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Like most of what we do, there is no Class 1 level evidence for two service developments in our trust (Guy’s and St Thomas’ in London) as service models. Nevertheless we believe that they work and our managers support them.

Their design was based on published studies and local data. At a time when the planning initiative and the money often seems to be out of grasp of geriatrician leaders, you might be encouraged too. Both developments are based on the National Service Framework, particularly standards 1, 2 and 4 about equity without ageism, assessment fit for purpose and general hospital care of older people. Both employ the comprehensive geriatric assessment (CGA) approach, applied through multidisciplinary old age teams working in new settings.

POPS (Proactive Care of Older People undergoing Surgery)

Scoping the problem
The idea of POPS arose directly from discussions in the trust-wide NSF implementation group, which identified that clinical standards on ageing issues were suboptimal among surgical patients. Danielle Harari, a geriatrician and currently our head of service, secured charitable funding for development work which showed that:

• older patients undergoing elective surgery had high preoperative co-morbidity linked to significant post-operative problems (compatible with published evidence),
• preoperative assessments were inadequate to identify most of the potentially remediable factors,
• few patients were referred to our specialist services or community therapists
• GPs, assessment nurses and many surgeons acknowledged the need for improvement.

The POPS team (geriatrician, specialist nurse, physiotherapist, OT, social worker) was set up with further charitable funding. Patients with medical co-morbidities and functional dependencies were targeted through CGA 2-12 weeks pre-surgery. Treatment was at home or in clinics. Patients were followed through surgery to post-discharge (see Figure1 below).

Winning support
A minority of surgeons were initially sceptical but pre-op assessment nurses enthusiastically supported and used the referral criteria. It was soon clear that the exit strategy from developmental to core funding would need support and data to satisfy a range of stakeholders.

Equitable access to surgery has been improved by replacing eyeball impressions about surgical fitness with evidence based medical judgements. By timely medical optimisation based on surgeons and nurses employing simple assessment based referral criteria late cancellations have been reduced, increasing efficient use of theatre time. Preventing and better treatment of postoperative complications has improved clinical effectiveness and service efficiency through, for example, reductions in hospital stays (25%) and unplanned readmissions (over 50%) in elective orthopaedics. Further details have been presented to the BGS i.

Unsurprisingly, questionnaire-based evaluation of patients and surgical staff has demonstrated high satisfaction. Key factors to gain support were the iterative development process which increased understanding and acceptability of key clinical stakeholders, and a flexible approach to solving other pressing clinical issues such as emergency surgical longstayers.

Based on quantitative and qualitative data supplied by this evaluation, the surgical department’s business case for 2005/2006 proposed that mainstreaming the POPS service costing £320K annually could reduce trust costs by double this amount. Hence a new team with consultant geriatrician was established with trust funding from April this year.

OPAL (Older Persons Assessment and Liaison Team)
This team was driven by the need for reduced hospital bed use but again addressed this through a CGA approach with the expectation of improving clinical standards as well.

Service context
Since we became part of the acute trust (in 1988) we have retained separate elderly care wards with ward based multidisciplinary teams, taking patients on a needs basis. In recent years, several factors including junior doctor hours and the 4 hour wait rule in the A&E have resulted in fewer direct admissions to us from primary care, most patients spending 24 hours or more on the admission wards (60 beds with HDU). Subsequent access to our service (84 beds plus a stroke unit) was referral based, with consequent inconsistencies and delays.

Funding context
A financial decision to close 30 medical beds was seen by geriatrician Adrian Hopper, now head of the medal service, as an opportunity for service development through reinvestment. The idea was to apply CGA skills more pro-actively in general medicine. The business case was based on comparative benchmarking work as well as local data showing delays and inefficiency related to clinical decision making.

The service and its effect
The published literature provided evidence on factors associated with clinically adverse outcomes, long hospital stays and readmissions. A CGA case finding tool (one page of A4) was designed. The specialist team (‘OPAL’) [ex ward manager nurse, senior physiotherapist, half-time geriatrician] screened all acute medical patients aged 70+ within 24 hours of admission (M-F) to identify moderate-high clinical risk. The geriatrician saw the patients in the Clinical Decision Unit each morning. Depending on clinical need, actions included:(1) rapid transfer to elderly care unit (ECU) (2) case management on general medicine wards (3) referrals to specialist geriatric clinics (e.g. falls, continence). Essential to the approach is agreement with GIM consultant colleagues and bed managers for this pro-active approach. Particular clinical situations which have been helped by OPAL include:

• identification and management of delirium
• end of life issues of care home residents
• rapid discharge and investigation of patients with falls and syncope
• management of potential re-admitters by discharge and rapid access to day hospital.

Quick and dirty evaluation was what the trust management required to approve ongoing funding. Prospective comparison was made of two cohorts of patients: ‘before-OPAL’ (August 2004) and ‘after-OPAL’ (August 2005) with blinded data abstraction from hospital notes/OPAL database. Prevalence of “geriatric” problems was similar, but their identification and clinical management improved, delay to appropriate transfer to the ECU was reduced, and total hospital length of stay fell 31%(LOS) ii. By the end of the 22 month period since the inception of OPAL, the adult GIM service ran on 50 fewer beds, LOS for all GIM patients over 70 has fallen significantly, and despite taking a more problematic caseload to the ECU wards, LOS has also fallen there.

Whilst many factors may have played a part in this, the independent opinion of the NHS Institute for Innovation and Improvement is that our service is a top performer for the index frail elderly condition of urinary tract infection (personal communication).

Research and Generalisability
So, our experience is that CGA can work. Not a surprise perhaps. Are there any lessons for other hospitals? To secure funding is always a mix of luck and planning. Capitalising on the opportunities presented and meeting the urgent local expectations is good for getting new things started but also impedes the creation of class 1 evidence. Does this matter? The effectiveness of clinical services like these is likely related to: a) casemix, which could be described in detail in an RCT and therefore lend weight to generalisability, local “usual care”, which is difficult to capture and is constantly changing; and b) enthusiastic clinicians, also an elusive quality.

So the research approach of “realistic evaluation” which explores context-mechanism-outcome relationships is as applicable as an orderly RCT. Our ongoing work therefore includes this approach, incorporating evaluations of specific components such as the OPAL case finding tool and the adjustments of POPS that may be necessary for different surgical groups.

Finbarr C Martin
Consultant Geriatrician: R & D lead for Medicine
Acknowledgments to Danielle Harari, Adrian Hopper, and the POPs and OPAL teams

References
i Harari D, Babic-Illman A, Lockwood L, Hopper A, Martin FC. Proactive Care of Older People undergoing Surgery (‘POPS’): Pilot Evaluation. BGS Autumn 2005 Scientific meeting, abstracts on line at http://ageing.oxfordjournals.org/archive
ii Hopper A, Martin FC, Buttery A, O’Neill S, McGovern R, Shillo P, Harari D. The Older Persons Assessment and Liaison Team ‘OPAL’: Pilot Evaluation of Comprehensive Geriatric Assessment (CGA) in Acute Medical Inpatients. BGS Spring 2006 Scientific meeting, abstracts on line at http://ageing.oxfordjournals.org/archive