Evaluation and establishment of a ward-based geriatric liaison service for older urological surgical patients: Proactive care of Older People undergoing Surgery (POPS)-Urology.

OBJECTIVE: To assess the impact of introducing and embedding a structured geriatric liaison service, Proactive care of Older People undergoing Surgery (POPS)-Urology, using comprehensive geriatric assessment methodology, on an inpatient urology ward. PATIENTS AND METHODS: A phased quality improvement project was undertaken using stepwise interventions. Phase 1 was a before-and-after study with initiation of a daily board round, weekly multidisciplinary meeting, and targeted geriatrician-led ward rounds for elective and emergency urology patients aged ≥65 years admitted over two 1-month periods. Outcomes were recorded from medical records and discharge documentation, including length of inpatient stay, medical and surgical complications, and 30-day readmission and mortality rates. Phase 2 was a quality improvement project involving Plan-Do-Study-Act cycles and qualitative staff surveys in order to create a Geriatric Surgical Checklist (GSCL) to standardize the intervention in Phase 1, improve equity of care by extending it to all ages, improve team-working and streamline handovers for multidisciplinary staff. RESULTS: Phase 1 included 112 patients in the control month and 130 in the intervention month. The length of inpatient stay was reduced by 19% (mean 4.9 vs 4.0 days; P = 0.01), total postoperative complications were lower (risk ratio 0.24 [95% confidence interval 0.10, 0.54]; P = 0.001). A non-significant trend was seen towards fewer cancellations of surgery (10 vs 5%; P = 0.12) and 30-day readmissions (8 vs 3%; P = 0.07). In Phase 2, the GSCL was created and incrementally improved. Questionnaires repeated at intervals showed that the GSCL helped staff to understand their role better in multidisciplinary meetings, improved their confidence to raise issues, reduced duplication of handovers and standardized identification of geriatric issues. Equity of care was improved by providing the intervention to patients of all ages, despite which the time taken for the daily board round did not lengthen. CONCLUSION: This is the first known paper describing the benefits of daily proactive geriatric intervention in elective and emergency urological surgery. The results suggest that using a multidisciplinary team board round helps to facilitate collaborative working between surgical and geriatric medicine teams. The GSCL enables systematic identification of patients who require a focused comprehensive geriatric assessment. There is potential to transfer the GSCL package to other surgical specialties and hospitals to improve postoperative outcomes

UK medical teaching about ageing is improving but there is still work to be done: the Second National Survey of Undergraduate Teaching in Ageing and Geriatric Medicine

Introduction: in 2008, a UK national survey of undergraduate teaching about ageing and geriatric medicine identified deficiencies, including failure to adequately teach about elder abuse, pressure ulcers and bio- and social gerontology. We repeated the survey in 2013 to consider whether the situation had improved.Method: the deans of all 31 UK medical schools were invited to nominate a respondent with an overview of their undergraduate curriculum. Nominees were invited by email and letter to complete an online questionnaire quantifying topics taught, type of teaching and assessment undertaken, and the amount of time spent on teaching.Results: one school only taught pre-clinical medicine and declined to participate. Of the 30 remaining schools, 20 responded and 19 provided analysable data. The majority of the schools (95–100%) provided teaching in delirium, dementia, stroke, falls, osteoporosis, extra-pyramidal disorders, polypharmacy, incontinence, ethics and mental capacity. Only 68% of the schools taught about elder abuse. Thirty-seven per cent taught a recognised classification of the domains of health used in Comprehensive Geriatric Assessment (CGA). The median (range) total time spent on teaching in ageing and geriatric medicine was 55.5 (26–192) h. There was less reliance on informal teaching and improved assessment:teaching ratios compared with the 2008 survey.Conclusions: there was an improvement in teaching and assessment of learning outcomes in ageing and geriatric medicine for UK undergraduates between 2008 and 2013. However, further work is needed to increase the amount of teaching time devoted to ageing and to improve teaching around elder abuse and the domains of health used in CGA

Guidelines for Perioperative Care for Emergency Laparotomy Enhanced Recovery After Surgery (ERAS) Society Recommendations: Part 1—Preoperative: Diagnosis, Rapid Assessment and Optimization

BackgroundEnhanced Recovery After Surgery (ERAS) protocols reduce length of stay, complications and costs fora large number of elective surgical procedures. A similar, structured approach appears to improve outcomes, including mortality, for patients undergoing high-risk emergency general surgery, and specifically emergency laparotomy. These are the first consensus guidelines for optimal care of these patients using an ERAS approach.MethodsExperts in aspects of management of the high-risk and emergency general surgical patient were invited to contribute by the International ERAS Society. Pubmed, Cochrane, Embase, and MEDLINE database searches on English language publications were performed for ERAS elements and relevant specific topics. Studies on each item were selected with particular attention to randomized controlled trials, systematic reviews, meta-analyses and large cohort studies, and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Recommendations were made on the best level of evidence, or extrapolation from studies on non-emergency patients when appropriate. The Delphi method was used to validate final recommendations. The guideline has been divided into two parts: Part 1—Preoperative Care and Part 2—Intraoperative and Postoperative management. This paper provides guidelines for Part 1.ResultsTwelve components of preoperative care were considered. Consensus was reached after three rounds.ConclusionsThese guidelines are based on the best available evidence for an ERAS approach to patients undergoing emergency laparotomy. Initial management is particularly important for patients with sepsis and physiological derangement. These guidelines should be used to improve outcomes for these high-risk patients