Improvements in the peri-operative care of high risk non-cardiac surgical patients

19 October 2011

Regarding the recent review article on managing peri-operative risk in patients undergoing non-cardiac surgery, we present audit from our institution and the development of peri-operative pathways that are consistent with its recommendations.

Broomfield Hospital, Chelmsford is a busy district general hospital undertaking a significant number of elective and emergency high risk surgical procedures each year, particularly colorectal, upper GI, urological and vascular. We conducted two audits of our high risk elective surgical population, from April to December 2009 and for the year 2010. Our primary outcome measures were pre-assessment attendance, post- operative placement, complication rates, mortality and length of stay (LOS). In 2009 we identified 98 elective patients, of these 42% had been pre-assessed in preparation for a variety of surgical procedures. They had a mean age of 67 years (SD11years). The modal ASA was II with only 43% ASA III/IV patients admitted to a critical care unit post-operatively. The post-operative complication rate was 39%, ranging from confusion to re- laparotomy . Mortality rate was 1%. Median hospital LOS was 10 days. This data is consistent with that from previous studies.[1]

Cardiopulmonary Exercise Testing (CPET) was introduced to the anaesthetic pre-assessment clinic as part of the routine pre-operative assessment of this high risk group towards the end of 2009. Following assessment by a consultant anaesthetist and CPET, patients were stratified to the appropriate post-operative care area as a result of their anaerobic threshold and other physiological parameters measured by CPET. [2,3] Not all patients could be assessed in this manner due to limitations in the availability of clinicians. The 2010 audit identified 121 elective patients, 100% of which had been pre-assessed by a consultant anaesthetist, for a variety of surgical procedures. They had a mean age 68 years (SD 11years). The modal ASA was III with 72% ASA III/IV patients electively admitted to a critical care unit post operatively. The post- operative complication rate was 20%, and mortality was 2% (all patients had extended hospital or ITU stays). In this audit the median critical care unit LOS was 4.5 days with an overall median hospital LOS of 10 days.

By promoting consultant led pre-assessment and CPET, we have managed to reduce complication rates from 39% (2009) to 20% (2010). This has been achieved through focused peri-operative care of the high-risk patient and greater elective post-operative critical care unit admission of such patients (from 42% in 2009 to 72% in 2010). We also appear to be operating on patients with a greater burden of co-morbidities, since the modal ASA has increased from II (2009) to III (2010). Median hospital LOS remained unchanged despite an apparent increase in co-morbid disease.

As suggested by the review we are continuing to audit our patient data as part of an ongoing quality improvement process. We are now performing 30-40 CPET tests per month due to increased referral rates from surgical colleagues, increased clinical capacity and the local evidence suggesting improved outcome. Multi-disciplinary discussion between GPs, cardiologists, chest and ICU physicians now facilitates pre-operative optimisation and peri-operative planning.[4] Data from the first two months of this year of 60 patients show that 100% of patients are being admitted to the appropriate post-operative destination as per our pathway, the post-operative complication rate has fallen to less than 15%, and thus far there have been no re-admissions to the critical care unit or deaths.

Most complications and deaths that follow non-cardiac surgery occur in high-risk patients. We agree that it is imperative for hospitals to develop strategies to identify such patients and ensure their high-quality peri-operative care. Our experience supports the view that this approach improves patient outcomes and is associated with fewer complications.

References

1. Pearse RM, Harrison DA, James P, Watson D, Hinds C, Rhodes A, et al. Identification and characterisation of the high-risk surgical population in the United Kingdom. Crit Care 2006;10:R81.

2. Older P, Hall A, Hader R. Cardiopulmonary exercise testing as a screening test for perioperative management of major surgery in the elderly. Chest 1999;116;355-62.

3. Carlisle J, Swart M. Mid-term survival after abdominal aortic aneurysm surgery predicted by cardiopulmonary exercise testing. Br J Surg 2007;94:966-69.

4. Improving Surgical Outcomes Group. Modernising care for patients under-going major surgery. Improving outcomes and increasing clinical efficiency. June 2005.http://www.ebpom.org/publications

Competing interests: None declared

Dr Ben Maddison, Consultant Anaesthetist

Dr Alistair Hughes, Dr Sameer Hanna-Jumma, Dr Kevin Kiff

Broomfield Hospital, Chelmsford

Click to like: