Case Studies: Specific Patient Groups

Specific patient groups

The type of perioperative care patients experience, and the pathway they are put on, can vary depending on their particular medical conditions.

Ante-natal Care

Barnet Hospital, Royal Free Trust- Transformation of high risk ante-natal anaesthetic clinics from face to face to virtual clinics in a busy DGH

What was the problem/issue?

High risk obstetric patients requiring anaesthetic pre assessment during pandemic, with the need to offer an alternative from face to face appointments.


How did you know there was a problem?

  • Speed of pandemic and need to limit patients coming into hospital unnecessarily to reduce patient risk
  • Some patients who would benefit from pre assessment were not recieiving it until in active labour

The number of patients affected?
8-10% on background of 5.5-6,000 deliveries.
With approx. 70% women receiving anaesthetic care during their delivery. So a small proportion of women are referred.

What solutions were identified?

  1. Utilising digital technology (telephone calls and video calls) during pandemic to ensure good, effective and seamless anaesthetic peri-operative assessment of obstetric patients
  2. Collaborative working amongst health care professionals and patients using different technology applications. Ensuring feedback was gained throughout in order to make positive tweaks and changes to the virtual clinics for a successful outcome
  3. We have implemented an e-learning which covers how staff should use the platform to connect with patients. As this is new territory for a lot of staff there isn’t training in place for staff on how to get the best out of a video appointment in respect to consultation technique. We have worked closely with the undergrpointments.
  4. Every medical school in the country is now teaching about remote consulting.  It’s also important to bear in mind that we are still in an 'emergency operating mode' of teaching, having had two national lockdowns and both national and local restrictions that have caused huge and rapid changes in the way that medical school teaching is delivered - to enable students to continue to learn under these circumstances - at the same time as considerable upheaval in health service delivery.  
  5. Telemedicine is not new, particularly for some countries, and medical schools across the UK have been collaborating to share ideas and learn from each other over the past eight to nine months.  
  6. New subjects and domains of professional behaviour are added to the curriculum all the time and incorporated into assessments - this isn’t an unusual situation in that regard; evaluation and reflection are part of the course,aduate programme leads to ensure there is a clear process in place for students to join in on video ap

Why were these solutions chosen?

  • Digital technology widely utilised amongst anaesthetists and obstetric patient cohort (patient cohort tends to be young, have smart phones and are technology savvy)
  • National recommendations to perform virtual clinics and avoid unecessary patient footfall within hospitals
  • Several digital platforms to use that were NHS ‘safe.’
  • Prior to pandemic, NHS plan to use technology to develop stronger relationships between care givers and service users, and to develop better-integrated, team-based services and to deliver holistic, whole-person rather than narrowly bio-medical care
  • Individual services are responsible for the quality of their consultations/training in the same way they would be for a face to face clinic. There shouldn’t be a distinction between the 2 because they are just as important. In the event that a video or telephone consultation is insufficient staff always have the open to use face to face clinics to complete the consultation.

What were the barriers?

  • Change behaviour always takes time to create a uniform and seamless process
  • Digitial technology and data warehousing in the NHS (success of digital innovation often depends on what might appear to be small details such as how long it takes for health care staff or patients to log on or how hard it is to rectify a small inputting error.)
  • Non face-to-face clinics can help reduce unnecessary visits to hospitals, but are still a relatively new model of care. Guidance in the current climate is changing at a rapid pace
  • Small percentage of patient cohort will find using the technology difficult
  • Work space: finding appropriate rooms to undertake videocalls that met appropriate social distancing requirements
  • Key challenges are around equipment and internet connection largely on the Trust side as well as having a place for patients to contact much like you would have in a physical clinic.  IT are working extremely hard to upgrade the infrastructure to deal with the rapid shift to remote working.  We have implemented a virtual receptionist which greets patients and checks them in . They are also a point of contact should the patient have issues joining.

What were the enablers?

  • Enthusiastic and committed staff
  • Digital savvy users (Clinicians and patients)
  • Able to use translator service during virtual clinic
  • Less admin required compared to face to face clinics
  • Overall NHS trend to move from face to face clinics to virtual clinics
  • Less resources required- fewer rooms required, digital applications can be downloaded on personal mobile phones, clinic can be carried out whilst working from home
  • National mandate on virtual clinics to be offered

Which disciplines were involved?     
 Anaesthetics, admin anaesthetic staff, midwives, obstetricians, managers, patients

What evidence (qualitative or quantitative) is there to demonstrate impact (either positive or negative) on:

  • morbidity/mortality
  • patient record outcomes
  • patient experience
  • process measures (e.g. reduction in referral times, hospital bed days, readmissions, cancellations etc.

