Perioperative Medicine for Older People: Translating a Geriatrician-Led Perioperative Care Model From an Inner London Teaching Hospital to a District General Hospital

Introduction: The Need for Geriatrician-Led Perioperative Services

The global surgical population is aging at a faster rate than the general population. The increasing burden of frailty and comorbidity in older patients is associated with perioperative morbidity and mortality. Despite this, there is often a case for proceeding with surgery in older, frailer adults to achieve increased longevity and maintain or improve quality of life. The needs of this population are inadequately met by traditional perioperative care models. International reports and guidelines have called for geriatrician-led, integrated perioperative care pathways to address this problem.

The perioperative medicine for older people (POPS) model, originally conceived and developed at Guy's and St Thomas’ National Health Service (NHS) Trust (GSTT), London, has served as an exemplar in this field. Since beginning as a pilot project in 2003, POPS has established a UK-wide collaborative driving national and international change. This chapter will describe how implementation science methods were used to develop the POPS model at an inner London academic medical center (GSTT) and translate it to a community district general hospital (Dartford and Gravesham Trust [DGT]) while retaining fidelity to the model's guiding principles.

Context: Establishment of POPS Service, Evidence Base, and Scaling Challenges

The POPS service was initially piloted in 2003 in older patients scheduled for elective hip and knee arthroplasty. It was based on Comprehensive Geriatric Assessment (CGA) and optimization, which uses multidisciplinary, holistic assessment toprompt multidomain interventions, and has been shown to improve morbidity and mortality in older patients. It was hypothesized that preoperative CGA and optimization would improve access to surgery and reduce postoperative complications and length of stay (LOS). A geriatrician-led care model including preoperative CGA and optimization, and collaborative postoperative ward care was tested.

Trial design was informed by the Framework for Design and Evaluation of Complex Interventions to Improve Health, which was produced by the UK Medical Research Council in 2000. A “before and after” exploratory trial compared a cohort of 54 patients receiving standard orthopedic care with a 54-patient cohort receiving POPS care. The intervention reduced postoperative complications (notably, pneumonia incidence was reduced by 80% and delirium by 70%), and LOS was shortened by a median of 4.5 days. This study led to the establishment of a substantively funded POPS service that has grown over the past 19 years. In 2004 the team included a geriatric medicine attending (0.2 FTE), a geriatric medicine trainee (0.8 FTE), and a full-time physiotherapist, occupational therapist, social worker, and clinical nurse specialist. In 2022 the team now includes 4.4 FTE attendings, 5 full-time clinical nurse specialists, 4 full-time senior residents, 11 junior residents, an occupational therapist, and an administrator.

In the intervening period, the POPS team has conducted a series of studies demonstrating the impact of CGA in different surgical subspecialties, including a single-site randomized controlled trial that examined the impact of preoperative CGA and optimization on vascular elective surgery patients. It demonstrated a 40% reduction in LOS in the group receiving CGA (predominantly because of fewer medical complications) and was shown to be cost effective. This evidence has subsequently informed additional single-site service evaluations. A systematic review of CGA-based perioperative services for older people has also shown improved outcomes in the emergency setting. In emergency laparotomy, big data studies have confirmed the benefit of geriatrician involvement as part of a collaborative perioperative pathway affecting mortality and LOS.

Having established an evidence-based single-site service with sporadic uptake at other similar institutions, the challenge of spread to less well-resourced units remains. This chapter now describes the translation of the POPS model from GSTT (POPS@GSTT) to DGT (POPS@DGT).

Intervention

The POPS@GSTT model was translated to DGT in three phases, as will be described, and outcomes were evaluated using a mixed methods study. DGT is a 463-bed district general hospital in a deprived area of Kent County, 16 miles east of GSTT. The partnership between the two sites was approved as one of 50 programs in NHS England's Acute Care Collaboration Vanguard Scheme in 2015. This secured £25,000 funding for the pilot project, which was used to facilitate 2 days per week of input from senior residents in geriatric medicine. They were supported educationally through personal mentoring and a weekly half-day multidisciplinary team meeting led by senior geriatricians from POPS@GSTT.