New guidelines for the perioperative care of people living with frailty undergoing elective and emergency surgery-a commentary

Frailty is common in the older population and is a predictor of adverse outcomes following emergency and elective surgery. Identification of frailty is key to enable targeted intervention throughout the perioperative pathway from contemplation of surgery to recovery. Despite evidence on how to identify and modify frailty, such interventions are not yet routine perioperative care. To address this implementation gap, a guideline was published in 2021 by the Centre for Perioperative Care and the British Geriatrics Society, working with patient representatives and all stakeholders involved in the perioperative care of patients with frailty undergoing surgery. The guideline covers all aspects of perioperative care relevant to adults living with frailty undergoing elective and emergency surgery. It is written for healthcare professionals, as well as for patients and their carers, managers and commissioners. Implementation of the guideline will require collaboration between all stakeholders, underpinned by an implementation strategy, workforce development with supporting education and training resources, and evaluation through national audit and research. The guideline is an important step in improving perioperative outcomes for people living with frailty and quality of healthcare services. This commentary provides a summary and discussion of the evidence informing the standards and recommendations in the published guideline.

National clinical audit for hospitalised exacerbations of COPD

Introduction

Exacerbations of COPD requiring hospital admission are burdensome to patients and health services. Audit enables benchmarking performance between units and against national standards, and supports quality improvement. We summarise 23 years of UK audit for hospitalised COPD exacerbations to better understand which features of audit design have had most impact.

Method

Pilot audits were performed in 1997 and 2001, with national cross-sectional audits in 2003, 2008 and 2014. Continuous audit commenced in 2017. Overall, 96% of eligible units took part in cross-sectional audit, 86% in the most recent round of continuous audit. We synthesised data from eight rounds of national COPD audit.

Results

Clinical outcomes were observed to change at the same time as changes in delivery of care: length of stay halved from 8 to 4 days between 1997 and 2014, alongside wider availability of integrated care. Process indicators did not generally improve with sequential cross-sectional audit. Under continuous audit with quality improvement support, process indicators linked to financial incentives (early specialist review (55–66%) and provision of a discharge bundle (53–74%)) improved more rapidly than those not linked (availability of spirometry (40–46%) and timely noninvasive ventilation (21–24%)).

Conclusion

Careful piloting and engagement can result in successful roll-out of cross-sectional national audit in a high-burden disease. Audit outcome measures and process indicators may be affected by changes in care pathways. Sequential cross-sectional national audit alone was not generally accompanied by improvements in care. However, improvements in process indicators were seen when continuous audit was combined with quality improvement support and, in particular, financial incentives.

National audit in COPD is feasible and can improve process indicators, particularly when continuous audit is associated with quality improvement initiatives and financial incentiveshttps://bit.ly/3eiOvOY

41 Using Patient Centred Care to Redesign Integrated Discharge Services in Derby

Background

Discharge to Assess as outlined by the Department of Health was adopted in Derby in 2016. Previously the discharge pathways to community settings from the acute trust were complex. Challenges included: Operating from a traditional residential care home.No integration of community health staff and social care teams leading to delays in treatment and decision making as well as multiple referrals and hand-overs and no joint communication which was confusing for patients.Stakeholder anticipation of 6 weeks length of stay.Limited responsiveness to capacity demand within planned and unplanned community physiotherapy.Changing the culture and mind-set of staff.Different health and social care processes and procedures, IT systems, working patterns, contracts and pay scales.

Methods

A new service model, joint processes and standard operating procedures was developed with the patient at the centre of the design. Trusted assessment and information sharing reduce multiple assessments and hand overs, ensuring a smoother and improved patient experience.

Outcomes

Triage of patients from the Integrated Discharge Hub to the appropriate pathway, early discharge planning, board rounds and MDT's and timely assessments combined with an enablement ethos have increased the flow of patients through the service, decreased care package hours and increased capacity through reducing both length of stay and delayed transfers of care. The health and social care teams are now delivering fully integrated care and undertaking joint training. This has led to a reduction in treatment times from 20 days to 12 days, reductions in DTOC to average of 8 days per month and improved access to community based routine therapy from 85% of referrals being seen by 6 weeks 2017-18 to 99% in 2018-19.

