Perioperative Medicine

On a freezing cold Friday in January, the Royal College of Anaesthetists held a stakeholder event launching their vision for the future of Perioperative Medicine: the delivery of integrated care to those undergoing high risk surgery, provided by a perioperative team, to enable better patient outcomes and experience within the context of more effective and efficient use of finite resources.

The morning was attended by the great and the good and whilst dominated by anaesthetists there was a wide representation including the BGS and the Royal College of Physicians.

A simple but effective five minute animated film introduced the concept along with a vision document both available on the website www.rcoa.ac.uk/perioperativemedicine

The speakers used powerful statistics:  16 billion pounds spent on surgery each year in the NHS, 20 million referrals for elective surgery which continues to increase year on year, 27,000 undergoing surgery each day of which 700 are high risk.  The overall on-table mortality lies in the region of 0.06% but with in-patient mortality at 3.6%.  There is also a significant morbidity with up to 15% of those undergoing elective surgery experiencing often predictable and potentially preventable complications with prolonged post-operative morbidity.

Yet it seems that we know the answers, supported by a reasonable evidence base and shown to be cost-neutral, if not cost-saving.  This has been demonstrated by Enhanced Recovery Programmes in a number of conditions, the successes of the hip fracture programmes with widespread implementation of orthogeriatrics and in the Proactive Care of Older People undergoing Surgery (POPS).  Jugdeep Dhesi eloquently presented the work of the POPS team and represented both acute medicine and geriatric medicine on the expert panel emphasizing the importance of recognising frailty and the benefits of comprehensive geriatric assessment.

It was suggested that the majority of the public would assume that joined up personalised care for those undergoing high risk surgery already exists in the NHS but sadly we know this not to be true.  All agreed that it should not be left to the overburdened medical registrar to sort out in the middle of the night.

The future is likely to be Perioperative Medicine.  Work on a curriculum, a training programme and workforce planning have already begun.  The BGS and the RCP both vocalised their support.  Those keen to be involved should register their interest at perioperativemedicine@rcoa.ac.uk

Helen Wilson, Consultant Orthogeriatrician 

Healthcare professionals come together for the BGS Falls Symposium

We finish our coverage of falls awareness week with a blog by Bryony Elliott, Geriatric Trainee in Nottingham. She tweets at @BryonyBryboss.

On Friday the 7^th June interested health care professionals from around the country assembled at Nottingham City Hospital to learn about Falls. It was the Trent BGS Falls Symposium.

What struck me first was the diverse group of professionals in the lecture theatre. Looking at the delegate list there were consultants and trainees in geriatric medicine, physios, occupational therapists, nurse specialists, and from all across the country too. A variety of people with a lot of enthusiasm, which was great to behold.

May issue of Age and Ageing out now

The May 2013 issue of Age and Ageing, the journal of the British Geriatrics Society is out now.

A full table of contents is available here, with editorials, research papers, reviews, short reports, case reports book reviews and more. Hot topics this issue include:

• Pathogenesis and management of osteoarthritis
• Risk factors for abuse in older people
• The cost of stroke in Ireland
• Preventing iatrogenic illness
• Quality of life with advancing age

The Editor’s View article can be read here.

This issue’s free and open access paper are:

• Elder abuse: a systematic review of risk factors in community-dwelling elders
• Which part of the Quick mild cognitive impairment screen (Qmci) discriminates between normal cognition, mild cognitive impairment and dementia?
• Cardiovascular risk factors and cognitive decline in adults aged 50 and over: a population-based cohort study
• The transition to living alone and psychological distress in later life
• Prevalence of sarcopenia in community-dwelling older people in the UK using the European Working Group on Sarcopenia in Older People (EWGSOP) definition: findings from the Hertfordshire Cohort Study (HCS).

Commissioning hip fracture care – the NICE way

Dr Karthik Kayan is onsultant orthogeriatrician at Stockport NHS Foundation NHS Trust.

Prof Opinder Sahota is consultant in elderly medicine at Nottingham University Hospitals NHS Trust and Joint Chairman of the Falls and Bones SIG at the BGS.

It is well known in geriatric medicine circles that hip fractures are the most common osteoporotic fracture affecting predominantly older people.

Currently, the incidence of hip fracture emergency admission is around 70,000 in the UK and will continue to increase as the population ages. The projected incidence for hip fracture in the UK is 101,000 by 2020. The crippling effects of hip fracture are significant for the patient as independence is affected and a number of them die within a year of sustaining a fracture. The cost of managing osteoporotic fractures is £1.7 billion and over 90 per cent of this is due to health and social care costs associated with the fracture.

New recruits needed to help build services for frail older people undergoing operations

Dr Jugdeep Dhesi is Chair of the BGS Peri-operative Care of Older People Ungergoing Surgery SIG (POPS) and is consultant physician and clinical lead for the POPS service at Guy’s and St Thomas’ Hospitals.

The number of frail older people undergoing elective surgical procedures is rapidly increasing. In fact the number of older people undergoing operations, as a proportion of all those having surgery, is increasing more rapidly than is the proportion of frail older people across the population as a whole.

There are a number of reasons for this. Advances in surgical technique and improvements in anaesthetic management have made it possible to operate safely on patients who would have been considered too frail for surgery in the past. At the same time patients and doctors now expect that they will be able to receive operations much later in life.  

National Hip Fracture Database Reports on Developments in Acute and Post-Acute Care

Dr Helen Wilson, is co chair of the National Hip Fracture Database (NHFD), a joint endeavour of the BGS and the British Orthopaedic Association to improve the care of patients with fragility fractures.

Hip fracture, which usually results from the combination of a fall and pre existing osteoporosis, is the most common serious injury of older people, with around 76,000 cases occurring per year across the UK. Many patients are already frail. Mortality is high, residual disability common, and care costly. Although there is good evidence on best practice in surgical, medical and rehabilitation care following hip fracture, such care and its outcomes – in terms of return home and also of mortality – continue to vary.

The NHFD has published a supplement to its 2012 National Report which demonstrates continuing improvements in acute care but  highlights variations in post-acute care and overall length of NHS stay.

Geriatricians’ Corner:- Ortho-geriatrics…..A tale of two specialities

Much akin to Charles Dickens’ famous tale of two cities, the orthopaedic bastille has been stormed with the publications of the Blue book and BOAST 1 guidelines. Supported by heavy artillery in the form of the new HRG tariff for hip fractures, the revolution has well and truly begun. Ortho-geriatric services across UK have been transformed and this has catapulted this emerging sub-speciality onto the map. As a trainee, the changes have been marked, radical and at times near miraculous. Orthopaedic junior doctors are actually taking time to document AMTS scores (Abbreviated Mini-Mental Test Score) in the admission clerk-in whilst Ortho-geriatricians are culturing a knack of looking at post-op wounds and prescribing post-op venous thrombo-prophylaxis.