To our knowledge, this is the first study amongst emergency surgeons from around the world focusing on awareness of perioperative risk scoring and frailty, assessment of frailty and barriers to multidisciplinary management of frail emergency surgical patients. It demonstrated that frailty is underassessed and undertreated despite a satisfactory level of awareness of the frailty syndrome, due to insufficient knowledge regarding perioperative frailty assessment and lack of trained staff. Models such as POPS are not universally recognised and there is much uncertainty about the role of frailty scoring in an emergency setting.
Even though almost all respondents agreed that frailty influences outcomes in emergency surgery patients, only a small proportion routinely assessed it due to lack of knowledge or training on frailty scoring. CFS was the most popular frailty scoring tool, perhaps because it is quick and easy to assess which lends itself easily to an urgent emergency setting. Nonetheless, it is hard to distinguish if it is used as recommended or if a gestalt assessment is made, subjective to the observing physician: 3 of our respondents admitted to “eyeballing” the patient. Others used inappropriate tools, such as RSTs when asked how they frailty score patients. This suggests there is poor awareness of the distinction between the tools and what they are informing, leading to inappropriate use in the perioperative setting. More knowledge on the condition of frailty and its consequences may help clarify the distinction between medical co-morbidities and frailty and how it informs our care, thus optimising outcomes for our elderly patients who likely bear the burden of both. The fact that there are so many scoring schemes further suggests they are not consistent or that the scientific evidence to justify their use is weak. Future research could assess the best scoring systems and clarify where they are useful, although national guidelines in the UK advocate using CFS as the initial screening tool in all settings.
Most of our respondents were unaware of the POPS model or CGA, with only 4 respondents using CGA. Although more respondents from Europe seemed to be aware of the models than in other continents, this may be attributed to the fact that most respondents were Europeans, as well as because both models are British and may not have circulated beyond Europe yet. We would expect there to be more awareness in Europe and in academic hospitals than in rural hospitals, particularly seeing as most respondents were consultant level. However, this lack of awareness even by seniors in these settings, suggests that the burden of frailty may be even more poorly managed in non-academic hospitals and developing countries.
Key barriers for those who did not assess frailty included staff being unsure of whose responsibility it is to do so and poor knowledge regarding validated frailty scoring tools. Providing clear guidelines about frailty scoring, what stage of admission and by whom it must be done, may help guide preoperative optimisation. This may be more beneficial if the frailty scoring translated directly into clinical management. The emergence of novel Artificial Intelligence (AI) systems may have a role to play in the identification of frailty (17, 18) and optimization of multimorbid geriatric care (19) in the future. Using AI may help omit human bias and speed up holistic frailty management, which would be particularly useful in an emergency setting.
Only 66.6% of respondents use a validated RST and document the results on patients prior to emergency surgery. Tools such as ESAS and ACS- NSQIP are best to use in emergency general surgery (20), but showed poor uptake by our respondents. Guidelines such as those by ERAS (Enhanced Recovery after surgery) also suggest NELA and POSSUM as they are more likely to predict actual risk in emergency laparotomy patients (21). Whilst they were also used, they are more time consuming, which may explain why they are used significantly less than the more popular ASA (22).
Anaesthesia was still the specialty most associated with perioperative medicine, despite growing evidence that multispecialty care teams are more effective than any one specialty alone(8, 11). Models such as POPS highlight the effectiveness of involving specialty geriatric input early in the management of frail surgical patients, although the role of a perioperative physician is still ill-defined. Despite surgical trainees being poorly educated on managing frail patients (16), our study found that only a quarter of respondents routinely ask for geriatrician input and that this is primarily done when there are complications or specific comorbidities which require managing. This “reactive” model of care has been shown to be less effective than proactive management (11). Very few respondents had a geriatrician embedded in their team, despite evidence that specialties such as orthogeriatrics show significantly improved outcomes post-hip fracture (23).
Despite post-operative geriatrician input having been shown to reduce patient mortality after emergency laparotomies (24) and reduce inpatient stay after GI surgery (25), we found that there are still barriers to implementing this into practice. A UK study suggested lack of funding at an administrative level as a key barrier to organising this model of care and training in CGA (11). Core barriers for our respondents was lack of staffing, which combined with lack of awareness of the role of geriatrician in emergency surgical setting meant many were unable to involve geriatricians in the routine management of frail emergency patients. Most respondents said surgical trainees conducted frailty assessment highlighting the gap in providing surgical trainees with clear guidelines and ensuring they have sufficient support. This is in line with current attitudes of UK trainee surgeons who feel they are inadequately supported by geriatricians and feel they would benefit from shared management of patients (16). Recirculating this survey amongst trainees might give us a better idea of their knowledge and perceptions around perioperative frailty management.
A key limitation of this study is the low response rate; thus, it would be more statistically sound to say this is a subset of data and any inferences would not be representative of the whole population. Another limitation was that most respondents were from Europe, despite the survey being sent to all the members of WSES around the world. Repeating the survey in the future may mitigate this. However, the limited response may also indicate a lack of knowledge of this important topic amongst our target population deterring them from participating. There is scope for respondent bias due to participants being members of WSES and most respondents being from Europe and general surgery, which may reflect that perioperative medicine is of more interest in this region and specialty than others. Nonetheless, we would expect respondents who chose to participate due to specialist interest in this topic to be more aware of POPS and frailty than others, thus the poor awareness highlighted by this study is worrying as it is likely to be pervasive throughout other regions and specialties in medicine. Future research could look at practices of surgeons in other specialities as a comparison.
Our results highlight the gap in translating perioperative frailty management guidance into routine clinical practice. The burden of perioperative management is not being sufficiently undertaken by emergency surgical teams and there is uncertainty around the perioperative management of frailty. More engagement on the role and benefits of the perioperative physician and its impact on patient outcomes may translate into future funding for training on CGA and to support the organisation of multispecialty surgical teams. Increasing awareness of existing clinical practice guidelines may encourage more hospitals worldwide to uptake this into routine practice.
In conclusion, we found that whilst most surgeons are aware of the importance of frailty in affecting surgical outcomes, there is poor awareness of the role of CGA, and the various models and guidance that positively influence the outcomes of high risk and frail emergency surgical patients. Formal frailty assessment is not routinely done and the key barriers to this seem to be lack of knowledge about frailty and assessment, lack of trained staff and uncertainty around whose responsibility it is. The establishment of multidisciplinary teams with geriatric input would eliminate these uncertainties and share the burden of perioperative management of frail emergency surgical patients to ensure better outcomes in the long term. This study will hopefully raise awareness and encourage participants to review the relevant literature, leading to the development of more comprehensive guidelines regarding frailty management in the emergency surgical setting.