Surgeons are increasingly diversified in their technical expertise, whilst care of acute and long-term medical disease is ever more sophisticated. It is no longer realistic to expect surgeons to have an in-depth knowledge of recent advances in the management of patients with complex needs, who develop acute medical problems. Improving the quality of care early after surgery represents a major challenge.
All hospitals deliver a package of perioperative care that is focused on the needs of the individual patient, as determined by the specific surgical procedure. Specialised surgical wards are a historic feature of the NHS, delivering expert management of the common problems that may occur after surgery.
Multi-disciplinary input
However, as surgeons become more diversified in their technical expertise, and the care of acute and long-term medical disease becomes ever more sophisticated, a clear gap has opened in terms of the ability of the surgical team to provide care to the surgical patient with complex medical needs, such as heart failure or pneumonia. Physicians are well trained in the management of acute and chronic medical disease, but may have less insight into how major surgery may modify such conditions. Anaesthetists have an excellent understanding of how complications develop after surgery, but are rarely given the time to review and assess patients on the general surgical ward.
Improving the quality of care early after surgery is perhaps the biggest challenge we face as we work to make perioperative care a reality. But again, we can identify many examples of care within the NHS today which convince us that effective change is worthwhile and achievable.
Caring for long-term disease after surgery
Twenty years ago, it was very common to find that patients were not offered surgical treatments because of increased risk due to co-morbid disease. As perioperative care has improved, we find that these patients are now offered surgery as a matter of routine, with the same expectations of success as the wider surgical population. Maintaining high standards of care for patients with long-term diseases, becomes a major challenge as they undergo surgery.
Diabetes care is an important example. This disease is associated with increased rates of cancellation before surgery, complications such as wound infections, and prolonged hospital stay after surgery. Patients are now routinely admitted on the day of surgery, even for major procedures, creating particular challenges for diabetic patients. One NHS trust in the south of England has set up a service to tackle this. All diabetic patients are offered an additional screening test called HbA1c as part of their routine preoperative assessment. Those with high values are seen by the diabetic team within ten days, to review their diabetic medication in the context of surgery, as well as to offer other routine care that diabetic patients need.
This service provides important support, but requires on average only one day each week from the diabetic nurse specialist to accommodate referrals. The service promotes communication between diabetes experts, surgeons and anaesthetists to ensure high quality care within an efficient surgical service. Importantly, colleagues in primary care have also commented on the utility of this approach which provides a valuable model of care for the short-term management of surgical patients with long-term disease. The introduction of perioperative care teams would help us to ensure that all long-term diseases are managed in this way during the perioperative period.
Extra care for the high-risk patient
Many patients need extra care immediately after surgery, particularly if they need major surgery. For many years, we have admitted these patients to a Critical Care Unit for 24–48 hours after surgery. However, despite increased resources the demands on these services remain high. When critical care beds are not available, clinicians must decide between cancelling surgery, or proceeding with less care than they believe the patient needs. This situation is bad for patients, bad for the NHS and very stressful for hospital staff.
However, surgical patients don’t need all the facilities that a modern intensive care unit offers. In fact, a much simpler facility would be more efficient and still offer the care patients require. After cardiac surgery, all patients are admitted to critical care as standard. However, in most hospitals this is part of a nurse-led, protocol-driven form of care known as ‘fast-track’ cardiac surgery.
One hospital in London has for many years admitted all high-risk patients to an ‘Overnight Intensive Recovery’ unit which functions much like a normal post-anaesthetic care unit. Patients are admitted for up to 24 hours before they are discharged to the ward or to a fully-equipped intensive care unit, depending on need. This provides a facility for the provision of cardiac or respiratory organ support (much like a critical care unit), as well as a focus on pain management and other common postoperative problems (much like a post-anaesthetic care unit). Patient flow is not a problem because places in the unit are not considered to be hospital ‘beds’.
There are now several NHS hospitals that use this model of care for patients who would traditionally be admitted to a critical care unit after surgery. This ensures all patients receive the level of care they need whilst avoiding the need to cancel procedures when critical care beds are not available.