Positives
Positive staff feedback and informal patient feedback
Reduced wait times by patients
Flexibility within system to allow last minute additional appointments to be booked
Less inconvenience for patients when attending virtual appointment (no need for travel, childcare, time of work)
Records are electronic- minimises risk of some records being on paper and some being recorded electronically.

Negatives
Patient DNAs still remain
Unable to physically examine patient

Dr Yohinee Rajendran (ST7 Anaesthetic registrar North Central London Deanery)
Dr Sonia Brocklesby (Consultant Anaesthetist, Deputy Regional Advisor)
Dr Sanjana Singh (Consultant Anaesthetist, Lead for Obstetric Anaesthesia)

 

Patients with diabetes

The Perioperative team at the West Suffolk recognised that multidisciplinary team working with reorganisation of services would lead to better outcome (length of stay and less morbidity) of the elective surgical patient with diabetes.

To promote the reorganisation of services we appointed a dedicated diabetes surgical nurse. Amongst other tasks, she has communicated with the local GPs and most diabetic surgical patients are now referred to the surgeon with the most recent HbA1c, as well as concurrent medication.

All the patients are seen in pre-operative assessment (POA), and  the pathway is designed to facilitate every patient with diabetes to be managed in the day surgery unit (DSU) when possible, as we recognise that DSU is the best place to perform elective surgery on patients with diabetes. This is because the risk of iatrogenic complications is minimised. In addition, when the patients are reviewed in PAU, they are all counselled to ensure that they know how to manage their diabetes medication to promote day of surgery admission (both for DSU and main theatres). In view of the recognised risk of hypoglycaemia , all patients in PAU are pre-prescribed rescue treatment for any inpatient  hypoglycaemia.

In the rare occasions that we do need to use a variable rate intravenous insulin (VRIII) , the default fluid is 5% dextrose in 0.45% saline with premixed potassium.

All diabetic related medication incidents are reviewed, and lessons are constantly being learnt.

With this transformation of services, the majority of patients with diabetes are now being managed in DSU and the length of stay of our elective diabetic orthopaedic patients (mainly hip and knee replacements) is comparable to non-diabetics.

Referrals to a diabetic team at the Royal Bournemouth Hospital are made from a generic screening unit or nurse practitioners from specialist teams. If decisions are required regarding management of surgical pathway, patients are referred to an anaesthetic pre-assessment clinic. From 2010 until 2012, average length of stay of diabetic patients has reduced from 1.8 days higher than non-diabetic patients, to a similar level.

Type 2 diabetes mellitus is a growing health problem associated with significant adverse impact upon outcomes in the perioperative period.  The latest NHS Digital Health Survey reveals that the prevalence of type 2 diabetes has more than doubled since 1994 to approximately 8% of the adult population and expectations are for this trend to continue.  Of similar concern is the issue of the increasing number patients living with undiagnosed diabetes and prediabetes who present for scheduled surgery.

There is emerging evidence to support concerns surrounding the increased risk of major perioperative complications associated with stress hyperglycaemia in the perioperative period.  Furthermore, patients with untreated chronic hyperglycaemia who subsequently develop hyperglycaemia in the perioperative period are more prone to suffer from cardiac complications than those with treated diabetes.    Detection and careful clinical management of patients at risk of stress hyperglycaemia in advance of surgery holds significant theoretical potential to prevent avoidable perioperative complications.

The NCEPOD Highs and Low report (Dec 2018) has highlighted that satisfactory monitoring of established diabetic patients’ blood glucose levels in the perioperative period is an ongoing challenge. The historical lack of evidence of adverse outcomes associated with perioperative hyperglycaemia combined with evidence of harm from intravenous insulin infusions designed to maintain tight blood glucose control in the hospital setting has led to a less interventional approach to perioperative diabetic control.

