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How do we develop successful perioperative patient pathways for all patients?

Dr David Alcorn Consultant Anaesthetist at NHS Greater Glasgow and Clyde spoke at today’s Improving and Enhancing Perioperative Care conference on:

  • extending the principles of enhanced recovery to deliver a patient pathway before, during and after surgery
  • how do we move from enhanced recovery to perioperative medicine
  • how do we develop pathways to cater for all high risk patients regardless of surgical specialty or  whether the surgery is performed on an elective or emergency basis? 
  • our experience in Glasgow

 

David stated that 'Perioperative medicine is not going to work unless everyone is doing the same thing'. 'The main risks we see are cardiovascular disease, respiratory disease, renal disease, CNS disease and Diabetes' 'Obesity causes more concern for the perioperative care of a patient'. 'There is evidence to suggest if you improve your exercise activity before an operation, your recovery will be better'

David also discussed the use of post operative mobility scoring. - 9 different questions which help us find out if a patient is high or low risk of post operative complications.

David concluded the presentation by stating that 'Collecting data is key to improving perioperative care. Trying to get all hospitals to be consistent and agree on what data to collect is a problem we have'

 

Dr David Alcorn's full presentation is available to download at the end of this page

Abstract of David’s presentation 
Developing Patient Pathways
I have been involved in the care of high risk individuals for all my anaesthetic career in the West of Scotland. As a consultant in Intensive Care for 9 years and in providing anaesthesia for elective and emergency operations, my approach has undoubtedly changed, as has that of most of my colleagues.

In Paisley we have been looking at the care of the high risk patient, both from the enhanced recovery point of view and from the viewpoint of emergency work. While ERAS has taught us to treat all patients in the same way, it would seem that Perioperative Medicine is looking specifically at the care of the high risk patient only. 

In Paisley, we have an extremely high rate of cardiovascular disease, respiratory issues, obesity, renal and vascular disease, as well as one of the highest rates of cirrhosis in Western Europe. Obesity and diabetes are both high in prevalence and  although the rates of diabetes in the community seem not too high, they are rates in the community and not for presentation to hospital. In short, therefore, we have years of experience of the sick patient and we have adapted and simplified our approach to deal with the unique issues. 

In Enhanced Recovery, it has become commonplace to treat all patients with the same approach. Doing as little as possible to disrupt their physiology is now the approach of the surgeon and the anaesthetist and this has proved beneficial for the patient. Each day is seen as a means for the patient to attain set goals, be that getting out of bed and going for a walk or getting all drips and catheters out. In the high risk emergency patient, while we can predict their likelihood of survival, we have no framework to give each day meaning and purpose. By perpetuating the methods of our own teachers, are we doing harm to the patient, where what is at stake is not just the LOS or the surgeon’s reputation but the patient’s life?

The NELA project may be as good as compulsory in England and Wales, but in Scotland only 5 hospitals have enrolled patients. Seeing this worthy project has been a remarkable process and has taught us much about our own practice as anything which may have come before. From the Sepsis 6 and timing of 1st antibiotics to the time it takes to get the result of a CT and the seniority of staffing  in theatre, we can map the progress of the patient from entry to discharge and make Quality Improvements along the way.

For elective patients, the prospect of surgery may be daunting enough, but with multiple co-morbidities to contend with, optimizing a patient for surgery can be a struggle. While the cardiovascular and renal risks can be altered to a degree (perhaps by starting a Beta-blocker?), given enough time we could change the patient’s BMI, lipid profile, fitness and nicotine dependency, the constraints of an 18 week treatment period can make this difficult. What we have changed is the way in which patients are instructed on taking their drugs (especially for SDAs) and especially for their diabetic medication. While older practice has suggested stopping diabetic medication and using insulin infusions, we have used a different approach (along with the diabetologists) to give a drug-specific pathway and thus vastly reduce cancellations, complications and prolonged stays. Better perioperative diabetic control reduces the chance of wound infections, CVS problems and patient harm from hypo-glycaemia.

The ERAS pathway in theatre is easy to follow and we have (unconsciously) used the same approach for emergencies and high risk patients i.e. short-acting anaesthetics, aggressive anti-sickness medication, no pre-meds, along with markedly reduced CVP and arterial lines, unless for specific indications. All our emergencies now get Sugammadex to reverse the NDMR as do our high-risk patients. The patients who can be extubated at the end of the case do not then need to go to ITU, saving at least £500 per patient day in HDU instead of ITU.

