A survey of UK peri-operative medicine: pre-operative care

Perioperative shared decision making - How do we train clinicians?

Objective

Decision making about high-risk surgery can be complex, particularly when outcomes may be uncertain. Clinicians have a legal and ethical responsibility to support decision making which fits with patients' values and preferences. In the UK, preoperative assessment and optimisation is led by Anaesthetists in clinic several weeks prior to planned surgery. Training in supporting shared decision making (SDM) has been identified as an area of need among UK anaesthetists with leadership roles in perioperative care.

Methods

We describe adaptation of a generic SDM workshop to perioperative care, in particular to decisions on high-risk surgery, and its delivery to UK healthcare professionals over a two-year period. Feedback from workshops were thematically analysed. We explored further improvements to the workshop and ideas for development and dissemination.

Results

The workshops were well received, with high satisfaction for techniques used, including video demonstrations, role-play and discussions. Thematic analysis identified a desire for multidisciplinary training and training in using patient aids.

Conclusion

Qualitative findings suggest workshops were considered useful with perceived improvement in SDM awareness, skills and reflective practice.

Innovation

This pilot introduces a new modality of training in the perioperative setting providing physicians, particularly Anaesthetists, with previously unavailable training needed to facilitate complex discussions.

Opportunities for shared decision-making about major surgery with high-risk patients: a multi-method qualitative study

BACKGROUND

Little is known about the opportunities for shared decision-making when older high-risk patients are offered major surgery. This study examines how, when, and why clinicians and patients can share decision-making about major surgery.

METHODS

This was a multi-method qualitative study, combining video recordings of preoperative consultations, interviews, and focus groups (33 patients, 19 relatives, 36 clinicians), with observations and documentary analysis in clinics in five hospitals in the UK undertaking major orthopaedic, colorectal, and/or cardiac surgery.

RESULTS

Three opportunities for shared decision-making about major surgery were identified. Resolution-focused consultations (cardiac/colorectal) resulted in a single agreed preferred option related to a potentially life-threatening problem, with limited opportunities for shared decision-making. Evaluative and deliberative consultations offered more opportunity. The former focused on assessing the likelihood of benefits of surgery for a presenting problem that was not a threat to life for the patient (e.g., orthopaedic consultations) and the latter (largely colorectal) involved discussion of a range of options while also considering significant comorbidities and patient preferences. The extent to which opportunities for shared decision-making were available, and taken up by surgeons, was influenced by the nature of the presenting problem, clinical pathway, and patient trajectory.

CONCLUSIONS

Decisions about major surgery were not always shared between patients and doctors. The nature of the presenting problem, comorbidities, clinical pathways, and patient trajectories all informed the type of consultation and opportunities for sharing decision-making. Our findings have implications for clinicians, with shared decision-making about major surgery most feasible when the focus is on life-enhancing treatment.

Frailty in the over 65's undergoing elective surgery (FIT-65) - a three-day study examining the prevalence of frailty in patients presenting for elective surgery

Background

Frailty increases the risk of perioperative complications, length of stay, and the need for assisted-living after discharge. As the UK population ages the number of frail patients presenting for elective surgery in the UK is likely to grow. Despite the potential benefits of early diagnosis, frailty is not uniformly screened for in UK elective surgical patients and its prevalence remains unclear. The primary aim of this study was to assess the prevalence of frailty in patients aged over 65 years undergoing elective surgery.

Methods

We performed a prospective cross-sectional observational study in eight UK hospitals. Data were collected over three consecutive days with follow-up at 30 days. HRA approval was obtained (REC 20/SC/0121) and signed informed consent obtained. Participants were eligible for inclusion if they were 65 years or older and undergoing elective surgery. Pre-operative data were collected from hospital notes by anaesthetic trainees. A member of the research team blinded to the pre-operative dataset screened each participant for frailty pre-operatively using the Reported Edmonton Frail Scale (REFS). Post-operative data were collected from the notes on day of surgery and at 30 days. Participants were defined as “frail” if they scored 8 or more on the REFS.

