Seen the doctor on the Tele? Patient centred care needs to arrive for all, and none more urgent than for our older patients

Chris Subbe is a Consultant in Acute, Respiratory & Critical Care Medicine. He is a Service Improvement Fellow with the Health Foundation. He does research on patient safety at Bangor University. He tweets @csubbe

Unsurprisingly many of us have more medical needs as we get older. While some people manage to stay remarkably fit, for others it is getting more difficult to get around town or worse across country. The hike around an overflowing car park of an inner-city hospital does surprisingly little for mobility, and most people get little value from sitting in an outpatient waiting area to wait while their medical team is struggling with the application of queuing theory to healthcare.

A few years ago, when granddad was sent a follow-up appointment for his cardiac surgery several months after the operation, I was suspicious. I rang the secretary of the colleague who had done an amazing job on his heart to ask for the reason for the review. “An important part of quality assurance: we like to make sure that everything has gone well”. I explained that granddad had been in hospital, survived prolonged rehabilitation, and had already been followed up by an excellent local geriatrician and one of our brilliant cardiologists. He felt well. I suggested cancelling the appointment.

We talk a lot about delirium after hip fracture, but what can we do about it?

Dr. Susan Freter is an Associate Professor of Medicine at Dalhousie University, and a staff geriatrician at the Nova Scotia Health Authority in Halifax, Canada.  She has a special interest in delirium prevention and management in orthopaedic patients.  

Geriatricians talk a lot about post-operative delirium.  It is common after surgeries, especially in people with a lot of risk factors (or we could say, especially in the presence of frailty), and even with recovery it makes for a bad experience.  The occurrence of hip fracture, which mostly befalls patients who are older and frail, demonstrates this routinely.  We know that taking extra care with at-risk patients can help to prevent delirium.  Taking extra care can manifest in different forms: educating the caregivers, paying attention to hydration (is the patient actually drinking the cup of water that is plonked down in front of them?), paying attention to constipation (preferably before a week has gone by), making sure hearing aids are in the ears, and using medication doses that are geared for frailty, rather than for strapping 20 year olds. But how can what we talk about be translated into what we do? Does the ‘doing’ actually work in practice?

Perioperative Assessment at the BGS Autumn Meeting

Dr Jugdeep Dhesi is Chair of the BGS Perioperative 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. She will be Chairing the POPS Session at the BGS Autumn Meeting.

Older surgical patients are presenting us geriatricians with challenges. How should geriatric medicine fit into the national agenda for perioperative medicine? Which models of care work best in improving outcomes for this complex multimorbid group of patients? Do different surgical subspecialties require different approaches? How should these services differ between the district general and teaching hospital? Should elective and emergency older surgical patients be given equivalent geriatric medicine input? How can we balance the frequent calls to involve geriatricians in the care of older surgical patients against the numerous unfilled consultant posts in ‘traditional’ geriatric medicine that already exist? These issues will be explored in the POPS SIG session at the BGS meeting in Glasgow (Friday 25th November).

Top of the POPS: the future of perioperative care

Jason Cross is an Advanced Nurse Practitioner for the Proactive Care of Older People Undergoing Surgery (POPS) team at Guy’s and St Thomas’ Hospital and is a member of the BGS POPS Special Interest Group. He Tweets at @jdcross1970

It’s been an exciting and challenging three years since I last wrote in the BGS blog, and while the messages haven’t changed much, the field of perioperative medicine continues to gather momentum.

In 2012 I wrote about the publication of An Age Old Problem (2011) and Access All Ages (2012) and how both these reports highlighted the deficiencies in surgical care for the older patient, and how geriatrician input was cited as an essential component to improving these issues.

These recommendations have been further supported by the recent publication of the new perioperative pathway vision document from the Royal College of Anaesthetists, titled Perioperative Medicine: The Pathway to Better Surgical Care. Here we note an emphasis on collaborative working with a focus on improving the outcomes and efficiency throughout the surgical pathway.

Improving perioperative care – we want your views!

Oliver Boney is a research fellow at the National Institute of Academic Anaesthesia. Here he describes a nationwide research priorities exercise, asking all clinicians who look after surgical patients (as well as patients themselves) what research efforts would make a real difference to improving patient care.

In tandem with its Perioperative Medicine programme, the National Institute of Academic Anaesthesia (NIAA) is running a research consultation exercise, asking ‘What anaesthetic or perioperative research would improve patient outcomes?’

Older people who need surgery are recognised to be at higher risk of a worse postoperative outcome than younger counterparts.However, death after major surgery such as hip fracture repair remains stubbornly high: 8% at 30 days and nearly 30% at 1 year; 30-day mortality after emergency laparotomy for people over 75 years old approaches 25%. How might we improve? Where should efforts be focused?

There is evidence that collaborative working, including input from geriatricians in the perioperative pathway, can improve outcomes in older patients after surgery, but a recent survey highlighted patchy provision of geriatric services in surgery across the UK.

Anaesthetists and surgeons are realising that the benefits of integrated multidisciplinary perioperative care, as demonstrated by the Royal College of Anaesthetists’ recent launch of its vision for the future of Perioperative Medicine (read the recent BGS blog article on this). Although there are many stakeholders in perioperative care, the national priorities for directing research studies and budgets are not yet defined.

Please fill in the survey to define the agenda for all people undergoing surgery. Your views will ensure issues related to older people are noted. To fill in the survey, go to: https://niaa.org.uk/PSPSurvey#pt.