We wished to determine the proportion of adult patients attending our preoperative clinic who presented a potential increased risk of perioperative stress hyperglycaemia (i.e. patients with known diabetes, undiagnosed diabetes and undiagnosed pre-diabetes respectively). During 2018, 12.5% of our preoperative clinic population presented with known diabetes, which is in keeping with 2018 PQIP report finding of 13%. To identify those with undiagnosed hyperglycaemia, we employed the validated University of Leicester Diabetes Risk Score screening tool in accordance with NICE guidance PH38 (to identify patients deemed at “high risk” of having or developing type 2 diabetes).

A total of 8151 patients were screened between March and December 2018 in our pre-operative clinic. 1198 (12.4 %) were found to be at “high risk” category for diabetes.  1049 of these patients accepted an offer of HBA1c testing.  7% of patients tested had an HbA1c in the diabetic range and 24% of patients had an HbA1c in the pre-diabetic range according to UK reference range. Patients diagnosed with new diabetes (at a rate of approximately 2 per week) are now postponed and stabilised prior to elective surgery. Blood glucose monitoring during the perioperative period is now recommended for all identified pre-diabetic and diabetic patients to identify the development of perioperative stress hyperglycaemia.

In summary, HbA1c testing of the highest risk category of screened patients suggests that approximately 20% of our adult population present to our preoperative clinic with either undiagnosed pre-diabetes or diabetes. Identification of such patients in the preoperative period is warranted to help prevent avoidable perioperative complications and provides an ideal opportunity to improve patients’ long term health prospects in addition to improving short term surgical outcomes.

After introducing the UK’s first specialist pre-assessment clinic for patients with diabetes on a surgical pathway, the average length of stay for inpatients with diabetes at the Royal Bournemouth hospital has reduced to a level consistent with non-diabetic patients.

Since a ‘Root Cause Analysis Prescription Error Pathway’ was implemented, there has been a significant reduction in prescription errors and the Royal Bournemouth Hospital is now the best performing trust within Wessex with regards to insulin management and reduction in medication errors.

The Perioperative Quality Improvement Programme (PQIP) recommend that all patients with diabetes should benefit from a care plan – developed in collaboration between healthcare professionals and the patient – that is activated on admission to hospital. Diabetes UK recommend that hospitals should have a multidisciplinary perioperative diabetes team in place.

Patients with Cancer

The positive role for exercise in oncology is now well recognised and increasingly evidenced in the literature.  Inspired by this, Dr. Thomas Collyer, a consultant in anaesthesia, intensive care and perioperative medicine at Harrogate and District NHS Foundation Trust, began a journey to incorporate physical activity into cancer care in Harrogate.  Over 18 months Dr. Collyer and a small perioperative team developed a business case for a fully integrated exercise and wellbeing service. In December 2018 they successfully secured an award for approximately £720,000 from Yorkshire Cancer Research, to run a two year pilot service. The Active Against Cancer service, run by Harrogate and District NHS Foundation Trust and funded by Yorkshire Cancer Research, launched 6 months later on 15th July 2019.

Active Against Cancer has grown to consist of a service manager, lead physiotherapist, lead physical trainer and cancer care coordinator.  There is also a team of 10 level 4 trained, cancer specialist physical trainers delivering exercise classes, including Pilates and Yoga.  The team are highly skilled and experienced in providing safe and effective fitness programmes, specifically for patients with cancer.

Active Against Cancer is open to patients at all stages of the cancer journey, irrespective of cancer site, prognosis or fitness level. This includes patients who have been recently diagnosed and are awaiting treatment (prehabilitation), those who are currently receiving treatment (maintenance) and those who have completed their treatment (rehabilitation). There is a well-established referral pathway with the majority made by the cancer nurse specialists; within the first 7 months of opening Active Against Cancer has had over 550 referrals. Patients are informed that exercise forms an important part of their cancer care; in essence, activity and wellbeing is being prescribed to the patients.

Initially patients are invited for a 1-1 assessment which aims to assess the patient’s current activity levels, highlighting any limitations and setting goals to address these. The assessment information is then used to inform an individualised exercise programme. The exercise programmes are delivered at Harrogate Sports and Fitness Centre, away from the hospital setting, by the dedicated team. Classes are specific to an individual’s fitness level and stage of treatment.  They can vary from high intensity interval training to chair based low intensity classes. Nordic walking, dancing, yoga and pilates are also on offer.