Results

Two hundred twenty eight participants were recruited during the study period of whom 218 proceeded to surgery. There were 103 females and 115 males. Median age was 75 years (interquartile range 70–80). Thirty-seven participants (17.0%) were identified as frail. Frail patients were older, had a higher ASA score, were more likely to have carers and were more likely to be anaemic or present with ECG abnormalities. There were no differences in gender, BMI, place of residence or smoking status for patients identified as frail versus non-frail. There was no difference in length-of-stay between frail and non-frail patients, although those identified as frail were less likely to be discharged to their own home.

Conclusion

We found the prevalence of frailty in a mixed population of elective surgical patients aged 65 or over to be 17.0%. Furthermore, we found the REFS to be a practical tool for pre-operative frailty screening. Frail patients presented for elective surgery with modifiable co-morbidities which could have been optimised pre-operatively. Early screening could highlight frail patients, allowing time for pre-operative planning and evidence-based optimisations of comorbidities. We therefore encourage the adoption of frailty assessment as a routine part of pre-operative assessment.

Perioperative Risk Stratification and Modification

This article discusses the important topic of perioperative risk stratification and the interventions that can be used in the perioperative period for risk modification. It begins with a brief overview of the commonly used scoring systems, risk-prediction models, and assessments of functional capacity and discusses some of the evidence behind each. It then moves on to examine how perioperative risk can be modified through the use of shared decision making, management of multimorbidity, and prehabilitation programs, before considering what the future of risk stratification and modification may hold.

Preoperative Intravenous Iron and Erythropoietin to Treat Severe Anemia in Patient With Stage 4 Kidney Disease Before Oncologic Surgery: A Case Report

Preoperative treatment of anemia with intravenous iron is inconsistent despite known risks of anemia and allogeneic blood transfusions. Limited research exists on the effectiveness of preoperative intravenous iron for chronic kidney disease (CKD) patients. We discuss a patient with severe anemia from advanced CKD, endometrial cancer, and menometrorrhagia. Her hemoglobin increased more than 2 g/dL after erythropoietin and two 750-mg ferric carboxymaltose infusions 5 weeks before a total abdominal hysterectomy and avoided blood transfusions perioperatively. By raising hemoglobin, preoperative intravenous iron and erythropoietin reduce blood transfusions and consequent risk of future allograft rejection and alloimmunization in potential transplant recipients.

Understanding decision making about major surgery: protocol for a qualitative study of shared decision making by high-risk patients and their clinical teams

INTRODUCTION

Surgical treatments are being offered to more patients than ever before, and increasingly to high-risk patients (typically multimorbid and over 75). Shared decision making is seen as essential practice. However, little is currently known about what 'good' shared decision making involves nor how it applies in the context of surgery for high-risk patients. This new study aims to identify how high-risk patients, their families and clinical teams negotiate decision making for major surgery.

METHODS AND ANALYSIS

Focusing on major joint replacement, colorectal and cardiac surgery, we use qualitative methods to explore how patients, their families and clinicians negotiate decision making (including interactional, communicative and informational aspects and the extent to which these are perceived as shared) and reflect back on the decisions they made. Phase 1 involves video recording 15 decision making encounters about major surgery between patients, their carers/families and clinicians; followed by up to 90 interviews (with the same patient, carer and clinician participants) immediately after a decision has been made and again 3-6 months later. Phase 2 involves focus groups with a wider group of (up to 90) patients and (up to 30) clinicians to test out emerging findings and inform development of shared decision making scenarios (3-5 summary descriptions of how decisions are made).

