36 Older Surgical Patients Pathway: Improving Care for Frail Older People in General Surgery

Abstract

Abstract Background The Older Surgical Patients Pathway (OSPP) was established in 2014 and aims to improve care for frail older people on General Surgery (GS) wards at Sheffield Teaching Hospitals NHSFT (STH) by delivering consultant-led Comprehensive Geriatric Assessment (CGA). The OSPP team proactively review frail, surgical patients 75 years or older. Introduction Patients over 75 account for 10% of admissions in GS at STH, occupying 33% of bed-nights (14,000/year, costing approximately £4.2 M). They may present a challenge to surgical staff due to multiple co-morbidities, cognitive or mental capacity concerns, leaving them vulnerable to clinical decompensation, with subsequent increased health and care needs. Geriatrician input prior to 2014 was ad hoc and reactive. OSPP was developed to improve and co-ordinate care in this vulnerable group. Methods The project team consisted of surgeon, geriatrician, senior nurse with service improvement expertise and data analyst. Stakeholder events were held to raise awareness and target interventions. Through regular review of outcomes with iterative testing and service redesign, the main interventions have been: • Introduction of a frailty screening tool. • Embed a geriatrician into the colorectal unit, providing clinical review and leadership. • Establish regular, frequent multidisciplinary team meetings. • Use of eWhiteboard. • Training for multiple professions in geriatrics and general surgery. • Gather objective (see table) and subjective outcome measures (staff survey and Foundation Programme feedback). • Access to CGA for all over 70 year olds who have undergone emergency laparotomy. Results The OSPP team review approximately 200 frail older patients per year in detail. The objective results, compared to baseline data from 2014, are in the table. The reduction in LoS equates to a saving of 700 bed-nights (at £300/bed-night, a total financial saving of £210 k) over 5 years. Thirty six more patients are returned to usual place of residence per annum. Multiple staff groups on the colorectal unit have greater awareness of frailty and its consequences and more than 150 junior doctors have received extra support and training in this area. Conclusions OSPP has improved quality of care for frail older people in general surgery in Sheffield in both objective and subjective measures. This template could be used to replicate this service in other surgical specialities with a large cohort of frail older patients.