In addition to the physical benefits of exercise, Active Against Cancer also aims to improve the mental and emotional wellbeing of patients. Classes are designed to be fun and group based, providing a platform for peer-to-peer support. Twice weekly walk and talk sessions, coffee mornings and regular patient led social events are also open to the friends, family and careers of patients. Dr Emma Radcliffe, Active Against Cancer Service Manager has said ‘We are already seeing patients grow in confidence, create new friendships and develop support networks. Ultimately we hope to promote long term behavioral change, so that our patients, their friends and their families all enjoy the benefits of exercise and being physically active for years to come.’

The successful integration of Active Against Cancer into the cancer care pathways, and the overwhelming popularity of the service, has meant that the service has had to expand rapidly. Active Against Cancer has employed and trained an increasing number of physical trainers and increased studio hours in order to deliver an expanded timetable of classes. Another challenge has been ensuring the site is accessible to all patients. The service is currently working with local voluntary driver schemes and exploring the possibility of implementing satellite classes at different venues across the Harrogate District to improve accessibility.

Although in its infancy, Active Against Cancer has been a huge success with patients. The service has been rated  4.9 / 5 for overall patient experience, with 96% ‘strongly agreeing’ that they feel safe and well supported whilst exercising. Debbie, a regular service user has said ‘This is more than an exercise group; it’s a whole community that helps patients to recover both physically and psychologically from the diagnosis, through treatment and beyond.

In summary Active Against Cancer is a novel exercise referral service for patients living with and beyond cancer in Harrogate.  It is hoped that the service will not only improve the health and wellbeing of patients but also pave the way for others to develop similar services. 

Dr Tom Knapp, Anaesthetic and Perioperative Fellow at Harrogate and District NHS Foundation Trust

Website: www.activeagainstcancer.org.uk 

Email: Info.activeagainstcancer@nhs.net Twitter: @AAC_Harrogate

Patients with anaemia

Project OPERA: Optimising PERioperative Anaemia in colorectal surgery patients in Belfast City Hospital

As part of a wider strategy to introduce formal Enhanced Recovery After Surgery (ERAS) pathway a large retrospective audit performed in 2018 identified that 45% of our elective colorectal patients were anaemic at the time of surgery. We know that this can have many consequences including increased post-operative complications and length of stay and the need for blood transfusion (which is also associated with poorer outcomes).

Our aim is to reduce the percentage of patients undergoing elective bowel resection for colorectal cancer with pre-operative haemoglobins less than 130g/dL from 45% to 25% by June 2019.

As these patients were on a red flag pathway time to surgery was short which meant we had to identify and treat iron deficiency anaemia (IDA) earlier in the patient’s treatment pathway.

We undertook a range of changes using a PDSA methodology including:

  • Surgical, anaesthetic and nursing teams were educated regarding audit results.
  • We agreed that bloods including full blood count and haematinics should be sent from endoscopy at time of identification of tumour (advancing diagnosis by at least 1 month).
  • Surgeons agreed to add these blood tests to a new “endoscopy staging pack”.
  • We liaised with colleagues in cancer services to promote our new staging pack and designed poster.
  • Agreed with programme treatment unit new process to prioritise red flag referrals for IV iron.
  • Our cancer tracker now emails ERAS nurse with new suspected CRC cases to enable all patients are followed up.
  • ERAS nurse checks blood results on receipt of emails so prompt referral can be made.
  • We have developed an updated evidence based algorithm for treating IDA.

At UHS we have an established perioperative medicine service which includes, CPET, surgery school and high risk shared decision making clinics. Whilst piloting a perioperative anaemia service for colorectal, urology, HPB, Upper GI and Maxfax patients at UHS, we identified that referrals from the surgical teams were often too late to allow optimum treatment time for IV iron. To avoid the dilemma of whether or not to delay surgery to treat anaemia, we looked at ways of identifying anaemic patients within our own service to avoid having to rely on surgical teams making direct referrals.

We started to check haemoglobin [Hb] levels of patients attending for a CPET. It was identified that many patients had not had a recent [Hb] check. We therefore used a Hemocue device to undertake ‘point of care’ [Hb] tests on all patients who did not have a recent [Hb] result available (within 7 days of CPET). If the Hemocue identified a [Hb] of <130 g/L in males and 120 g/L in females the CPET team requested a full panel of haematinics to assess the degree and underlying cause of anaemia. Request of the haematinics as a “bundle” of tests was also set up to automatically notify the anaemia team that the bloods had been sent. In this way the results could be looked at immediately and a plan for treatment activated without any further referrals needed.

