Case Studies: Surgery-specific initiatives
Trauma and hip fracture
We provide a seven-day consultant led theatre service for acute trauma and orthopaedic surgery. The ‘Perioperative Trauma Anaesthetist’ provides standardised care for all trauma patients through a standardised perioperative medicine pathway.
The Trauma Anaesthetist, i.e. the ‘anaesthetist of the week’ provides care for the full day theatre session for all seven days a week. There is an additional ‘perioperative ward anaesthetist’ who provides perioperative care in partnership with the orthogeriatrics and the wider team. This involves pre-optimization (including fluids, analgesia, medications etc.), structured risk assessment, communication with patients & family and medical management aimed at expediting early surgery and continued postoperative care enabling rapid rehabilitation.
The ‘Trauma ward anaesthetist’ joins the multidisciplinary board round on week days and performs a structured postoperative ward round for all hip fracture and high-risk patients. Continuous ongoing data collection enables us to provide feedback and quality improvement.
The lead anaesthetist is part of the multidisciplinary meeting conducted once every two weeks.
Standardization in health care has been shown to have a positive impact on patient care. We would like to share our achievements and experience to enable and spread learning across the organization.
Anaesthetists are important providers of perioperative care and perioperative optimization before and after major surgery and influence the long-term outcomes of patients such as return to previous state of fitness, disability free survival etc.
The simple process of standardization of care resulted in significant improvement in outcomes and ultimately quality of patient care. Our findings show that small investments in the perioperative environment can have large returns.
What did we change?
We “Standardised” our practice for the peri-operative management of patients with hip fracture care in 2015 in our hospital. We share our experiences and the findings below.
We were able to demonstrate significant improvements in perioperative care. The baseline data from 2013-14 is available from the 2014 National Sprint Audit2. It showed, we were lagging behind in several aspects of perioperative care such as compliance with regional anaesthesia, maintaining stable intraoperative haemodynamics, level of senior cover, etc.
The latest National hip fracture database (NHFD) report1 demonstrates significant improvements in several aspects of perioperative care as illustrated in the below graph. This is also available to view in the Anaesthesia Dash board section of the NHFD report published by the Royal college of Physicians.
Impacts of change:
We have achieved significant improvements in structure, process and outcome measures for patients, and the data is available in the latest National Hip Fracture Database Annual Report1. There are many outcomes which are a significant improvement from the 2014 National Sprint Audit2 (ASAP) findings.
How did we achieve change?
Producing good outcomes requires a prompt, coordinated, multidisciplinary approach, delivered by senior personnel, using integrated care pathways that standardize care and engagement of key stakeholders in this process.
Our primary goal was to improve quality of care, reduce variation and enable continuous measurement of data, analysis and feedback.
We took a very pragmatic approach to the issue of ‘variation in practice’ and strongly believed changes in ‘processes and structure’ of the service delivery are more likely to produce desired changes.
Anaesthetic techniques and perioperative care was standardized using standard operating procedures which were based on the best evidence and guidance available. We adopted the Plan, Do, Study and Act (PDSA) model for quality improvement leading to standardization of structure and processes of care leading to improved outcomes.
We provided perioperative care for the whole perioperative journey which includes optimizing analgesia, fluid status, background medical issues and expediting early surgery.
The continuous data collection and database which are capable of providing continual feedback and periodic run charts, along with standardized care and minimized variations in practice, not only with the anaesthetic but the whole perioperative period, we believe is the key to our success and improvement in outcomes which are sustainable long term.
What did it cost?
Our project was cost neutral providing good value for money.
At the West Suffolk Hospital, we have become the leading unit in Eastern region, and the sixth best in the country for fractured hip management, according to data collected in the National Hip Fracture Database (NHFD). This has largely been the result of changes made in response to Best Practice Tariff (BPT) introduced several years ago. This specified a set of criteria that had to be met in order to be granted an uplift on the standard tariff per patient. We were able to appoint a dedicated orthogeriatric consultant, and two trauma practitioner nurse specialists. Our multidisciplinary team also includes an orthopaedic lead consultant, a lead consultant anaesthetist, a dedicated data analyst, and a lead physiotherapist. We meet regularly (at least fortnightly) to review the care of all fractured hip patients.
