Abstract
Introduction:
Emergency laparotomy is associated with high risk of mortality and morbidity. NELA best practice tariff identifies Geriatrician input as a key performance indicator for all patients over 80 years of age and those who are over 65 and living with frailty. Evidence suggests geriatrician-led comprehensive geriatric assessment (CGA) may improve post-operative outcomes, but only 8% received one between 2019-2020 in our Trust (national average 27%). The aim of this project was to create a standardised referral system between general surgeons and ageing and complex medicine (ACM) team.
Method:
This 3 cycle quality improvement project consisted of two key multi-faceted interventions, which were assessed using data from secretaries’ emails and the Health Information System (HIS). The first intervention was a standardised referral proforma and pathway, aiming to reduce inappropriate and increase NELA referrals. The second intervention involved appointing a dedicated NELA nurse (summer 2024), who undertook a digital transformation project to improve the acute abdomen pathway, including building an electronic referral process to ACM team.
Results:
The first intervention improved referrals for NELA patients from 0 (Sept 2023-Jan 2024) to 6 (March-June 2024). Since building the digital pathway and the referral order going live in March 2025, we have received and completed 18 NELA referrals (March-June 2025). Frailty scoring was made mandatory in the surgical assessment document and referral became active automatically. Geriatricians working on the frailty session absorbed the referrals and completed CGAs for all patients. In NELA audit figures, this has improved our performance from 40% of patients having had a geriatrician review in March 2024 to 100% for the period November 2024 to January 2025.
Conclusions:
By working together across surgical and medical specialities, and particularly by creating the digital pathway for acute abdomen, we have significantly improved the percentage of general surgery patients receiving geriatrician review.
Comments
Role of NELA nurse
Thank you for sharing this - really good to see the difference you've made :)
I'm curious about the role of the NELA nurse in achieving this change - do you think you would have been so successful without the role, and can you tell me anymore specifically about what they do / did. Finally, do you envisage this being a permanent role?
Thank you
Role of NELA nurse
Thanks for your comments and questions
As NELA nurse for the Trust I work between all specialities to ensure the outcomes for our laparotomy patients. Within the role I work with radiology, Emergency care, the surgical team and Age and complex medicine to ensure all staff are aware and educated on the importance of our acute abdominal pathways and NELA and how these can improve patient care. Specifically for this project it was important to educate referrers on the invaluable input from our age and complex medicine team and how by identifying frailty and streamlining the referrals process we could improve mortality. Although some other trusts have this as a permanent role, I do this within my 4 pillars as surgical ACP working in Ambulatory Emergency Care.
Nice work!
Thank you for your work. Ensuring older people going forward to laparotomy have had a CGA is very likely to have a positive impact. The combination of using of the frailty score to identify and the team supporting via frailty outreach and NELA nurse seems to have created a win-win.