What was the impact?

The impact of the introduction of the Hemocue in the CPET Lab and the automated referral system using the haematinics “bundle” enabled anaemic patients to be identified earlier in their surgical pathway. Early identification resulted in anaemic patients receiving iron 2-3 weeks prior to surgery, therefore maximising the effectiveness of the iron treatment. Prior to this intervention there were up to 10 missed opportunities for optimisation of anaemia per month. This has now reduced by 50%.

Barriers / Enablers/ Sustainability

The only barriers to the effectiveness of this service was when patients were referred late in their pathway to the CPET service. However with regular feedback and data sharing of outcomes with the surgical teams this is rarely a problem.

There is an ongoing cost associated with the loan of the Hemocue device and consumables. However this is offset by the cost of a serum [Hb] test which would have otherwise been done.  

This intervention has proved to be effective in identifying anaemia earlier in the surgical pathway and is likely to be sustainable as it has minimal impact on the workload of the exercise physiologists conducting CPET.

A preoperative anaemia-screening programme for patients undergoing elective surgery has been established and integrated into patient preoperative assessment. The primary aim of the service is to reduce perioperative blood transfusions, and the associated costs and complications of allogeneic blood transfusions.

Initially targeting patients undergoing high blood use specialities such as orthopaedic surgery, the resulting reduction in transfusion rates, shorter hospital stays and reduced perioperative complications seen in these specialties, has  paved the way to open referrals from all  other speciality areas.

The service has evolved and expanded over 10 years and now takes referrals for patients undergoing all types of surgery, predominantly pre-operatively but also perioperatively. With the timely use of IV Iron many surgical patients who would have started their surgical journey anaemic, respond to treatment, and are undergoing surgery with normal blood counts. These patients are less likely to require blood transfusions and therefore the risks associated with this limited resource. 

With increased use of other transfusion alternatives, such as perioperative  cell salvage and education surrounding restrictive transfusion  triggers, we are able to support our surgical teams  to achieve lower transfusion rates and improved surgical outcomes. 

Patients at risk of blood transfusion perioperatively are identified in the nurse-led preoperative assessment clinic, referral to a specialist anaemia nurse is made to assess suitable optimisation options, including timely intravenous iron replacement and advice to follow blood conservation techniques intra-operatively eg. Point of care testing and cell salvage.

Anaemia is common in cardiac surgical patients. The National ACTA audit from 12 Cardiac Centres in the UK and 19,0333 patients showed that 31% (range 23-45%) had anaemia. Controlling for Euroscore these patients had an independent association with Transfusion, increased mortality and increased length of hospital stay.1 With this in mind, and as a participating centre we developed an Anaemia Preassessment and Treatment pathway. Given that the commonest cause of anaemia in the Surgical Population is Iron Deficiency Anaemia (IDA)2, the algorithm only involves one test of Iron status. This is unlike other algorithms that involve Transferrin Saturation and Total Iron binding Capacity. From previous work looking at the cost effectiveness of all of these tests and whether these tests added any further information we have found that Ferritin is adequate in picking up patients who would benefit from Intravenous Iron Pre Surgery, particularly patients that are likely to have major blood loss or haemodilution.

The Anaemia algorithm is illustrated in slide 1. The preassessment nurses in Cardiac Surgery follow this and patients are asked to come in for Intravenous Iron, which is delivered as in the Cardiac Day Case Unit. Patients are made aware of the rationale behind IV Iron by a short presentation which is displayed outside the consulting rooms where they are seen by the surgeons as well as the Day Case and Inpatient wards. (see Powerpoint )We have developed a simple to use prescription for Total Dose Intravenous Iron Therapy. This particular iron is given over a short time period, requires minimal nursing intervention and only one visit for the patient to hospital. The Prescription is illustrated in slide 2. So far we have seen an increase in Haemoglobin over a 4-6 week period of between 100-200 g/L. Our local data is showing that these patients are requiring less and even no Packed Red Cell Transfusion during their hospital stay.

Iron deficiency anaemia is common in patients undergoing colorectal surgery and this can be easily missed considering the nature of the pathology. Hence in close co-ordination with our Transfusion Team, Consultant Haematologists, Consultant Colorectal Surgeons and the Pre-operative team involving our nurses and Consultant Anaesthetists we have created a care pathway  that will benefit our patient cohort.

