Improving delays in Geriatric Medicine referral for Older surgical inpatients admitted following orthostatic hypotension & falls

Introduction

Orthostatic hypotension (OH) is a common, under-recognised, and potentially reversible cause of falls in older adults. Older patients admitted under surgical specialties following falls frequently have frailty, polypharmacy, and high anticholinergic burden (ACB), predisposing them to OH and recurrent falls. National Institute for Health and Care Excellence (NICE) guidance, Royal College of Physicians (RCP) recommendations, and the National Audit of Inpatient Falls advocate routine lying and standing blood pressure (LSBP) measurement as part of comprehensive falls assessment. However, OH is often identified late in surgical patients, resulting in delayed referral to Geriatric Medicine and missed opportunities for early multidisciplinary intervention. This Quality Improvement Project aimed to improve the quality and timeliness of referrals from surgical specialties to the Geriatric Medicine (Care of the Elderly; COTE) team by promoting early identification and management of OH in older adults admitted following falls.

Method

A retrospective review of referrals from surgical specialties to the Geriatric Medicine team was performed between August and November 2025. Patients aged ≥65 years admitted with falls and fall-related injuries, including rib fractures, cervical spine injuries, distal radius fractures, patella fractures, head injuries, and recurrent falls, were included. Baseline measures included documentation of LSBP according to RCP guidance (0, 1 and 3 minutes), medication review, and ACB assessment prior to referral.

A multidisciplinary intervention was implemented in December 2025 and January 2026. This included targeted education sessions for surgical junior doctors and ward nursing staff, ward-based educational posters, collaboration with pharmacy teams to facilitate medication review and ACB scoring, and monthly Plan–Do–Study–Act (PDSA) cycles with regular audit and feedback. Outcome, process, and balancing measures were monitored throughout the project.

Results

Forty patients were referred during the baseline period. Only 6/40 referrals (15.0%) contained documented LSBP measurements prior to referral to Geriatric Medicine, despite polypharmacy and/or high ACB burden being present in 39/40 patients (97.5%).

Initial post-intervention analysis was undertaken between February and April 2026. Of 16 referrals relating to falls and/or orthostatic hypotension, 9 referrals (56.3%) contained documentation of LSBP measurements, medication review, and ACB scoring prior to referral, representing an absolute improvement of 41.3 percentage points compared with baseline.

To assess wider changes in clinical practice, observation charts of surgical inpatients admitted following falls were audited in May 2026. Documentation of LSBP measurements according to RCP guidance was present in 39.3% of observation charts, compared with 15.0% at baseline. Following identification of postural blood pressure changes, optimisation of antihypertensive medications was documented in 26.6% of patients, compared with an estimated baseline rate of 5.0%.

Conclusion(s)

This project demonstrated that a multidisciplinary approach incorporating education, pharmacy involvement, and continuous quality improvement methodology can substantially improve the recognition and management of orthostatic hypotension in older surgical inpatients. Significant improvements were observed in referral quality, documentation of LSBP measurements, and medication optimisation. System-level changes, including modification of the electronic COTE referral form to incorporate mandatory LSBP and ACB assessment fields, are expected to further enhance sustainability. Expansion of the project across multiple hospital sites within the Health Board may facilitate wider adoption of evidence-based falls prevention strategies and improve outcomes for older adults at risk of falls secondary to orthostatic hypotension.