Multidisciplinary quality improvement programme for older patients admitted to a vascular surgery ward^*

Abstract

Background Older vascular surgical patients are at high risk of hospital‐associated complications and prolonged stays. Aims To implement a multidisciplinary co‐management model for older vascular patients and evaluate impact on length of stay (LOS), delirium incidence, functional decline, medical complications and discharge destination. Methods Prospective pre‐post evaluation of a quality improvement intervention, enrolling pre‐intervention (August 2012–January 2013) and post‐intervention cohort (September 2013–March 2014). Participants were consenting patients aged 65 years and over admitted to the vascular surgical ward of a metropolitan teaching hospital for at least 3 days. Intervention was physician‐led co‐management plus a multidisciplinary improvement programme targeting delirium and functional decline. Primary outcomes were LOS, delirium and functional decline. Secondary outcomes were medical complications and discharge destination. Process measures included documented consultation patterns. Administrative data were also compared for all patients aged 65 and older for 12 months pre‐ and post‐intervention. Results We enrolled 112 participants pre‐intervention and 123 participants post‐intervention. LOS was reduced post‐intervention (geometric mean 7.6 days vs 9.3 days; ratio of geometric means 0.82 (95% confidence interval CI0.68–1.00), P = 0.04). There was a trend to less delirium (18 (14.6%) vs 24 (21.4%), P = 0.17) and functional decline (18 (14.6%) vs 27 (24.3%), P = 0.06), with greatest reductions in the urgently admitted subgroup. Administrative data showed reduced median LOS (5.2 days vs 6 days, P = 0.03) and greater discharge home (72% vs 50%, P < 0.01). Conclusions Physician‐led co‐management plus a multidisciplinary improvement programme may reduce LOS and improve functional outcomes in older vascular surgical patients.

Geriatrician perspectives on perioperative care: a qualitative study

“…There were mixed opinions on whether to start with an inpatient or preadmission outpatient service. There is growing evidence for both inpatient [34][35][36][37] and outpatient geriatrics perioperative models of care [16]. However, translating clinical trial models of care into the real world healthcare setting is challenging and limited by resource availability.…”

A retrospective analysis of the investigative practices of acute limb ischaemia presenting with an unknown aetiology

“…In view of the multitude of potential aetiologies, early multi-disciplinary physician collaboration is suggested to facilitate appropriate investigation and subsequent management strategies. 10…”

“…Although it could be expected that in ‘real‐world’ clinical situations consultation from physicians would be the next port of call for providing expertise on investigation of non‐surgical ALI causes, we report that only 44% of patients with unexplained ALI had a vascular medicine consult. In view of the multitude of potential aetiologies, early multi‐disciplinary physician collaboration is suggested to facilitate appropriate investigation and subsequent management strategies 10 …”

Sharing the helm: medical co‐management for the older surgical patient

“…27 These findings have informed quality improvement efforts in other vulnerable emergency surgical patients including general surgery, 28,29 emergency laparotomy 2,30 and vascular surgery. 31 Collaborative care models have shown better care coordination, 29,31 decreased complications including delirium and functional decline, 31,32 shorter hospital stays 31,32 and potential cost savings 33 . Observational data from the National Emergency Laparotomy Audit (NELA) in the United Kingdom (UK) show that postoperative geriatrician review is associated with lower mortality in older emergency laparotomy patients, 34,35 while meta-analyses of studies of co-management of surgical patients by geriatricians 36 or general physicians 37 suggest that mortality benefits accrue in models including a multidisciplinary team in addition to the medical specialist.…”

“…Collaborative models based on CGA were first established in hip fracture patients, who are often frail, with robust evidence from randomized controlled trials that they reduce nursing home placement and may reduce mortality and length of stay 27 . These findings have informed quality improvement efforts in other vulnerable emergency surgical patients including general surgery, 28,29 emergency laparotomy 2,30 and vascular surgery 31 . Collaborative care models have shown better care coordination, 29,31 decreased complications including delirium and functional decline, 31,32 shorter hospital stays 31,32 and potential cost savings 33 .…”