Improving perioperative care for older people

Increasing numbers of older patients are having surgery in the NHS, with one-in-five over-75s predicted to undergo surgery annually by 2030, at a cost of £2.7 billion.

Jugdeep Dhesi, Consultant

While surgery has many benefits, it is also true that older patients often have other healthcare issues and face a higher risk of perioperative complications. For patients this can mean poor experiences, resulting from multiple referrals and disjointed care. For healthcare systems, this is seen in higher health and social care expenditure, resulting from late cancellation of surgery, prolonged hospital stay and high readmission rates.

Perioperative medicine for Older People undergoing Surgery (POPS) was first established at Guys and St Thomas’ NHS Foundation Trust to improve clinician- and patient-reported outcomes for older people undergoing surgical procedures. The POPS model comprises a geriatric-medicineled, multidisciplinary and multispeciality service, providing Comprehensive Geriatric Assessment (CGA) and optimisation of patients. This is delivered for both emergency and elective surgical patients across all surgical subspecialties. In practice, this takes the form of holistic assessment, optimisation and shared decision making in a one-stop specialised POPS clinic, followed by ward-based care delivered through co-management between POPS and surgical teams. In the elective patient group, two thirds of patients have a new diagnosis made, three quarters have medications changed, and lifestyle advice is provided in over half of patients, with individualised perioperative plans and shared decision making documented in almost all. 2

This streamlined approach reduces the need for multiple pre-operative appointments and onward speciality referrals, and avoids last minute cancellations.3 Crucially, patients undergoing CGA and optimisation have fewer complications, shorter length of stay, and a resulting decrease in healthcare utilisation cost. 4 A similar approach is delivered for patients admitted as emergencies on surgical wards, with comparable results across surgical subspecialties.

Adapting to new challenges

The Covid-19 pandemic has resulted in ever increasing waiting lists and delays to surgical treatment. Addressing this challenge requires new and innovative approaches; CGA-based POPS services can form a key component of the new model of care with their proven clinical- and costeffectiveness: 3

1. Employment of POPS allows a reframing of waiting lists as preparation lists. POPS facilitates early preoperative assessment, medical optimisation and prehabilitation (through lifestyle modification, exercise, nutrition, and psychological preparation). It reduces the need for multiple referrals (eg anaemia clinic, GP review of hypertension or a parallel prehabilitation service) and in turn negates the need for an individual patient to be on multiple waiting lists.

2. A POPS approach supports early and effective shared decision making. Holistic CGA-based assessment helps patients weigh up risks and benefits to make the decision that is best for them in the context of co-existing health issues. Following POPS assessment and in collaboration with their clinical team, 1-in-7 patients opt to be removed from surgical waiting lists. 2

3. Using a POPS approach helps flow through primary, secondary and community services. The team help to identify patients suitable for day surgery, addressing current variation across the country in day surgery rates. POPS also improves flow through the hospital by ensuring early decision-making regarding need for level two and three care, and reduces late cancellations of surgery, length of stay and readmissions.

Next steps for managers and leaders

The POPS@GSTT team have supported hospitals in the NHS and internationally to establish their POPS services adapted to the local context. To scale this up across the NHS, an NHS Elect POPS Network has been established. Within the last 18 months, two cohorts totalling thirteen NHS Trusts have completed the 6-month programme, and have implemented sustainably funded POPS services adapted to their local context.

The programme consists of a range of individually tailored learning and development events led by national clinical and improvement experts. Monthly core events, webinars and masterclasses focus on key topics e.g. setting up a POPS service, application of QI techniques to support change and the approach to measurement and understanding your data. Access is also provided to vital online resources such as the POPS toolkit, as well as opportunities to build links with other participating sites.

As managers and leaders coordinating the delivery of NHS care, IHSCM members are uniquely positioned to drive the adoption of these clinically- and cost-effective services.

Recruitment is now underway for the third POPS Network cohort. Any interested organisations should contact jugdeep.dhesi@gstt.nhs.uk, networksinfo@nhselect.org.uk or visit www.POPSolderpeople.org

1. Fowler, A. J., Abbott, T. E. F., Prowle, J., & Pearse, R. M. (2019). Age of patients undergoing surgery. The British journal of surgery, 106 (8), 1012–1018. https://doi. org/10.1002/bjs.111481

2. Shahab, R., Lochrie, N., Moppett, I. K., Dasgupta, P., Partridge, J. S. L., & Dhesi, J. K. (2022). A Description of Interventions Prompted by Preoperative Comprehensive Geriatric Assessment and Optimization in Older Elective Noncardiac Surgical Patients. Journal of the American Medical Directors Association, S1525-8610(22)00643-0. Advance online publication. https://doi.org/10.1016/j. jamda.2022.08.009

3. Partridge, J. S. L., Moonesinghe, S. R., Lees, N., & Dhesi, J. K. (2022). Perioperative care for older people. Age and ageing, 51 (8), afac194. https://doi.org/10.1093/ageing/ afac194

4. Partridge, J. S., Harari, D., Martin, F. C., Peacock, J. L., Bell, R., Mohammed, A., & Dhesi, J. K. (2017). Randomized clinical trial of comprehensive geriatric assessment and optimization in vascular surgery. The British journal of surgery, 104 (6), 679–687. https://doi.org/10.1002/ bjs.10459

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