Red alert – stop the clock: impact of an automated referral system for severe aortic stenosis on time to comprehensive geriatric assessment and advanced care planning

Background

In severe aortic stenosis (AS), timely assessment for intervention is essential, while patients with advanced frailty, dementia, or limited life expectancy may benefit from conservative management and advance care planning (ACP). Although guideline-directed frailty assessment is recommended, implementation is inconsistent. At our centre, a consultant geriatrician supports the valve multidisciplinary team by assessing frailty and guiding treatment decisions.

Purpose

To develop and pilot an automated referral pathway for severe AS (“Red Alert Pathway”) and evaluate its impact on time to comprehensive geriatric assessment (CGA) and ACP compared with a traditional referral pathway.

Methods

We identified patients with severe AS who underwent CGA and ACP via the traditional pathway and analysed pathway timelines. The Red Alert Pathway was implemented using existing IT systems, automatically flagging patients aged ≥70 years with a peak aortic valve velocity ≥4.0 m/s at the time of diagnostic echocardiography, for consultant review.

Suitable patients underwent telephone screening assessing symptoms, frailty, cognition, suitability for intervention, Katz score, and Clinical Frailty Scale. Patients were then triaged to surveillance, further investigation, or CGA. Reasons for not undergoing screening included inpatient echocardiography, inability to contact the patient, or patients already known to the valve pathway. Time intervals from diagnostic echocardiography to referral, screening, and CGA were analysed.

Results

From January 2025 to January 2026, 24 patients (M:14, F:10; median age 84.5) underwent CGA and ACP via the traditional pathway. Median time from diagnostic echocardiography to CGA was 375 days.

Between October 2025 and February 2026, the automated pathway identified 116 patients (M:65, F:51, median age 81). Of these, 54 underwent telephone screening: 41 proceeded to further investigations and 7 to surveillance. 6 patients (M3, F3, median age 84.5) were referred for CGA, with 5 having to ACP and DNAR discussions and 1 undergoing transcatheter aortic valve implantation (Figure1).

Under the automated pathway, all 116 patients were referred within 1 day of diagnostic echocardiography, with consultant review within 1 day of referral. Telephone screening occurred a median of 2 days later, with a median of 6 days from echocardiography to screening. CGA occurred a median of 8.5 days after screening, giving a median of 22 days from diagnostic echocardiography to CGA (Figure 2).

Conclusion

An automated referral pathway enabled rapid identification and review of frail patients with severe AS, reducing time to CGA and ACP from a median of 375 days to 22 days. This pilot service redesign supports more timely, personalised, and guideline-aligned care for these patients, utilising specialist geriatric expertise efficiently. It may represent a scalable model for frailty-focused valve care.