The important things to try to get right in theatre would seem to be ventilation, fluids and monitoring. There are an increasing number of trials using the ITU approach of increasing PEEP, low volumes and recruitment manoeuvres to aid oxygenation. There is also a trend towards the use of lower FiO2 in order to try to prevent atelectasis. Our own audits of fluid management suggest that hyperchloraemic acidosis is much less prevalent in our elective and emergencies and that NELA has given us an opportunity to carry on into HDU the same fluids approach, currently being monitored as a QI project. While our use of LiDCO and CardioQ shows some sign for improvement, Current research projects testing the response to Passive Leg Raising with the help of the cardiologists seek to show us who is a fluid responder before going to theatre, rather than giving inadequate fluid (“keep them dry”) or giving fluids to a non-responder, thus causing oedema. In the same trial, we will prescribe an exercise programme and test their ACE genotype to try to show a correlation with fluid and exercise response with outcome.

In the short term we are looking at producing an emergency care pathway, similar to many already in existence, though tailored to our own population. We are changing to the use of the POMS post-operative morbidity surveys as advocated in this September’s Anaesthesia, but using them for all our elective and emergency patients, at least for a trial period. The use of the same perioperative pathway for all our patients would make this transition much easier.

Finally, it has been shown again and again that the ERAS nurse aids education of patients, reduces readmission rates, greatly helps data collection and makes the running of such a service seamless. Is it not time to create the role of a nurse with the role of the perioperative period for all patients? This is something we are looking at as an extension of the ERAS role, but the Emergency Laparotomy Nurse would be helping with the care of the non-elective patient, which is perhaps the area in most need.

David Alcorn
September 2015

A Trial of Intraoperative Low-Tidal-Volume Ventilation in Abdominal Surgery N Engl J Med 2013; 369:428-437

Ventilation with low tidal volumes during upper abdominal surgery does not improve postoperative lung functionBr. J. Anaesth. (2012) 109 (2): 263-271

High versus low positive end-expiratory pressure during general anaesthesia for open abdominal surgery (PROVHILO trial): a multicentre randomised controlled trial. Lancet. 2014 Aug 9;384(9942):495-503

Protective mechanical ventilation during general anesthesia for open abdominal surgery improves postoperative pulmonary function. Anesthesiology. 2013 Jun;118(6):1307-21

Perioperative fluid therapy: a statement from the international Fluid Optimization Group http://www.perioperativemedicinejournal.com/content/4/1/3

Chest 2002; 121:2000-2008
Crit Care Med 2004; 32:691-699
Crit Care Med; 32:644-648
Crit Care Med 2006; 34:1402-1407

https://www.scottishmedicines.org.uk/files/advice/sugammadex_Bridion_FINAL_FEBRUARY_2013_for_website.pdf

Postoperative morbidity survey, mortality and length of stay following emergency

Dr Davod Alcorn 
I have been a consultant anaesthetist for 12 years and have seen considerable change in our hospital and trust. I was an ITU consultant for 9 years and while that role was eventually not for me, the experience I gained was hugely beneficial for changing the way we look at the sick or high risk patient. We were the only hospital in Scotland to be included in the Improving Surgical Outcomes Group and were leaders when Greater Glasgow took up ERAS, having been involved in setting up Paisley’s ERAS service in 2005. We were the last hospital in the trust to get an ERAS nurse. I have been involved in the setting up of the Scottish database for ERAS and remain an adviser to the Scottish Government on this. 

Outside of the hospital, I have been married for 23 years and have 2 boys. I am a keen cyclist and bike mechanic and also a keen golfer. I am also a huge music fan, reliving my teens via my turntable and my guitars.

Future events of interest:

Always Events®: A positive approach to Improving Patient Care
Thursday 22 October 
Hallam Conference Centre, London

British Association of Day Surgery Conference: Innovation & Quality in Day Surgery
Thursday 26 November 2015 
ICO Conference Centre, London

National PROMs Summit 2015
Tuesday 1 December 2015 
Colmore Gate, Birmingham

Measuring, Understanding and Acting on Patient Experience Insight
Friday 29 January 
Hallam Conference Centre, London


Download: Dr David Alcorn full presentation

12 October 2015

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