Conclusions

The integrated service delivers more for less resulting in significant savings in the healthcare and social care system while maintaining quality standards and outcomes.

A multicentre randomised controlled trial of day hospital-based falls prevention programme for a screened population of community-dwelling older people at high risk of falls

Objective: to determine the clinical effectiveness of a day hospital-delivered multifactorial falls prevention programme, for community-dwelling older people at high risk of future falls identified through a screening process.

Design: multicentre randomised controlled trial.

Setting: eight general practices and three day hospitals based in the East Midlands, UK.

Participants: three hundred and sixty-four participants, mean age 79 years, with a median of three falls risk factors per person at baseline.

Interventions: a day hospital-delivered multifactorial falls prevention programme, consisting of strength and balance training, a medical review and a home hazards assessment.

Main outcome measure: rate of falls over 12 months of follow-up, recorded using self-completed monthly diaries.

Results: one hundred and seventy-two participants in each arm contributed to the primary outcome analysis. The overall falls rate during follow-up was 1.7 falls per person-year in the intervention arm compared with 2.0 falls per person-year in the control arm. The stratum-adjusted incidence rate ratio was 0.86 (95% CI 0.73–1.01), P = 0.08, and 0.73 (95% CI 0.51–1.03), P = 0.07 when adjusted for baseline characteristics. There were no significant differences between the intervention and control arms in any secondary outcomes.

Conclusion: this trial did not conclusively demonstrate the benefit of a day hospital-delivered multifactorial falls prevention programme, in a population of older people identified as being at high risk of a future fall.

The national clinical audit of falls and bone health: the clinical management of hip fracture patients

BACKGROUND

The standards of care for older people who present with a fractured neck of femur (#NOF) have been defined by previously published national guidelines. To assess compliance with these standards the Healthcare Commission commissioned the Clinical Effectiveness and Evaluation Unit (CEEU) for the Royal College of Physicians to deliver 'The National Clinical Audit of Falls and Bone Health for Older People'.

METHODS

The audit was developed by a multi-disciplinary team using available best evidence to set audit standards. All acute hospital trusts admitting orthopaedic trauma cases and all primary care trusts (PCTs) in England were recruited. Patients >65 years old presenting with a proven #NOF were included in the audit with a target of 20 cases per participating site.

RESULTS

Data was entered for 3184 #NOF patients. 80% (2555/3184) were female with a median age of 83 years admitted from their own home (68% 2152/3184). Over 97% (3172/3184) presented to the A&E department on the same day as the fall (88% 2813/3184). The time in the A&E department was less than 2h in only 20% (640/3133) of cases with 23% (716/3133) having a stay of >240min. 35% (1080/3088) of #NOF patients were operated on within 24h of admission. Causes of delay to theatre included awaiting medical review (59% 566/956) or organisational reasons (29% 278/956). 48% (1480/2998) of patients were sat out of bed within 24h. Only 35% (1115/3184) of patients were cared for in an orthogeriatric setting. The median length of stay for the #NOF patients was 16 days with an interquartile range of 10-27 days.

CONCLUSIONS

There are currently unacceptable wide variations in the delivery of clinical care to older people presenting with a #NOF. Of concern were the long lengths of time in A&E for many patients and the low level of routine access to pre-operative medical assessment. It is hoped that the launch of joint initiatives between the British Orthopaedic Association and the British Geriatric Society aimed at delivering service improvements in this area should lead to improved outcomes.

