Should physicians routinely be involved in the care of elderly surgical patients? YesBMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d1070 (Published 04 March 2011) Cite this as: BMJ 2011;342:d1070
- 1Norfolk and Norwich University Hospital NHS Foundation Trust, Norwich NR4 7UY, UK
- 2Royal Surrey County Hospital, Guildford, UK
Older people are the greatest users of acute hospital services in the UK, accounting for 45% of total NHS expenditure. Many present acutely to surgical teams, and some require major operations. In a large, recent, multicentre study of surgical patients aged over 70 from Australia and New Zealand,1 a fifth had at least one complication and 1 in 20 died. The recent National Confidential Enquiry into Perioperative Deaths (NCEPOD) report, An Age Old Problem, reviewed cases of patients aged over 80 who died within 30 days of surgery.2 In only 37.5% (295/756) was care described as “good” by a peer group of seniors who assessed the cases (“good” being the standard they would accept for themselves or their trainees). Surgeons acknowledge that this population poses a particular challenge when they require surgery and recognise a multidisciplinary approach is necessary.3
Older people are often frail and have multiple comorbidity and cognitive impairment, and they may be prescribed numerous medications. Their needs are often complicated by disability and increasing dependence. General physicians are experienced in managing complexity, balancing the effects of one disease and its treatment on another; however the “geriatric process” is also essential.4 The concept of comprehensive geriatric medical assessment includes collateral history to provide background information about an individual, their level of independence, and their wishes. This holistic approach requires regular medication review, assessment over time, and continuity of care with multidisciplinary involvement.5 6
Geriatricians can help optimise preoperative assessment and predict care and rehabilitation needs after acute care, ensuring continuity from admission to discharge. They are well placed to contribute to decisions about the potential benefit of surgery, recognising frailty and other factors that affect outcome. Some patients will not survive, and geriatricians are experienced in end of life care.
Hip fracture has led the way with a well reviewed evidence base7 underpinning the clinical and political drive to improve the quality of care for patients.8 In England, a best practice tariff offers additional funding for high quality care and requires patients to be jointly managed by orthopaedic surgeons and experienced geriatricians.9 This has resulted in reduced time between admission and surgery, more patients returning home, a reduction in 30 day mortality, and improved secondary prevention.10 Handbooks and protocols can help guide junior doctors on basic management of elderly surgical patients and help manage common complications. However the best practice tariff for hip fracture has specified the early involvement of an experienced geriatrician.
The inclusion of physicians in acute surgical pathways must be the first step, but this should also be extended to elderly people having elective surgery. The recent proactive care of older people undergoing surgery (POPS) programme showed that an evidence based, comprehensive assessment of at risk older elective patients contributed to better clinical effectiveness and efficiency, with reduced postoperative complications and improved mobility resulting in earlier discharge.11 This work has been now been transferred to other centres and to emergency pathways.
Can this be delivered in a timely and affordable fashion? To extend this approach to all elderly patients having emergency surgery would seem to require a significant increase in the number of geriatricians, but recent workforce predictions suggest that we are overproducing geriatric trainees for the number of consultant jobs in the future, with a potential surplus of 230 in the UK by 2014.12 Alternatives may also be considered. Many rehabilitation wards are run by trained non-consultant grade doctors overseen by established geriatric consultants. In some trusts, acute physicians already work closely with geriatricians to provide a comprehensive consultant led service, particularly for out of hours care. Nurse consultants are involved in the POPS programme and have been effective in other areas, providing the meticulous approach, continuity, and consistency of care required.
This still leaves the question of how this can be funded. A whole pathway review, solving problems and encouraging better patient flow, can result in improved efficiency and reduction in length of stay.13 In England the additional tariff for high quality care is being extended to other conditions such as day case and short stay surgery. This should drive forward commissioning of services that include physicians in all acute surgical care pathways. The National Audit of Quality Outcomes is also a useful driver to support local business cases, but data must be accurate and complete.14
The elderly are core business. The principles of geriatric medicine are taught at undergraduate level, but there is much room for improvement.15 Increasing routine involvement of geriatricians on surgical wards will support and improve learning for foundation doctors, hopefully embedding this approach in their future practice.
Acute hospitals must adapt to the needs of elderly patients awaiting surgery. The way forward will be to provide the routine involvement of physicians appropriate to the task.
Cite this as: BMJ 2011;342:d1070
Competing interests: The authors have completed the unified competing interest form at www.icmje.org/coi_disclosure.pdf and declare no support from any organisation for the submitted work; KW is a clinical coordinator for NCEPOD and an author of the An Age Old Problem. She is seconded from her trust to NCEPOD for one session a week.
Provenance and peer review: Commissioned; not externally peer reviewed.