Chapter 14 Vascular 2026

Published: 27/04/2026

14.2 Frailty in vascular surgical patients

Dr Ankita Sahni, Dr Judith Partridge, Dr Jugdeep Dhesi

Why do this quality improvement project?

Frailty is prevalent in patients with arterial disease and plays a key role in informing shared decision making in those with aortic aneurysms and critical limb-threatening ischaemia.  Frailty refers to a multisystem decline in physiological reserve that results in an increased vulnerability to stressor events.  It is a significant risk factor for perioperative complications including delirium, falls, hospital-acquired deconditioning and can delay hospital discharge. 

To intervene and modify frailty, accurate identification must first occur.  In patients where frailty and its associated issues are non-modifiable, understanding the impact on their risk profile improves shared decision making to avoid decisional regret. 

Background

The majority of patients undergoing vascular surgical procedures are aged over 65 years old1.  In the recent SNAP 3 study, frailty was present in one in five surgical patients over the age of 602.  Frailty affects clinical outcomes 2,3 and is associated with higher decisional regret in those undergoing non-cardiac surgery4. 

The National Vascular Registry has collected data on frailty since 2019.  However, the incidence of frailty has not been reported due to limitations in data completeness and the use of an unvalidated frailty scale1.

Preoperative comprehensive geriatric assessment (CGA) and optimisation improves postoperative clinical outcomes and can inform decision making5.  Current Centre for Perioperative Care (CPOC) guidelines recommend all patients with frailty undergo CGA and optimisation6.

Best practice 

  • British Geriatrics Society/CPOC Guideline for Perioperative Care for People Living with Frailty Undergoing Elective and Emergency Surgery6
  • Vascular Society: A Best Practice Clinical Care Pathway for Peripheral Arterial Disease7
  • Guidelines for the Provision of Anaesthesia Services for Vascular Procedures 20258

Suggested data to collect

Pre-admission/on admission

Standards Suggested data to collect

Assessment of frailty

  • All patients over age 65 admitted under vascular surgery should have clinical frailty scale (CFS) documented
  • All patients under age 65 at risk of frailty admitted under vascular surgery should have a frailty status documented (e.g. Edmonton Frailty Score)

Proportion of patients in whom frailty has been documented (CFS >5*, EFS >8)

 

*May be changed to CFS ≥4 pending new CPOC guidance.

Optimisation of frailty and screening for associated geriatric syndromes

  • All patients living with frailty (CFS>5) should undergo CGA and optimisation prior to surgery

     

Proportion of patients with frailty who undergo CGA

Number and type of optimisation implemented (e.g. referrals to therapies, medication changes, investigations ordered)

Screening for cognitive impairment:

  • All patients living with frailty should have assessment of cognition documented using a validated tool (4AT/MoCA/miniCog)

If cognitive impairment identified:

  • All patients and their relatives should be counselled on risk of delirium
  • Mental capacity assessment should be undertaken

Proportion of patients in whom 4AT/MoCA/miniCog has been documented

 

Proportion of patients with cognitive impairment in whom:

  • Delirium risk has been discussed and documented
  • Capacity regarding surgery has been assessed and documented

 

Shared decision making

Standards Suggested data to collect

Shared decision making 

All patients with frailty, advanced multimorbidity and/or cognitive impairment should be counselled on:

  • Intended benefits of surgery
  • Medical, surgical and functional risks of surgery
  • Alternatives to surgery
  • Natural history if no surgery is performed

Proportion of patients in whom shared decision making documented

 

Compare frailty score, number of comorbidities and presence/absence of cognitive impairment in operative and non-operative patients

 

 

Advanced care planning (ACP)

  • All patients living with frailty should have treatment escalation plans (TEP) and ACP undertaken

Proportion of patients with documented TEP and ACP

 

 

During admission

Standards Suggested data to collect

Assessment and management of delirium

  • All patients at risk of delirium should have a 4AT documented daily
  • All patients with delirium should be assessed by a professional with training in delirium to manage precipitating factors and challenging behaviour

