Article Figures & Data
Figures
- Fig 1.
Postoperative medical complications and 30-day readmission rate in emergency general surgical patients.
Tables
- Table 1.
Summary of evaluation KPIs and associated improvement steps over time for POPS@DGT scale-up
Challenge Enablers Barriers Achieving organisational readiness for change NHS England money available to pump-prime project funding
Resources, ie staffing in place
Clinical and implementation expertise on-hand from GSTFT
Chief executive with belief in benefit of service: ‘the right thing to do’
Success in National awards, ie shortlisting for BMJ and HSJ awards, raising trust profile
Negativity regarding the likelihood of investment in new projects resulted in weak belief among clinical staff in their ability to deliver change, and therefore poor collective commitment to change
Achieving individuals’ readiness for change Some staff perceived current service as not adequately addressing needs of older patients, generating desire/tension for change. More pronounced among nurses and AHPs
Sessions for clinical and management staff demonstrated purpose of service and potential improvements, setting a shared vision
Proactive engagement of staff throughout implementation process (through conception, introduction, and improvement work) facilitated ‘buy-in’
Individuals with prior experience of working with similar models of care in other centres were early acceptors and advocates of service
Some staff perceived current service as working adequately, generating limited desire for change. More pronounced among doctors. Example comment ‘We managed before you’
Some individuals described introducing change as synonymous with introducing more work, leading to reluctance to engage
Service implementation encountered individuals resistant to change throughout. The reasons could not always be understood or defined. Commitment to consistently delivering quality clinical work proved more powerful than other methods of persuasion for this group
Ensuring acceptability of intervention The intervention being introduced appealed to clinical staff – ‘common sense’ service with strong patient focus
Active process of engaging clinical staff in implementation process demonstrated desire to adapt service to new context
Early and frequent sharing of outcome data demonstrated efficacy of service
Evidence for the service (both published and anecdotal) arose from tertiary centre. Some perceived this as irrelevant due to different context of DGH
Achieving multi-disciplinary working over silo working Close interdepartmental relationships were already in existence within the DGH setting, ie anaesthesia/general surgery
AHPs and nurses were familiar with MDT meeting model and enthusiastic to introduce it into general surgery
Education and training sessions for junior doctors and nurses encouraged understanding of and engagement with the service
Regular presentations at departmental meetings (surgery, anaesthesia, medicine) maintained high service profile and led to new opportunities to collaborate with improvement projects
Achieving buy-in from junior surgical doctors was challenging with a ‘surgery vs medicine’ culture. Initially ‘medical’ jobs were perceived as lower priority than ‘surgical’ jobs
Different working patterns hindered streamlined communication between teams, ie different handover times / consultant ward round times.
Challenging traditional role definition, – ie geriatricians offering preoperative assessment provoked mixed opinions, especially from anaesthetists
AHP = allied health professional; BMJ = British Medical Journal; HSJ = Health Services Journal.
Summary
What is known? Postoperative outcomes worsen with increasing age. Services using comprehensive geriatric assessment (CGA) methodology throughout the perioperative pathway demonstrate improvement in postoperative outcomes. Despite clear standards of care recommending assessment by a geriatrician in high-risk surgical groups, implementation of geriatric medicine services in routine surgical care (other than hip fracture) remains limited. What is the question? Is it possible to effectively and sustainably translate an established model of geriatrician-led perioperative care (perioperative medicine for older people undergoing Surgery (POPS)) from a tertiary centre to a district general hospital setting? What was found? A sustainable and substantively funded POPS service was established at a district general hospital. Within 18 months the service demonstrated reduction in length of stay and readmission rate, and improvement in patient- and staff-related outcomes. What is the implication for practice now? Quality improvement methodology should be used to facilitate the wider systematic scale-up of sustainable POPS services.
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