40IDENTIFICATION AND REFERRAL OF FRAIL ELDERLY SURGICAL PATIENTS TO THE ELDERLY CARE ASSESSMENT TEAM (ECAT)

Abstract

Evidence Base: Frail elderly patients have poor outcomes after surgery; surgical procedures are higher risk, there is an increase in medical complications and poorer cognitive outcomes (Wilkinson K, Martin IC, Gough MJ, NCEPOD, 2010). Evidence suggests improved outcomes in these patients when proactively reviewed by specialist geriatric teams, notably reduction in medical complications, length of stay and mortality (Partridge J, Harari D, BJS, 2017). In the Royal Infirmary of Edinburgh, current access to specialist geriatric review is by referral to the Elderly Care Assessment Team (ECAT) using an intranet based referral form. Change Strategy: We retrospectively analysed admission data for patients >75 years of age during a two week period. Frail patients were identified using the Health Improvement Scotland (HIS) scoring system (n = 14). Of these patients, 2 had been referred to ECAT, identifying an unmet need of 86% of patients (n = 12) who were not referred. Outcomes according to geriatric domains were measured in the "not referred" group; 50% had cardiac or renal complications of surgery, 15% required a catheter, 42% met sepsis criteria and 34% had delirium. 83% of patients had no documented anticipatory care planning discussion. There were 4 deaths. This demonstrated a high level of unmet need among frail elderly patients not assessed by ECAT. Findings were presented to colleagues in General Surgery. Barriers to ECAT referral were discussed and referral criteria circulated, along with teaching sessions addressing key geriatric syndromes. The referral form was replaced by use of a dedicated email inbox address to capture referrals. Change Effects: This led to an increase in referrals to ECAT in the following 2 weeks (n = 19, vs n = 2) Conclusions: We have demonstrated that a simple change in referral system can improve identification of frail elderly patients who may benefit from specialist geriatric review. Future work will focus on the use of frailty scoring to identify patients proactively within this busy surgical unit.