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.
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 firstname.lastname@example.org
Helen Wilson, Consultant Orthogeriatrician