We introduced a geographically embedded frailty unit, the comprehensive older person's evaluation 'COPE' zone within our emergency assessment unit (EAU). We collated data for all medical patients over 75 years admitted non-electively for one month before and after this service change. Significantly more patients were seen by a geriatrician on the EAU earlier in their admission in 2014 (33.4 vs 19.3%, p<0.001; 11 vs 20 h, p<0.001). More patients had documented comprehensive geriatric assessment and discussion in a geriatrician multidisciplinary team meeting (relative risk (RR) 3.3, 95% confidence interval (CI) 2.35-4.73, p<0.001; RR 3.6, 95% CI 2.26-5.57, p<0.001, respectively). More patients with markers of frailty were discharged directly from EAU (42.2 vs 29.0%, p = 0.006) without increasing readmissions. Mean length of stay was reduced (9.5 vs 6.8 days, p = 0.02). The introduction of the COPE zone has improved service delivery at the point of access for older people admitted to hospital.

Introduction Although high rates of in-hospital mortality have been described in older patients undergoing emergency laparotomy (EL), less is known about longer-term outcomes in this population. We describe factors present at the time of hospital admission that influence 12-month survival in older patients. Methods Observational study of patients aged 75 years and over, who underwent EL at our hospital between 8th September 2014 and 30th March 2017. Results 113 patients were included. Average age was 81.9 ± 4.7 years, female predominance (60/113), 3 (2.6%) lived in a care home, 103 (91.2%) and 79 (69.1%) were independent of personal and instrumental activities of daily living (ADLs) and 8 (7.1%) had cognitive impairment. Median length of stay was 16 days ± 29.9 (0–269); in-hospital mortality 22.1% (25/113), post-operative 30-day, 90-day and 12-month mortality rates 19.5% (22), 24.8% (28) and 38.9% (44). 30-day and 12-month readmission rates 5.7% (5/88) and 40.9% (36). 12-month readmission was higher in frail patients, using the Clinical Frailty Scale (CFS) score (64% 5–8 vs 31.7% 1–4, p = 0.006). Dependency for personal ADLs (6/10 (60%) dependent vs. 38/103 (36.8%) independent, p = 0.119) and cognitive impairment (5/8 (62.5%) impaired vs. 39/105 (37.1%) no impairment, p = 0.116) showed a trend towards higher 12-month mortality. On multivariate analysis, 12-month mortality was strongly associated with CFS 5–9 (HR 5.0403 (95% CI 1.719–16.982) and ASA classes III–V (HR 2.704 95% CI 1.032–7.081). Conclusion Frailty and high ASA class predict increased mortality at 12 months after emergency laparotomy. We advocate early engagement of multi-professional teams experienced in perioperative care of older patients.

Increasing numbers of older patients require Emergency admission under General Surgery (EGS). This is a group of heterogeneous and often complex individuals with varying degrees of multimorbidity, polypharmacy, functional, mobility and cognitive impairment. Our article describes the benefits of comprehensive assessment coupled with patient-centred multiprofessional interventions and timely discharge planning. We discuss diverse service models and describe our experience in the planning, development and consolidation of a perioperative service for older EGS patients.

Despite numerous national campaigns, frailty remains under-recognised in the hospital setting. We performed a survey of hospital-based clinicians across the UK to identify barriers to the identifi cation and best practice management of frailty in hospital. A total of 402 clinicians were surveyed across a range of grades, specialties and hospitals. Responses highlighted variable awareness and personal understanding of frailty, particularly among junior doctors and clinicians in non-medical specialties. Although 74% of responders agreed frailty assessments should be undertaken for all older people admitted to hospital, only 36% felt this was currently feasible with available resources. Free-text responses highlighted limited education, the perceived subjectivity of frailty assessments, scepticism as to their utility in the hospital setting, and defi ciencies in service provision. This was the fi rst survey of UK hospital clinicians regarding frailty assessments. Results highlight multiple areas for improvement and engagement.

Identifying general practice trainees at risk of failing the CSA early in their training is important so that supportive measures can be put in place to ensure training progression. The aim of this study was to determine aspects of the trainee's learning portfolio activity which might predict performance in the CSA. From the Mersey School of General Practice records, details were obtained for trainees who had completed their ST3 year between 1 August and 31 December 2012 with respect to the numbers of entries for the Mini Clinical Evaluation Exercise (Mini-CEX), case-based discussions (CBDs), directly observed procedures (DOPS), learning logs and personal development plans (PDPs) that they had carried out in each of their ST1 and ST2 years. Gender, university of qualification and years since qualification were also recorded. Records were obtained for 116 trainees (94 had passed their CSA). ST1 number of CBD and ST1 number of DOPS, university of qualification, gender, and shorter time since qualification were significantly associated with CSA pass. A multivariate model indicated that graduation from a European university and being female were both associated with an increased chance of passing. Longer time since qualification, non-European university graduation and male gender are the strongest predictors of failing the CSA. Portfolio activity is not a predictor of CSA outcome.