Anaesthetists and haematologists at the Royal Bournemouth Hospital have developed an algorithm to manage preoperative anaemia, to reduce perioperative blood transfusion. Anaemia is identified at the Anaesthetic Preoperative Assessment Clinic and the patients are then treated according to a flow chart.

Older people undergoing Surgery

Pro-active Care for Older people undergoing Surgery (POPS)

Established in 2004,the POPs multidisciplinary team is led by a consultant geriatrician and engages with the patient throughout the surgical pathway, from preoperative assessment through the surgical admission to discharge to the community.

The POPS service has reduced postoperative complications and length of stay as evidenced in a published pre- and post study conducted in elective orthopaedic patients and is now being replicated across other units in the UK (e.g., Nottingham, Reading, Addenbrookes, Sheffield)

Find out more about POPs here. 

Physicians in Perioperative Medicine- the Bristol Experience

It is well recognised at a national level that frail, older and multimorbid patients suffer adverse outcomes after surgery. Models of care have been piloted in the UK in which perioperative geriatricians have been aligned with surgical services to focus on medical issues in the perioperative pathway. Such service developments have been proven to positively influence patient outcomes, reduce complications and length of stay. 

In Bristol, we were well aware of these issues in patients undergoing vascular surgery. Perioperative mortality in abdominal aortic aneurysm repair was high in our centre and post-operative complications for complex vascular surgery problematic. There was an appetite amongst the surgical consultant body to pilot a new model of care. We aimed of improving patient outcomes for the approximately 800 patients aged >65 admitted under vascular surgery per annum.

Solutions

Following publication of a RCT trialling collaborative perioperative geriatric support for vascular surgery, the intervention (Geriatrician-led Perioperative Comprehensive Geriatric Assessment) was implemented into the patient pathway for frail, older or comorbid patients undergoing major vascular surgery.

The service was designed to embed perioperative geriatricians at various points throughout the surgical pathway. This was achieved in the preoperative setting to support patient selection and shared decision-making. 

Post-operatively, programmed daily medical ward rounds were established to proactively address medical complications, review emergency vascular admissions and to facilitate rehabilitation and discharge planning. 

The outcomes data revealed positive effects on length of stay (mean reduction 2.8 days) and complications (reduced by 56% in acute admissions). The service was progressively expanded to burns, colorectal and acute gastrointestinal surgery in 2018. Further successful outcomes and business-planned staff recruitment allowed expansion into Major Trauma in 2019. 

The service currently employs the model of care piloted in vascular surgery for UGI, LGI, Burns, Plastics and Major Trauma surgery teams. Further expansion has been requested by urology, spinal and neurosurgery and is currently being business-planned.

Challenges

There has been widespread support for this model of care across divisions and specialties. Gaining the support of surgical, anaesthetic or nursing bodies has not been problematic. 

Challenges have mainly focussed on obtaining sufficient time with medical job plans to deliver a service capable to improving perioperative clinical outcomes. This was achieved by persuasion of key stakeholders in medicine of the potential value of the service; this secured allocation of clinical DCCs to establish and expand the service from the initial pilot area in vascular surgery to other surgical specialties. 

Further development of manpower to deliver and evidence-base the service was achieved by reallocation of existing resource. Existing junior doctors were supported in collecting data to evaluate the impact and tutored in the principles of service development. 

The pilot-site in vascular surgery was selected to ensure the ambitions of the pilot-project could be reasonably achieved with the resource initially available. Positive outcomes data have subsequently permitted staged expansion into other surgical specialities (by request) with 4 medical consultants now carrying perioperative DCCs and 2.6 full-time perioperative clinical fellows (from physician-specialty backgrounds) supporting the service.  The potential roles of ANPs and Physician Associates are currently being evaluated. 

MDT Working

One of the main aims of this service development was to provide support to consultant surgeons and anaesthetists with challenging decision-making. This was reported by clinicians to be a real clinical challenge, especially when they were unclear whether the risk-benefit profile in high-risk patients supported surgical intervention. Our work in establishing a 3rd preoperative opinion adds a medical dimension, and provides evidence –based opinion on frailty, life-expectancy, medical comorbidity and surgical risk to support shared decision making. This is at the heart of modern multidisciplinary working. 

