What we would tell our colleagues about SNAP3

As Chief Investigator and Lead for the RCoA’s Sprint National Anaesthesia Project on frailty and multimorbidity (SNAP3), we were proud to see our outcomes paper published in the British Journal of Anaesthesia last month. Since then, we and our colleagues have taken every opportunity to share our findings with peers across the country, including at Anaesthesia 2025. 

One question keeps surfacing - a familiar one to anyone involved in research: how do we move from evidence to meaningful clinical change? We’ve sought to answer that question here, although we realise it’s easier said than done!

Frailty is more common than you think:

Recognising frailty in surgical patients is the first step toward informed, shared decision-making. When we identify people living with frailty, we can have more meaningful conversations with them and their loved ones about the risks, likely outcomes, and, where appropriate, involve geriatricians early. But identification is one of the main sticking points – SNAP3 highlights this issue. 

We found that one in five surgical patients over the age of 60 are living with frailty, yet most hospitals (71%) were not routinely screening for it in all older surgical patients. In short, we have likely been underestimating how many of our patients are living with frailty. A key first step is to make it routine to use tools such as the Clinical Frailty Scale (CFS) in all older surgical patients undergoing elective and emergency surgery.

The Clinical Frailty Scale offers a straightforward and replicable method for accurately assessing frailty. If you’re unfamiliar with how to assess frailty, there’s a brilliant short online education tool from AIMS, and you even get a certificate when you finish!

Real life application: Assess all patients older than 65 for frailty.

• Frailty has a bigger impact than previously thought.

The Clinical Frailty Scale scores patients on a scale of 1-9, ranging from ‘very fit’ to ‘terminally ill’. A patient's surgical presentation, proposed management, and personal expectations all influence perioperative planning, with their degree of frailty also playing an important role.

Patients living with moderate to severe frailty (CFS of 6 or 7) are often considered those most likely to benefit from frailty-specific adaptions to their perioperative pathway. SNAP3 dispels that misconception – our results show that even patients living with ‘very mild frailty’ with a CFS as low as 4 have worse perioperative outcomes.  

Real life application: Patients living with very mild frailty (CFS4) or higher should be considered to be at higher risk of adverse perioperative outcomes, and discussions / interventions tailored accordingly.

• Consider the whole perioperative pathway for patients living with frailty. 

We found marked differences in perioperative care services between hospitals, as detailed in SNAP3 our survey . For those of us who have worked in multiple trusts this will come as no surprise. But the results of SNAP3 are another indicator of the importance of optimising the perioperative care pathway to improve patient outcomes. Any changes we can make to embed practices such as individualised risk assessments, ‘prehabilitation’, enhanced recovery and better discharge planning are valuable. 

The RCoA’s Centre for perioperative care has a wealth of guidance and resources to support health care professionals make these changes, including guidelines for perioperative care for people living with frailty, co-authored with the British Geriatric Society. It’s a great resource for everyone involved in delivering care throughout the pathway, as well as for patients and their carers, managers and commissioners. 

Real life application: Use the resources available to help improve the perioperative pathway for patients living with frailty.  

Professor Iain Moppett is Chief Investigator for SNAP3, Chair of the RCoA Centre for Research and Improvement and a Professor of Anaesthesia and Perioperative Medicine at the University of Nottingham.

Dr Claire Swarbrick is the SNAP3 Lead and a ST6 anaesthetic registrar based in Peninsula Deanery.