Our aim is to ensure that our clinical care pathway is robust, appropriate and is followed for all patients, such that they are assessed and optimised for theatre within 36 hours, that they are cared for in a shared capacity by orthogeriatrics and orthopaedics, and that they can be mobilised early, with the aim of discharge quickly back to their place of residence wherever possible. In the 2016 NHFD report, we operated on 340 patients. In 85% patients we achieved all BPT criteria; 88% patients were operated on the day of, or the day after, admission; our length of stay and mortality figures are bleow national average. However, our admission to an orthopaedic ward within 4 hours remains low at 58%, and only 80% patients could be mobilised out of bed the day after surgery.
Currently we are working to increase the availability of physiotherapists in the 24 hours after surgery, and to improve the flow of patients through the emergency department, with the aim of admitting patients straight to a trauma assessment area on the ward, or in the theatre complex.
Orthopaedic Trauma and Spine Surgery
The Orthopaedic Trauma Service at Leicester Royal Infirmary cares for patients of all ages, and provides hip fracture care for around 800 patients a year. Since September 2016, Consultant Anaesthetists have combined with Orthogeriatricians and Orthopaedic Surgeons in a perioperative, multidisciplinary service for all patients with hip fractures.
Consultant Anaesthetists do ward rounds three mornings a week, attending hip fracture patients as well as complex trauma and spine surgery patients, for pre-operative assessment and planning.
York hospital has one of the lowest resourced critical cares units in the country. Our aim was to establish a perioperative service which would use our scarce resources appropriately and reduce the reliance on critical care for major colorectal surgery. Secondary aims were to reduce complication rates and ensure coordinated care throughout a patient’s surgical journey.
“What we did”
All colorectal surgical patients over the age of 55 were including in this project. We standardised our preassessment pathway incorporating fraility indexes, cognitive, ARISCAT scoring (amongst others) along with traditional cardiopulmonary exercise testing (CPET). Patients were formally risk stratified to low (<1%), medium (3%) or high risk (9%) based on various CPET variables. Patients in the low risk group were allocated to a standard care pathway and would be nursed in the ward environment. Those in the medium group (i.e. patients whom would traditionally go to critical care post operatively) were to be treated on an “enhanced perioperative pathway” in a level one, nurse led unit with invasive flow monitoring and protocolised fluid and vasopressor management. High risk patients would continue to be treated on our critical care unit.
The medium risk patients had parameters set (mean arterial pressure, urine output and lactate) by the operative anaesthetist. In the event of these deteriorating ward nurses were empowered to assess for fluid responsiveness by utilising passive leg raises and looking for changes in dynamic stroke volume measurements. This would determine whether a fluid bolus or a vasopressor agent was administered. Safety features were built into the protocol whereby patients would be escalated to critical care if maximal treatment had been reached. This pathway was backed up by a perioperative nurse specialist and daily anaesthetic consultant cardiorespiratory led ward rounds.
We used a control group to compare our data with. Our medium length of stay (LOS) reduced from 8 to 6 days with our variation significantly reducing, with prolonged LOS (>12 days) reduced from 25% to 9%.
Planned critical care usage reduced from 43% to 16-17% with unplanned critical care LOS also reducing. Both our major and minor complication rates reduced and complications directly related to fluid administration significantly reduced. Although IV fluid use in theatre remained static, patients postoperative fluid balance was significantly improved with a reduction in almost 1.5 litres at 24 hours.
- High-risk patients can be successfully cared for in the ward environment (rather than Critical Care)
- Critical Care style, cardiorespiratory reviews for all are beneficial. It’s often the patient’s comorbidities rather than the actual surgery that leads to the mortality.
- A ‘champion’ is key – Periop Med Nurse Specialist/ Practitioner
- Data is king! Without baseline and detailed perioperative data it is very difficult to assess change. PQIP data useful to assess morbidity and patient factors e.g. DrEaMing etc.
- Ward nurses and surgical colleagues positive about presence of consultant anaesthetists on surgical ward.