Proportion of patients in whom 4AT is documented daily

 

Proportion of patients with delirium who are managed according to delirium guidelines 

Proactive discharge planning

  • All patients with frailty should be supported by nursing staff to maintain independence including transferring to chair and performing personal care in chair/bathroom within 24h9
  • All patients with anticipated and actual deterioration in mobility and function from baseline should have a referral to appropriate therapies
  • All patients with frailty should be discussed in an MDT setting to identify barriers to discharge and anticipated discharge requirements

Length of stay in days

 

Place of discharge compared to admission

 

 

 

 

 

Quality improvement methodology

  • Identify stakeholders
  • Co-produce driver diagram
  • Map the patient journey
  • Identify opportunities for change, barriers and enablers
  • Use run charts to measure change using suggested metrics10

Examine patients undergoing surgery for peripheral arterial disease and aortic aneurysms as two separate groups/pathways. 

Example 1

Aim: All emergency admissions with critical limb-threatening ischaemia should have a documented frailty score.

Driver: (1) Education (2) Opportunistic assessments (3) Ease of documentation. 

Change ideas: (1) Teaching on frailty assessment and clinical implications (2) Engagement of stakeholders within multiple specialties (e.g. ED, Surgery and Medicine) (3) Electronic recording of CFS in triage or clerking proformas.

Example 2

Aim: All patients living with frailty with aortic aneurysms approaching intervention threshold should have a shared decision-making discussion documented.

Driver: (1) Information gathering of risks/benefits (2) Clear documentation of discussion (3) Advanced care planning if not for intervention.

Change ideas: (1) Assessment of medical risks through CGA and surgical risks through MDT (2) Documentation using ‘BRAN’ (‘benefits, risk, alternatives, doing nothing’) (3) Documented decisions for emergency management, ongoing surveillance.

References

  1. Waton S, Johal A, Li Q, et al. National Vascular Registry: 2024 State of the Nation Report. London: The Royal College of Surgeons of England; 2024.
  2. Swarbrick CJ, Williams K, Evans B, et al. Characteristics of older patients undergoing surgery in the UK: SNAP-3, a snapshot observational study. Br J Anaesth. 2025;134(2):328–340.
  3. Hewitt J, Carter B, McCarthy K, et al. Frailty predicts mortality in all emergency surgical admissions regardless of age: an observational study. Age Ageing. 2019;48(3):388–394.
  4. Agung Y, Hladkowicz E, Boland L, et al. Frailty and decisional regret after elective noncardiac surgery: a multicentre prospective cohort study. Br J Anaesth. 2024;133(5):965–972.
  5. Partridge JSL, Harari D, Martin FC, et al. Randomized clinical trial of comprehensive geriatric assessment and optimisation  in vascular surgery. Br J Surg. 2017;104(6):679–687
  6. Centre for Perioperative Care. Guideline for Perioperative Care for People Living with Frailty Undergoing Elective and Emergency Surgery. London: CPOC; 2021 (https://cpoc.org.uk/guidelines-and-resources/guidelines/perioperative-care-people-living-frailty)
  7. Boyle JR, Atkins ER, Birmpili P, et al. A best practice clinical care pathway for peripheral arterial disease. J Vasc Soc GB Irel. 2022;1(Suppl 3):S1–S13.
  8. Royal College of Anaesthetists. Guidelines for the Provision of Anaesthetic Services (GPAS) RCoA; https://www.rcoa.ac.uk/safety-standards-quality/guidance-resources/guidelines-provision-anaesthetic-services
  9. NHS England. Commissioning for Quality and Innovation (CQUIN): 2023/24 guidance. [CQUIN02: Supporting patients to drink, eat and mobilise after surgery]. 2023. https://www.england.nhs.uk/publication/cquin-2023-24-guidance/
  10. NHS Elect. Perioperative Medicine for Older People Having Surgery (POPS). London: NHS Elect; https://www.nhselect.nhs.uk/improvement-collaboratives/Clinical-networks/POPS