Developing a virtual geriatric perioperative medicine clinic: a mixed methods healthcare improvement study.

BACKGROUND: the Geriatric Perioperative Care clinic at North Bristol NHS Trust was suspended in March 2020 during the COVID-19 pandemic. A virtual clinic was piloted to deliver preoperative health optimisation and shared decision-making for patients undergoing critical elective surgery. No literature existed on virtual preoperative clinics for older people to support the development. OBJECTIVE: this healthcare improvement study describes the setup and delivery of the virtual clinic as its primary aim. Secondary aims included: assessing older people's access to technology and their digital literacy for virtual consultation; to describe barriers and facilitators for consultations, as well as evaluation of patient and clinician satisfaction with the consultations' mode of delivery and outcomes. METHODS: a mixed methods healthcare improvement study was undertaken through plan-do-study-act cycles, semi-structure interviews, and quantitative service benchmarking. RESULTS: the pilot evaluated 67 preoperative consultations (43.3% video, 56.7% telephone, mean age 75) with a mix of surgical pathology (vascular 88.1%, colorectal 10.4%, urological 1.5%). Patient feedback demonstrated improved understanding of conditions (90.6%), and adequate opportunity to express opinions and questions (96.2%). Clinicians preferred video consultations (adequate to deliver services: 89.7% video; 68.4% telephone). The greatest barriers to engagement, none of which were exclusions to participation, included cognitive impairment, sensory impairment, or needing technical assistance setting up video consultations (52.2%). CONCLUSIONS: delivering a virtual preoperative medical optimisation and shared decision clinic for older people is feasible. This study will aid other units in developing their own virtual preoperative clinics. Future work should evaluate perioperative outcomes of delivering a face-to-face versus virtual clinic.

Daily Medical Liaison is Associated with Reduced Length of Stay and Complications in Selected Patients Admitted to a Regional Vascular Surgery Service.

Older adults undergoing vascular surgery are particularly vulnerable to adverse outcomes by virtue of their vascular risk factors and medical comorbidities. This study aimed to determine the impact of daily medical liaison for patients aged 65 years and older admitted to a regional vascular surgery centre. This was a descriptive before-and-after study concerning 375 patients. The primary outcome measure was length of stay (LOS). Following intervention, we identified a reduction in mean LOS in the sample from 10.75 to 7.95 days (p = 0.635, 95% Confidence Interval [CI] 0-5 days) with a statistically significant reduction in mean LOS for "stranded" patients admitted for more than seven days (mean 7.84 days reduction, p = 0.025, 95% CI for mean difference, 1.5 to 14 days). These patients did not display elevated 30-day readmission rates (12/60 to 8/72, p = 0.156, 95% CI -3% to 21%). A non-significant reduction in postoperative complications was seen in all patients in the post-intervention cohort (1.09 to 0.86 per person, p = 0.181, 95% CI -0.11 to 0.56), reaching statistical significance in emergency vascular admissions (1.81 to 0.97 complications per person, p = 0.01, mean difference = 0.84, 95% CI 0.21-1.46). This study demonstrated reduced LOS and complications in selected older patients admitted under vascular surgery after the introduction of a daily medical liaison model. These data are amongst the first to reproduce randomised controlled trial findings in a non-trial setting. Subgroup analysis indicates that patients admitted with acute pathology and those with long LOS may benefit most from medical liaison where resources are finite.

Establishing a remote clinical advice service during the COVID-19 pandemic.

Service redevelopment has taken place across the NHS in response to the COVID-19 pandemic. At North Bristol NHS Trust, six vulnerable medical staff in non-patient facing roles set up a virtual advice service called 'Ask the Medical Reg'. This service aimed to provide senior medical support to inpatient and community teams for general medical and COVID-19-related queries. Here we outline the structure of our service and present data from the first 4 weeks of operation. We describe how the service has supported both junior doctors working within the hospital and GPs and paramedics, helping with complex decisions to prevent unnecessary admissions.

Establishing a proactive geriatrician led comprehensive geriatric assessment in older emergency surgery patients: Outcomes of a pilot study.

INTRODUCTION: Increasing numbers of older adults are presenting with acute surgical disease to the unselected general surgical take. General surgeons have little training to manage these patients. We developed a pilot service of proactive geriatrician input into older emergency general surgical patients in a single institution. We wanted to demonstrate if geriatricians improve the management of these patients. METHODS: Patients aged 70 years or older admitted acutely under the general surgeons were assessed proactively by a geriatrician using comprehensive geriatric assessment (CGA). Data were collected prospectively using a data collection form of any new issues detected and interventions made by the geriatricians in addition to the surgical plan. This information was entered into an excel database and analysed. RESULTS: We obtained data for 447 patients between November 2016 and July 2017. CGA led to additional diagnoses or interventions in 83% of patients. The most common problems identified included a new medical diagnosis (35.2%), polypharmacy (30%), recent falls (19.7%), weight loss (17.2%) and uncontrolled pain (16.7%). Abbreviated mental tests were performed in 87.5% patients, with 22% being detected with cognitive impairment. Frailty screening was performed in 97% of patients resulting in 38% being identified as frail. New interventions included stopping medications (40%), starting medications (28%) and referral to multidisciplinary teams (70.1%). Length of stay was reduced by 0.55 days. CONCLUSION: Proactive geriatrician input identifies medical diagnoses and geriatric syndromes missed by the surgical teams. Managing these issues has contributed to a reduced length of stay in these patients.

Top tips for a teaching fellowship.

BACKGROUND: Dedicated medical education posts are an exciting opportunity for doctors to focus on their development as clinical teachers. Within the seven hospital trusts that host students from the University of Bristol there are now 19 clinical teaching fellowship (CTF) posts. On starting a dedicated medical education post, the opportunities available can seem overwhelming, and on reflection many of the local 2012-13 CTFs would have changed their initial practice. The purpose of this article was to explore and collate the experiences of CTFs to produce a selection of practical 'top tips'. METHODS: A questionnaire was sent to all 19 CTFs via e-mail, asking them to state what they would do the same and what they would do differently if they had their time again. Dedicated medical education posts are an exciting opportunity for doctors to focus on their development as clinical teachers RESULTS: Eight themes were drawn from the 13 (68%) returned questionnaires, with each theme mentioned between four and 11 times. The themes included: keeping a portfolio of evidence; personal development; undertaking educational research; developing as a clinical teacher; and administration. CONCLUSION: Our aim for this article was to generate practical top tips for those doctors considering, about to start or having just commenced a dedicated teaching role, helping individuals to get the most from their time. It also explains what these teaching fellowships can involve, and gives those thinking of undertaking a dedicated teaching role a better idea of what to expect.