ETHICS AND DISSEMINATION

The study forms the first part in a 6-year programme of research, Optimising Shared decision-makIng for high-RIsk major Surgery (OSIRIS). Ethical challenges around involving patients at a challenging time in their lives will be overseen by the programme steering committee, which includes strong patient representation and a lay chair. In addition to academic outputs, we will produce a typology of decision making scenarios for major surgery to feed back to patients, professionals and service providers and inform subsequent work in the OSIRIS programme.

Findings of a feasibility study of pre-operative pulmonary rehabilitation to reduce post-operative pulmonary complications in people with chronic obstructive pulmonary disease scheduled for major abdominal surgery

Background: Patients with chronic obstructive pulmonary disease (COPD) are at increased risk of complications and death following surgery. Pulmonary complications are particularly prominent.  Pulmonary rehabilitation is a course of physical exercise and education that helps people with COPD manage their condition.  Although proven to improve health outcomes in patients with stable COPD, it has never been formally tested as a pre-surgical intervention in patients scheduled for non-cardiothoracic surgery.  If a beneficial effect were to be demonstrated, pulmonary rehabilitation for pre-surgical patients with COPD might be rapidly implemented across the National Health Service, as pulmonary rehabilitation courses are already well established across much of the United Kingdom (UK). Methods: We performed a feasibility study to test study procedures and barriers to identification and recruitment to a randomised controlled trial testing whether pulmonary rehabilitation, delivered before major abdominal surgery in a population of people with COPD, would reduce the incidence of post-operative pulmonary complications.  This study was run in two UK centres (Oxford and Newcastle upon Tyne). Results:  We determined that a full randomised controlled trial would not be feasible, due to failure to identify and recruit participants.  We identified an unmet need to identify more effectively patients with COPD earlier in the surgical pathway.  Service evaluations suggested that barriers to identification and recruitment would likely be the same across other UK hospitals. Conclusions:  Although pulmonary rehabilitation is a potentially beneficial intervention to prevent post-operative pulmonary complications, a randomised controlled trial is unlikely to recruit sufficient participants to answer our study question conclusively at the present time, when spirometry is not automatically conducted in all patients planned for surgery.  As pulmonary rehabilitation is a recommended treatment for all people with COPD, alternative study methods combined with earlier identification of candidate patients in the surgical pathway should be considered. Trial registration: ISRCTN29696295, 31/08/2017.

Preoperative behavioural intervention to reduce drinking before elective orthopaedic surgery: the PRE-OP BIRDS feasibility RCT

BACKGROUND

Heavy alcohol consumption is associated with an increased risk of postoperative complications and extended hospital stay. Alcohol consumption therefore represents a modifiable risk factor for surgical outcomes. Brief behavioural interventions have been shown to be effective in reducing alcohol consumption among increased risk and risky drinkers in other health-care settings and may offer a method of addressing preoperative alcohol consumption.

OBJECTIVES

To investigate the feasibility of introducing a screening process to assess adult preoperative drinking levels and to deliver a brief behavioural intervention adapted for the target population group. To conduct a two-arm (brief behavioural intervention plus standard preoperative care vs. standard preoperative care alone), multicentre, pilot randomised controlled trial to assess the feasibility of proceeding to a definitive trial. To conduct focus groups and a national web-based survey to establish current treatment as usual for alcohol screening and intervention in preoperative assessment.

DESIGN

A single-centre, qualitative, feasibility study was followed by a multicentre, two-arm (brief behavioural intervention vs. treatment as usual), individually randomised controlled pilot trial with an embedded qualitative process evaluation. Focus groups and a quantitative survey were employed to characterise treatment as usual in preoperative assessment.

SETTING

The feasibility study took place at a secondary care hospital in the north-east of England. The pilot trial was conducted at three large secondary care centres in the north-east of England.

PARTICIPANTS

Nine health-care professionals and 15 patients (mean age 70.5 years, 86.7% male) participated in the feasibility study. Eleven health-care professionals and 68 patients (mean age 66.2 years, 80.9% male) participated in the pilot randomised trial. An additional 19 health-care professionals were recruited to one of three focus groups, while 62 completed an electronic survey to characterise treatment as usual.