Multifactorial day hospital intervention to reduce falls in high risk older people in primary care: a multi-centre randomised controlled trial [ISRCTN46584556]

Falls in older people are a major public health concern in terms of morbidity, mortality and cost. Previous studies suggest that multifactorial interventions can reduce falls, and many geriatric day hospitals are now offering falls intervention programmes. However, no studies have investigated whether these programmes, based in the day hospital are effective, nor whether they can be successfully applied to high-risk older people screened in primary care. The hypothesis is that a multidisciplinary falls assessment and intervention at Day hospitals can reduce the incidence of falls in older people identified within primary care as being at high risk of falling. This will be tested by a pragmatic parallel-group randomised controlled trial in which the participants, identified as at high risk of falling, will be randomised into either the intervention Day hospital arm or to a control (current practice) arm. Those participants preferring not to enter the full randomised study will be offered the opportunity to complete brief diaries only at monthly intervals. This data will be used to validate the screening questionnaire. Three day hospitals (2 Nottingham, 1 Derby) will provide the interventions, and the University of Nottingham's Departments of Primary Care, the Division of Rehabilitation and Ageing Unit, and the Trent Institute for Health Service Research will provide the methodological and statistical expertise. Four hundred subjects will be randomised into the two arms. The primary outcome measure will be the rate of falls over one year. Secondary outcome measures will include the proportion of people experiencing at least one fall, the proportion of people experiencing recurrent falls (>1), injuries, fear of falling, quality of life, institutionalisation rates, and use of health services. Cost-effectiveness analyses will be performed to inform health commissioners about resource allocation issues. The importance of this trial is that the results may be applicable to any UK day hospital setting. SITES: General practices across Nottinghamshire and Derbyshire. Day hospitals:Derbyshire Royal Infirmary (Southern Derbyshire Acute Hospitals NHS Trust)Sherwood Day Service (Nottingham City Hospital Trust)Leengate Day Hospital (Queen's Medical Centre Nottingham University Hospital NHS Trust).

Reproducibility of circulatory changes to head-up tilt in healthy elderly subjects

OBJECTIVE

to assess the reproducibility of the cardiovascular responses to head-up tilt including cardiac output, stroke volume and peripheral resistance, in healthy older subjects using non-invasive methods.

PARTICIPANTS

twenty-five healthy community-dwelling volunteers with a mean age of 69+/-3 years.

METHODS

the subjects underwent head-up tilt table testing on two occasions at an interval of 6 weeks. Pulse interval and blood pressure data were collected, on a beat-to-beat basis using a non-invasive monitor (Finapres, Ohmeda), during 70 degrees head-up tilt table testing and stored for analysis.

ANALYSIS

the pulse interval and blood pressure data for the group were pooled and the relative changes in cardiac output, stroke volume and peripheral resistance were calculated using pulse contour analysis.

RESULTS

the systolic blood pressure, pulse interval, cardiac output and stroke volume fell immediately after tilt with a rise in peripheral resistance. These responses were similar, though the baseline systolic blood pressure levels were lower at the second visit (P=0.06).

CONCLUSION

these non-invasively assessed cardiovascular responses to head-up tilt in healthy older subjects show little variation between visits. The reproducibility of the responses in subjects with syncope and autonomic failure warrants further investigation.

Continuous cardiac baroreceptor measurement during tilt in healthy elderly subjects

INTRODUCTION

Abnormalities of cardiac baroreceptor sensitivity (BRS) may contribute towards the high prevalence of orthostatic hypotension and falls in the elderly. Most mathematical analyses used to determine BRS in the time or frequency domains assume a stationary physiological state and cannot be performed under dynamic change and therefore are not valid during tilt. We describe a new method of estimating BRS during tilt.

METHODS

Twenty-five healthy elderly volunteers with a mean age of 69 +/- 3 years underwent head-up tilt to 70 degrees, within 5 s, 3 times on 2 separate visits. Blood pressure (BP) and heart rate were recorded continuously using a Finapres beat-to-beat BP monitor and surface ECG. A continuous estimate of BRS was obtained by combining beat-to-beat linear regression with Legendre polynomial interpolation.

