Abstract
Introduction
Reducing the time people wait for elective care is one of NHS England’s priorities.[1] It is projected that by 2030 there will be 1.4million Londoners aged over 65[2] and increasing numbers of older people are undergoing surgery.[3] Frailty is a significant risk factor for surgical complications.[4],[5] Non-electiveOrthogeriatrics is well established, this is not the case for elective orthogeriatrics or indeed other specialities
The Centre for Perioperative Care (CPOC) and the British Geriatric Society developed evidence-based guidelines on perioperative care for people living with frailty.[6]Implementing these pathways can reduce length of stay by 4 days[7] and support 1 in 7 patients to decide not to go ahead with surgery.[8]
Method
The London Frailty Clinical Network mapped each London hospital against key CPOC standards. Other insights such as training were gained during discussions.
Each hospital was rated into five categories from covering most (elective and non-elective) specialities throughout the pathway, to only providing orthogeriatrics.
Results
Unwarranted variation was noted across London. Of the 28 sites included 5 (18%) only had non-elective orthogeriatics, 3 (11%) covered some non-elective, 7 (25%) covered most non-elective, 6 (21%) covered some specialities (elective and non-elective) across the pathway (pre and post-op), and 7 (25%) covered most elective and non-elective across the pathways.
Services reported they were keen to have a more preoperative care and proactive postoperative screening. Workforce considerations included the need for training and competencies, some areas only having one surgical liaison geriatrician and underutilisation of nursing and AHP staff.
Conclusion(s).
Ensuring evidence based perioperative care for older people is vital, not only to support people living with frailty, but also to ensure national elective care priorities are achieved. This mapping has identified unwarranted variation across London which needs to be addressed to drive improvements.
[2] POPPI, Population aged 65 and over, projected to 2035
[3] Fowler A, Abbott T, Prowle J, Pearse R. Age of patients undergoing surgery. Journal of British Surgery. 2019;106(8):1012–8
[4] Lin H-S, Watts J, Peel N, Hubbard R. Frailty and postoperative outcomes in older surgical patients: a systematic review. BMC Geriatrics 2016;16(1):1–12.
[5] Simon H, Paula T, Luz M, Nemeth S, Moug S, Keller D. Frailty in older patients undergoing emergency colorectal surgery: USA National Surgical Quality Improvement Program analysis. Journal of British Surgery. 2020;107(10):1363–71.
[6]CPOC and BGS Guideline for Perioperative Car for People Living with Frailty Undergoing Elective and Emergency Surgery, 2021
[7] Harari, D., et al., Proactive care of older people undergoing surgery ('POPS'): designing, embedding, evaluating and funding a comprehensive geriatric assessment service for older elective surgical patients. Age Ageing, 2007. 36(2): p. 190-6.
[8] Shahab, R., Lochrie, N., Moppett, I. K., Dasgupta, P., Partridge, J. S. L. and Dhesi, J.K. (2022) A description of interventions prompted by preoperative comprehensive geriatric assessment and optimization in older elective noncardiac surgical patients. J Am Med Dir Assoc, 23(12), 1948-1954.