INTERVENTIONS

The brief behavioural intervention comprised two sessions. The first session, delivered face to face in the preoperative assessment clinic, involved 5 minutes of structured brief advice followed by 15-20 minutes of behaviour change counselling, including goal-setting, problem-solving and identifying sources of social support. The second session, an optional booster, took place approximately 1 week before surgery and offered the opportunity to assess progress and boost self-efficacy.

MAIN OUTCOME MEASURES

Feasibility was assessed using rates of eligibility, recruitment and retention. The progression criteria for a definitive trial were recruitment of ≥ 40% of eligible patients and retention of ≥ 70% at 6-month follow-up. Acceptability was assessed using themes identified in qualitative data.

RESULTS

The initial recruitment of eligible patients was low but improved with the optimisation of recruitment processes. The recruitment of eligible participants to the pilot trial (34%) fell short of the progression criteria but was mitigated by very high retention (96%) at the 6-month follow-up. Multimethod analyses identified the methods as acceptable to the patients and professionals involved and offers recommendations of ways to further improve recruitment.

CONCLUSIONS

The evidence supports the feasibility of a definitive trial to assess the effectiveness of brief behavioural intervention in reducing preoperative alcohol consumption and for secondary outcomes of surgical complications if recommendations for further improvements are adopted.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN36257982.

FUNDING

This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 12. See the National Institute for Health Research Journals Library website for further project information.

The emerging specialty of perioperative medicine: a UK survey of the attitudes and behaviours of anaesthetists

BACKGROUND

In 2014, the Royal College of Anaesthetists (RCoA) launched the Perioperative Medicine Programme to facilitate the delivery of best preoperative, intraoperative and postoperative care through implementation of evidence-based medicine to reduce variation and improve postoperative outcomes. However, variation exists in the establishment of perioperative medicine services in the UK. This survey explored attitudes and behaviours of anaesthetists towards perioperative medicine, described current anaesthetic-led perioperative medicine services across the UK and explored barriers to anaesthetic involvement in perioperative medicine.

METHODS

Survey content based on the RCoA vision document was refined and validated using an expert panel. An anonymous electronic survey was then sent by email to the members of the RCoA.

RESULTS

Seven hundred fifty-eight UK anaesthetists (4.5% of the RCoA mailing list) responded to the survey. Of these, 64% considered themselves a perioperative doctor, with 65% having changed local services in response to the RCoA vision. Barriers to developing perioperative medicine included insufficient time (75%) and inadequate training (51%). Three quarters of respondents advocate anaesthetists leading the development of perioperative medicine.

CONCLUSIONS

Despite evidence of emerging services, this survey describes barriers to ongoing development of perioperative medicine. Facilitators may include increased clinical exposure, targeted education and training and collaborative working with other specialties.

Variation in Preoperative and Postoperative Physical Therapist Management of Patients Opting for Elective Abdominal Surgery

BACKGROUND

Evidence about the role of physical therapy in perioperative care pathways to improve postoperative outcomes is growing. However, it is unclear whether research findings have been translated into daily practice.

OBJECTIVE

The objectives of this study were to describe the current content and between-hospital variability of perioperative physical therapist management for patients undergoing colorectal, hepatic, or pancreatic resection in the Netherlands and to compare currently recommended state-of-the-art physical therapy with self-reported daily clinical physical therapist management.

DESIGN

This was a cross-sectional survey study.

METHODS

Hospital physical therapists were asked to complete an online survey about pre- and postoperative physical therapy at their hospital. To explore the variability of perioperative physical therapist management between hospitals, frequency variables were clustered to determine the level of uniformity. Latent class analysis was performed to identify clusters of hospitals with certain homogeneous characteristics on a 19-item dichotomous scale.

