Vasculogeriatrics: embracing shared care with our colleagues in geriatric medicine should not be a threat.

Devas and colleagues are credited with pioneering orthogeriatric care in the 1950s in Hastings, United Kingdom. He described the need to carefully consider all the patient's circumstances when planning their care. This approach remains highly relevant 70 years on.

Shared models of care are now well recognized in specialties like orthopaedics where benefits in mortality, morbidity and reduced length of stay have been shown mainly in hip fracture surgery. , , , , , Other disciplines have been slow to consider replicating this model, perhaps due to lack of evidence across other procedures, conflicting demands, funding barriers or perhaps, due to a perceived threat of loss of control over perioperative care. Reluctance may also stem from the perceived prying eyes of a physician into our decision making and outcomes, or possibly anticipating delays to surgery from medical incursions. Perhaps it is simply a lack of understanding of possible frameworks and potential gains?

We were offered the chance to emulate the orthopaedic model with a similar initiative at Sir Charles Gairdner Hospital in Perth in 2014, securing funding for a 0.1 FTE consultant in geriatrics with a 0.4 FTE geriatric registrar, equating to one consultant led ward round per week and weekday ward rounds by the registrar. Over time, this has evolved into a twice‐weekly geriatrician round with registrar support 6 days per week. Whilst the geriatric ward round did involve our vascular surgery juniors, it took place after the early morning surgical round so as not to interfere with patient flow, theatre or discharge deadlines. The juniors were quick to express their appreciation of a slower paced round with the opportunity to learn medicine as it pertains to the elderly, frail and co‐morbid—a skill base essential for many career pathways. The surprise came from the geriatric team who were astonished that we had been routinely managing some of the highest risk patients in the hospital for many years.

One of our major hurdles prior to the vascular geriatric service, was facilitating transfer of frail, co‐morbid patients to an appropriate downstream facility for rehabilitation or ongoing care. We rapidly came to appreciate the expertise of a consultant geriatrician in expediting and facilitating this by patient optimisation when discharges took place in days rather than weeks. Having ‘in‐house’ physician expertise created further benefits and time savings within the patient stay, including a reduction in the number of medical specialty consultations required. With the geriatric team helping to manage the perioperative period, there was a reduced requirement for external advice and consequent delay. This helped reduce our length of stay further, enabling us to admit higher volumes of patients with urgent problems through a limited number of beds at any one time. The ability of geriatricians to reduce length of stay for surgical patients is now well documented. , ,

In vascular surgery, where catheter‐based interventions are the norm and the endovascular possibilities are ever‐expanding, we are regularly faced with risk/benefit judgement calls. The involvement of the geriatricians in prognostication for complex patients facing major intervention has become valuable in assisting us in making the best possible decisions for our patients. Although some centres have Physician‐ assisted input, Geriatricians are expert at managing cognitive impairment and vascular dementia improving quality of care for these patients. , Other benefits from geriatric involvement include patient centred care with improvements in the management of geriatric syndromes (such as delirium, frailty and polypharmacy), perioperative risk reduction and enhanced communication with patients, relatives and the allied health team outside of a fast‐ paced surgical ward round. , , , ,

An unexpected gain was the emergence of a productive research group involving vascular surgery, vascular geriatrics, anaesthesia, renal medicine, podiatry and nursing. This group has delivered several QI projects, registrar projects, medical student projects and audits. Outcomes from the group have led to changes in unit practice, for example reduced use of myocardial perfusion scans in preoperative assessment, increased use of preoperative iron transfusion and measurement of frailty and sarcopenia, many have been presented at major vascular meetings. The understanding of research delivery and engagement of motivated individuals for change can be exponentially beneficial to any unit. It is satisfying to see juniors come away with an enhanced knowledge of medicine as it pertains to surgery through collaborations like this, as well as a presentation and a paper or two.

As our population ages and co‐morbid conditions such as diabetes and obesity increase, procedural risk in our patient cohorts will only get higher. By sharing patient centred goals and the perspective of experts in care of the elderly, we can mitigate the perioperative risk and streamline patient flow without compromising our way of work, personal preferences, schedules or control. , , Although clear to us that we and our patients only benefit by shared care with our geriatricians, patient reported outcomes will strengthen the case for a shared care model aside from cost‐effectiveness in a specialty where quality of life may have greater importance than quantity. The practical implementation of our model could provide a framework for other units who may wish to work together in this way.

Author contributions

Emily Jasper: Writing – review and editing. Kien Chan: Conceptualization; supervision; validation; writing – review and editing. Shirley Jansen: Conceptualization; project administration; writing – original draft; writing – review and editing. Christopher Wilson: Writing – review and editing.