RESULTS

The values for supine BRS prior to tilt on the two visits, calculated using the new regression method (10.4 +/- 8.2 ms/mmHg and 12.5 +/- 9.7 ms/mmHg) were similar to those using fast Fourier analysis (10.7 +/- 6.7 ms/mmHg and 12.4 +/- 7.1 ms/mmHg). A rapid fall in BP and pulse interval along with cardiac BRS values occurred with tilt within the first 20 s of onset on both visits and remained reduced up to 90 s post tilt (p < 0.01).

CONCLUSIONS

The values for cardiac BRS obtained using continuous time domain analysis agree well with those calculated using spectral methods and can be used to assess the dynamic changes in BRS to rapid perturbations in BP such as that occur with tilt.

A high diagnostic rate in older patients attending an integrated syncope clinic

OBJECTIVES

To describe the findings in the first year of an integrated syncope clinic for older patients and to review the published literature on "integrated" syncope clinics investigating older people.

DESIGN

Review of syncope clinic database and Medline search for relevant literature.

SETTING

Outpatient syncope clinics in two district hospitals in the same city.

PARTICIPANTS

Secondary referrals from the in- and outpatient population with recurrent unexplained presyncopal and syncopal symptoms.

RESULTS

The results of testing in 76 patients over the age of 60 years were available for analysis. A diagnosis was achieved in 67 (88%) of the patients with 76% of the diagnoses being cardiovascular in origin. The prevalence rates of neurocardiogenic syncope (32%) and carotid sinus syndrome (17%), however, differed from previously reported rates.

CONCLUSIONS

Evaluation of presyncopal and syncopal events in an "integrated syncope clinic" achieves a high diagnostic yield in older subjects.

Cardiac baroreceptor sensitivity is impaired after acute stroke

BACKGROUND AND PURPOSE

The blood pressure (BP) fall and increased BP variability after acute stroke have been previously described. The underlying pathophysiological mechanisms producing these findings are unclear but may include abnormalities of cardiac baroreceptor reflex arc and/or changes in sympathetic nervous system activity. To date, evidence of impaired cardiac baroreceptor sensitivity (BRS) after stroke is limited to patients with chronic disease as determined by invasive methodology. Therefore, it was proposed to assess cardiac BRS and sympathovagal balance with the use of novel noninvasive techniques after acute stroke.

METHODS

Thirty-seven acute stroke patients underwent simultaneous surface electrocardiographic and noninvasive beat-to-beat BP recording. Cardiac BRS was assessed by power spectral analysis techniques, and sympathovagal balance was determined from the ratio of the low- to high-frequency powers for pulse interval variability. The responses were compared with a control group matched for age, sex, and BP.

RESULTS

Median cardiac BRS was significantly lower in stroke patients than in control subjects (high-frequency alpha-index, 4.89 versus 6.50 ms/mm Hg; P = .007; combined alpha-index, 4.65 versus 5.46 ms/mm Hg; P = .02). Median normalized high- but not low-frequency power of systolic BP variability was significantly greater in stroke patients (11.0 versus 6.7 normalized units; P < .001), probably reflecting differences in the mechanical effects of respiration on BP in stroke patients. No significant differences were observed in the power spectrum of pulse interval variability between stroke patients and control subjects. Patients with tight hemisphere strokes, however, had a significant reduction in median high-frequency pulse interval power compared with patients with left hemisphere strokes (8 versus 20 normalized units; P = .03), which may reflect a change in sympathovagal balance in favor of increased sympathetic tone in this group.

CONCLUSIONS

The impairment of cardiac BRS may be important in explaining the increased BP variability after stroke. There was no significant difference in surrogate measures of sympathovagal activity between acute stroke patients and control subjects, but right hemisphere stroke patients had a significant alteration in the sympathovagal balance of pulse interval variability compared with left hemisphere stroke patients. This sympathetic predominance in right hemisphere strokes may be important in the development of cardiac arrhythmias after stroke. The prognostic implications of these findings need to be further explored.