RESULTS

Of 82 eligible Dutch hospitals, 65 filled out the survey (79.3%). Preoperative physical therapy was performed in 34 hospitals (54.0%; 2/65 responding hospitals were excluded from the data analysis). Postoperative physical therapy was performed in all responding hospitals, focusing mainly on regaining independent physical functioning. Latent class analysis identified a 3-class model. Hospitals in classes I and II were more likely to provide preoperative physical therapist interventions than hospitals in class III.

LIMITATIONS

The use of self-reported answers can lead to bias.

CONCLUSIONS

There was a wide degree of variability between hospitals regarding pre- and postoperative clinical physical therapist practice for patients opting for major abdominal surgery. Three different classes of daily practice were identified. Further translation of key research findings into clinical physical therapist practice is advised, especially for hospitals in which the physical therapist is not involved preoperatively. Moreover, improving uniformity by developing up-to-date clinical guidelines is recommended.

Preoperative Assessment of Older Adults

Older patients undergoing surgery have reduced physiologic reserve caused by the combined impact of physiologic age-related changes and the increased burden of comorbid conditions. The preoperative assessment of older patients is directed at evaluating the patient's functional reserve and identifying opportunities to minimize any potential for complications. In addition to a standard preoperative evaluation that includes cardiac risk and a systematic review of systems, the evaluation should be supplemented with a review of geriatric syndromes. Age-based laboratory testing protocols can lead to unnecessary testing, and all testing should be requested if indicated by underlying disease and surgical risk.

Where are we now in perioperative medicine? Results from a repeated UK survey of geriatric medicine delivered services for older people

INTRODUCTION

national reports highlight deficiencies in the care of older patients undergoing surgery. A 2013 survey showed less than a third of NHS trusts had geriatrician-led perioperative medicine services for older surgical patients. Barriers to establishing services included funding, workforce and limited interspecialty collaboration. Since then, national initiatives have supported the expansion of geriatrician-led services for older surgical patients.This repeat survey describes geriatrician-led perioperative medicine services in comparison with 2013, exploring remaining barriers to developing perioperative medicine services for older patients.

METHODS

an electronic survey was sent to clinical leads for geriatric medicine at 152 acute NHS healthcare trusts in the UK. Reminders were sent on four occasions over an 8-week period. The survey examined the nature of the services provided, extent of collaborative working and barriers to service development. Responses were analysed descriptively.

RESULTS

eighty-one (53.3%) respondents provide geriatric medicine services for older surgical patients, compared to 38 (29.2%) in 2013. Services exist across surgical specialties, especially in orthopaedics and general surgery. Fourteen geriatrician-led preoperative clinics now exist. Perceived barriers to service development remain workforce issues and funding. Interspecialty collaboration has increased, evidenced by joint audit meetings (33% from 20.8%) and collaborative guideline development (31% from 17%).

CONCLUSION

since 2013, an increase in whole-pathway geriatric medicine involvement is observed across surgical specialties. However, considerable variation persists across the UK with scope for wider adoption of services facilitated through a national network.

Undergraduate education in anaesthesia, intensive care, pain, and perioperative medicine: The development of a national curriculum framework

INTRODUCTION

The study describes the development of the first UK national framework to guide undergraduate education in anesthesia, perioperative medicine, critical care, and pain medicine.

METHODS

We followed an inclusive process of curriculum design aiming to promote high-level learning amongst students. We conducted telephone interviews with senior anesthetic educators at 33 UK medical schools to establish current provision and practice. We then held a consultative national workshop for educators, using focus group interviews to set broad aims for the final framework and gather information.

RESULT

Anesthesia undergraduate educators demonstrated a conceptual focus that moves beyond simple acquisition of knowledge to one geared to encouraging clinical behavioral change in learners to equip them for practice as new doctors. Respondents also highlighted the opportunities for promoting spiral, integrated, and longitudinal learning within the undergraduate curriculum. We also formulated eight key domains of practice in anesthesia and critical care and mapped 63 of the 106 General Medical Council's Outcomes for Graduates against these domains, and created a brief suggested syllabus.