- Education of nurses and surgeons to deliver care traditionally delivered in critical care required periop nurse specialist.
- Safety features of introducing arterial lines and vasopressors to the ward crucial.
- Encouraging standardisation of care in theatres for anaesthetists not regularly delivering colorectal lists.
- Perioperative medicine is not for everyone but for individuals looking for something new and different.
- The vast majority of this project is attention to detail, carrying out the basic tasks well and thoroughly and encouraging quality ward care.
- Continuing to fund the process after the initial project funds ceased. A business case was developed which was supported at senior exec level and this is now a fully funded service.
The National Enhanced Recovery Colorectal Initiative (NERCI) is a project within NHS Scotland, supported by the Quality and Efficiency Support Team (QuEST) of the Scottish Government launched in January 2016. Its aim is to reduce variation by agreement with a national protocol and discharge criteria for laparoscopic colorectal surgery.
The protocol was developed by a working group, representing healthboards who had already created and reduced length of stay by utilising enhanced recovery principles, via local pathways for colorectal surgery. This has embedded established practice which includes pre-operative optimisation and education, use of carbohydrate pre-load drinks and the post-operative priorities of returning patients to normal oral intake and mobilisation as soon as possible. The protocol acknowledges the movement of our specialty away from epidural analgesia for this type of surgery, towards use of intrathecal opiates and intravenous lidocaine infusions for analgesia. It advocates criterion led discharge and specific follow up after discharge from hospital.
We have developed a national toolkit to measure compliance with the protocol and specific clinically relevant outcomes: length of stay, reasons for delayed discharge, morbidity, admission to Level 3 critical care, mortality and readmission to hospital. We now have representation from all health boards in Scotland, have identified multidisciplinary project boards in each hospital site and have commenced data collection to inform monthly reports to the National Lead. National funding has been provided to drive forward the local programmes for a one year period to embed ERAS as the norm. We aim to expand to all colorectal procedures (elective) by September 2016. Data will be available nationally to learn and develop the evidence base for best practice in Scotland and further afield.
Contact NERCI National Lead: David.McDonald@gov.scot
Low risk patients for minor surgery are screened by questionnaire or telephone, while those for more complex procedures attend for nurse pre-assessment. High risk patients are assessed by a consultant anaesthetist.
Benefits include identification and treatment of patients deficient in iron and more effective perioperative planning for elective patients based on results of ‘shuttle walk’ tests.
Despite advances in surgical technology, anesthesia and analgesia techniques, complications after abdominal surgery remain relatively high and thus represent a priority for quality improvement in general surgery1,2. Even in the absence of complications, the postsurgical period is associated with a 20-40% reduction in physiological and functional capacity that, particularly in the elderly with comorbidities, may delay return to preoperative function for several months, if at all3. Poor preoperative physical performance has been shown to increase the risk of mortality4, number of postoperative complications5 and prolong functional recovery6
Enhanced Recovery After Surgery (ERAS) was introduced as a multi-modal system of care to optimize patients’ wellbeing throughout the perioperative period by reducing their surgical stress response. The ERAS protocols apply multiple care pathways, in order to expedite patients’ return to activities of daily living, and to reduce the length of hospital stay when compared to patients receiving ‘traditional’ perioperative management7-9.
There is now growing evidence that despite adoption of current ERAS protocols, patient reported outcomes of functional capacity suggest that patients are not fully recovered even 6–9 weeks after major abdominal surgery, especially for those with suboptimal physical function prior to surgery10,11.
There is increased number of elderly patients requiring major surgery, most of them presenting with complex medical conditions often combined with advanced frailty. Factors staying behind co-morbidities, advanced age and problems related to cancer or other pathology requiring surgery, put such patients in a very high risk group. It relates to surgery itself and to variety of perioperative complications, which can significantly impact on recovery time and compromise postoperative quality of life.
Identification of some risks, which can be target by specific intervention preoperatively can help to improve preoperative optimisation.