Additionally, a daily presence on the vascular ward by physicians has provided open access support for junior surgical doctors who previously struggled to obtain help from the hard-pressed duty emergency medical team. Furthermore, integration into the vascular team has developed relationships with nurses and AHPs in the vascular service, and provided continuity and trust between medical and vascular teams. Whilst medical commitments currently leave room for further improvement in multidisciplinary working, the expansion of the service and building of a larger perioperative team means that resource to work throughout the patient pathway and take a bigger role in discharge planning is on the horizon. 
 

Patient Outcomes

GIRFT data for the vascular service indicate that the Trust has exemplary nationally bench-marked mortality rates for EVAR and that major amputation rates are falling substantially. Whilst we cannot claim to be fully responsible for all improvements conducted across the regional network, our work has focused specifically on high risk surgery and aggressive management of medical complications in the highest risk patients. 

Specific before & after analysis conducted as part of the service development has revealed the greatest reductions in length of stay (LOS) for ‘stranded’ vascular patients staying over 7 days. These are patients who have faced medical post-operative complications and major functional decline. Although overall length of stay fell by 2.8 days in all vascular patients aged >65 after implementation of embedded medical liaison, in stranded patients we have seen a greater mean reduction in LOS by 7.8 days (P<0.05). This may be explained by the reduction in medical complications by 56% (P<0.05). 

These data reflect substantially improved care for the most vulnerable patients at highest risk of perioperative adverse outcome. Although mortality has not been shown to have fallen in vascular surgery, in emergency laparotomy, similar service evaluation shows that 30-day mortality fell by 74% (p=0.03) following implementation of daily physician support for acute surgical services.

Health Economics

The statistically significant reductions in length of stay that we have seen translate into improved patient flow. Bed modelling conducted by divisional manager’s estimates that our service development translates into 1500-3000 bed days saved per annum in the trust; this is equivalent to 5-10 additional surgical beds per year. The increased patient flow through the bed base is likely to improve turnover for elective surgical work, which in itself is an economic driver for the Trust through improved surgical income. 

Furthermore, since April 2019 the new Best Practice Tariff for Major Trauma has rewarded trusts for frailty assessment in patients aged over 65. We have incorporated Major Trauma liaison into the perioperative service and in doing so, ensured that all patients are reviewed and frailty scored in accordance with BPT requirements. This is projected to generate >£830,000 in the financial year, and could not be achieved without physicians embedded into surgical services. 

Additionally, we have evaluated the advantages of subjecting frail older patients to comprehensive geriatric assessment throughout their admission. This process generates active problem lists, and requires formal documentation of secondary diagnoses and defined complications. This approach has generated an additional £740 per patient reviewed by physicians. This figures extrapolates to >£380,000 of additional income for the numbers of patients seen in vascular surgery over a calendar year. It has also proven to be a strong financial driver indicating the economic value of our service development.

Feedback

Patient feedback has been supportive. We are currently working on how to robustly and scientifically evaluate the concepts of shared decision making and show that this has been improved. 

Wider NHS/Government Practice

This service development is naturally aligned with various facets of the NHS Long Term Plan for England. 

In the pre-operative setting, high risk patients receive a detailed, personalized risk assessment allowing better appreciation of the potential risks and benefits of surgery. This allows them to explore their options more carefully and provides less time-pressured forum for considered discussion. Patients (and their relatives) are honestly presented with their options and provided with bespoke, personalized perioperative management plans to identify the various perioperative issues than we can anticipate through pre-operative comprehensive geriatric assessment. 

Proactive and pre-emptive management of medical problems leads to better support throughout a safer surgical journey, and properly joined-up care at delivered at the right time by the right people with the right expertise. 

The results of this work show that comprehensive holistic assessment of our patients throughout the surgical pathway improves the accuracy of clinical coding and this means that our NHS Trust is fairly reimbursed for the work it undertakes. We have also showed improved in complications and inpatient length of stay (without increasing readmissions) which also reduces the overall costs of healthcare. These are examples of ensuring that taxpayers’ investment is used to maximum effect and that financial investment in the service is sustainable. These are important components of the NHS long Term Plan for England, but are equally applicable and relevant to the devolved nations. 

Learning

The associated outcomes of this service development work have included reductions in length of stay, perioperative complications and mortality.

These data have been presented locally, regionally, nationally and internationally at various meetings and conferences. Academic publications describing to process and results are currently in peer review with anticipated publication in 2020. 
 

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