CONCLUSIONS

The framework aims to provide support and guidance for medical schools in the development of competent, well-rounded doctors who are able to provide safe, patient-centered care in all areas of medical practice.

A prospective observational study of the impact of an electronic questionnaire (ePAQ-PO) on the duration of nurse-led pre-operative assessment and patient satisfaction

Objective

Standard pre-operative assessment at our institution involves a comprehensive history and examination by a nurse practitioner. An electronic pre-operative assessment questionnaire, ePAQ-PO® (ePAQ, Sheffield, UK) has previously been developed and validated. This study aimed to determine the impact of ePAQ-PO on nurse consultation times and patient satisfaction in low-risk patients.

Methods

The duration of pre-operative assessment consultation was recorded for American Society of Anesthesiology physical classification 1 and 2 patients undergoing pre-operative assessment by an electronic questionnaire (ePAQ-PO group) and standard face-to-face assessment by a nurse practitioner (standard group). Patients were also asked to complete an eight-item satisfaction questionnaire. Eighty-six patients were included (43 in each group).

Results

After adjusting for the duration of physical examination, median (IQR [min-max]) consultation time was longer in the standard compared to the ePAQ-PO group (25 (18–33 [10–49]) min vs. 12 (8–17 [4–45]) min, respectively; p <0.001). Response rate for the satisfaction questionnaire was 93%. There was no significant difference in patient satisfaction scores (38/39 in standard group vs. 39/41 in ePAQ-PO group were fully satisfied with their pre-operative assessment; p = 0.494).

Conclusion

Pre-operative assessment using ePAQ-PO is associated with a significant reduction of over 50% in the duration of the assessment without impacting on patient satisfaction.

A Foundation Programme educational placement in peri-operative medicine for older people: mixed methods evaluation

We established an innovative Foundation placement in peri-operative medicine for older patients in response to the need for training in 'whole patient' medicine and the challenge of fewer Foundation doctors in acute surgical roles. The placement and underpinning curriculum were co-designed with junior doctors and other clinical stakeholders. This resulted in a modular design offering acute and community experience and dedicated quality improvement project time. To evaluate the placement we used a mixed methods study based on Kirkpatrick's model of workplace learning. Level 1 (trainee reaction) was evaluated using Job Evaluation Study Tool questionnaires and nominal group technique. Levels 2 and 3 (trainee learning/behaviour) were assessed using a Likert-style survey mapped to curriculum objectives, e-portfolio completion, nominal group technique and documentation of completed quality improvement projects and oral/poster presentations. Sixty-eight foundation trainees underwent the new placement. A similar-sized 'control' sample (n = 57) of surgical Foundation trainees within the same Trust was recruited. The trainees in the peri-operative placement attained both generic Foundation and specific peri-operative curriculum competencies, and gave higher job satisfaction scores than trainees in standard surgical placements. The top three ranked advantages from the nominal group sessions were senior support, clinical variety and project opportunities. Universal project completion resulted in high rates of poster and platform presentations, and in sustained service changes at hospital level.

Clinical guideline and recommendations on pre-operative exercise training in patients awaiting major non-cardiac surgery

Despite calls for the routine implementation of pre-operative exercise programmes to optimise patient fitness before elective major surgery, there is no practical guidance for providing safe and effective exercise in this specific context. The following clinical guideline was developed following a review of the evidence on the effects of pre-operative exercise interventions. We developed a series of best-practice and, where possible, evidence-based statements to advise on patient care with respect to exercise training in the peri-operative period. These statements cover: patient selection for exercise training in surgical patients; integration of exercise training into multi-modal prehabilitation programmes; and advice on exercise prescription factors and follow-up. Although we acknowledge that further research is needed to identify the optimal exercise prescription in different clinical scenarios, we urge peri-operative teams to make use of these recommendations.