In the context of above evidence we’ve been working on improving and coordinating preoperative pathways for colorectal cancer patients (the only “major” general surgery group at YDH in the PQIP programme). The mainstream of our work around this group of patients includes:
1. Identification patients with preoperative anaemia – at the endoscopy appointment patients are checked for anaemia (including haemtinics) - if this is identified and patients are decided for surgery, there is a fast track referral for the preoperative iron infusion 9this part of pathway was recently subject to the audit).
2. In endoscopy a MUST score is performed and patients at risk of malnutrition are referred promptly to dieticians.
3. Once all results are back, patients are seen within 1-2 days by the consultant with colorectal nurse specialist – patients are encouraged to maintain activities, to keep healthy diet, to give up smoking or alcohol. Patients go straight round to preassessment for screening (including HbA1C testing in diabetic patients).
4. There is a small group of high-risk patients who are directly referred to consultant anaesthetist before the final decision about operation is made. It aims to give the early opportunity to review patient’s potential to undergo major surgery and to order more specific tests, should such be required prior to appointment with consultant anaesthetists in the preassessment clinic. There is a desire to formalise the MDT meetings between surgeons, anaesthetists, oncologist, physiotherapy etc in order to improve treatment decision making, which is patient centred and based on individualised risk assessment.
5. We’ve been working towards streamlining all above pathways to align them with prehabilitation, which would help not only improve patients physical status prior to surgery, but which could help to offer more holistic approach with assessment of patient’s emotional and psychological needs in the context of life changing diagnosis.
Current assessment of our outcomes
Based on the results from PQIP reports our data indicates (in the reference to report published in November 2018)
1. Thorough preoperative risk- assessment.
2. Strong evidence for compliance with ERAS for colorectal patients.
3. Slightly better than national average length of stay after major colorectal surgery and better result in achieving DREAMING patient post colorectal surgery.
There is real desire to start regular prehabilitation clinic within next couple of months. Funding has been secured and detailed work on its functionality is the priority among team involved in this complex project. Data collection and research activity around the impact of prehabilitation activity on our patients outcome is also planned.
1. Time required to create business case and to secure financial support for prehabilitaion clinic.
2. Time/scale and format of local MDT around complex patients is still under review without formal recognition from the management- the complex work around high risk patients is mainly done on expense on consultants SPA time.
3. Limited capacity of supporting resources (increased amount of patients being refereed for preop iron infusion over weights the capacity, so it can’t be fully delivered in timely manner).
We developed the EmLap pathway and incorporated three novel steps with electronically identifiable ‘tags’ (e-tags). We worked with stakeholders to agree escalation processes for each.
The three steps are the ‘2222-EmLap referral’ to Surgical Registrar (review within 30minutes), a unique ‘CT-EmLap’ request within our EPR (order to report scans within 3hrs) and prioritised electronic theatre booking (surgery within 6 hours). These interventions were supported by the paper pathway ensuring best medical care.
We observed impressive improvements in many of the NELA quality markers of perioperative care. Most importantly there has been a 2.5% absolute reduction (17% relative risk reduction) for in-hospital mortality.
Reconstructive Head & Neck Surgery
Following pressure on intensive care beds, all major cases with potential airway compromise undergo an elective percutaneous tracheostomy by the anaesthetic team who have also trained the wards on tracheostomy care. Following two years of this training, patients are now transferred directly from the recovery unit to the ward. The team is actively involved in better pre-operative optimisation of the patients to reduce many post-operative complications.
Lower Limb Amputation
Peripheral vascular disease if not dealt appropriately in patients with associated co-morbidities can have a significant impact on their mortality. Hence in order to improve our outcomes following lower limb amputations in vascular patients we introduced the Lower Limb amputation care pathway (Dr G Madden, Dr C Vaidyanath) in 2016. This is a stream lined process from the point of entry of our patients into hospital until discharge. It is a successful undertaking due to close co-ordination between the Anaesthetic department and Department of Vascular Surgery at UHCW, Coventry.
Following completion of a comprehensive research and guideline setting exercise by a multi-disciplinary group at Ninewells Hospital, patient reports of phantom limb pain after lower limb amputation have decreased from 81% to 8%. Other hospitals across Scotland have expressed an interest in adopting similar strategies.
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