in just a third of UK hospitals and where services did exist they tended to provide input predominantly in the postoperative period and reactively rather than proactively. This finding was confirmed in the first organisational report from the National Emergency Laparotomy Audit (NELA). However, it is encouraging to hear of new positions in perioperative medicine for older people being filled by geriatricians. Examples include new posts at Guy’s and St Thomas’, Imperial and Reading in addition to geriatric medicine involvement in redesigning surgical pathways beginning in Leeds and Glasgow. It’s also exciting to see that geriatricians are ‘wanted’, as demonstrated by a survey of surgical trainees (Shipway, in press) and by the recent Royal College of Surgeons coordinated care survey which stated as its first key recommendation that “geriatricians should work more closely alongside surgical teams both inside and outside hospital”. To support best practice and ensure that our voice is heard we need to foster collaboration through networks such as the BGS POPS SIG which is free to join and provides a useful forum for clinical service development, education and training and furthering the research agenda in this growing field.