Variability in clinicians' understanding and reported methods of identifying high-risk surgical patients: a qualitative study

Preoperative anaesthesia and other team meetings for complex cases: a narrative review

BACKGROUND

The conventional two-step process for surgical procedures - surgical followed by anaesthetic consultation - may not adequately address the needs of complex cases involving high-risk patients or procedures, leading to increased risks of adverse events. Although surgical team meetings (STM) and multidisciplinary team meetings (MDTM) were implemented many years ago, anaesthesia team meetings (ATM) have recently emerged as potential solutions to enhance perioperative management.

PURPOSE

We aim to systematically review and summarize the existing literature that reflects the main theoretical approaches, practices, effects, and clinical relevance of preoperative team meetings - with specific consideration to preoperative ATM - in managing difficult cases.

METHODS

We performed a narrative review of the literature (1980-2024) to identify studies focusing on the practice and the impact of preoperative meetings on patient outcomes, compliance with treatment plans, and teamwork quality. We provide here a qualitative synthesis of the findings.

RESULTS

Fourteen studies were identified: 11 consider preoperative multidisciplinary team meeting (MDTM), 2 consider preoperative surgical team meeting (STM), and only one anaesthesia team meeting (ATM).

CONCLUSIONS

There is currently not enough robust evidence that preoperative team meetings clearly improve hard patient's outcome parameters. And the place for ATM does not appear to have been studied to date. There is a need for well-designed studies to explore the impact of preoperative ATM on clinical practice improvement, quality of care, and patient outcomes.

Predicting Outcomes Following Lower Extremity Endovascular Revascularization Using Machine Learning

BACKGROUND

Lower extremity endovascular revascularization for peripheral artery disease carries nonnegligible perioperative risks; however, outcome prediction tools remain limited. Using machine learning, we developed automated algorithms that predict 30-day outcomes following lower extremity endovascular revascularization.

METHODS AND RESULTS

The National Surgical Quality Improvement Program targeted vascular database was used to identify patients who underwent lower extremity endovascular revascularization (angioplasty, stent, or atherectomy) for peripheral artery disease between 2011 and 2021. Input features included 38 preoperative demographic/clinical variables. The primary outcome was 30-day postprocedural major adverse limb event (composite of major reintervention, untreated loss of patency, or major amputation) or death. Data were split into training (70%) and test (30%) sets. Using 10-fold cross-validation, 6 machine learning models were trained using preoperative features. The primary model evaluation metric was area under the receiver operating characteristic curve. Overall, 21 886 patients were included, and 30-day major adverse limb event/death occurred in 1964 (9.0%) individuals. The best performing model for predicting 30-day major adverse limb event/death was extreme gradient boosting, achieving an area under the receiver operating characteristic curve of 0.93 (95% CI, 0.92-0.94). In comparison, logistic regression had an area under the receiver operating characteristic curve of 0.72 (95% CI, 0.70-0.74). The calibration plot showed good agreement between predicted and observed event probabilities with a Brier score of 0.09. The top 3 predictive features in our algorithm were (1) chronic limb-threatening ischemia, (2) tibial intervention, and (3) congestive heart failure.

CONCLUSIONS

Our machine learning models accurately predict 30-day outcomes following lower extremity endovascular revascularization using preoperative data with good discrimination and calibration. Prospective validation is warranted to assess for generalizability and external validity.

Intensive care utilisation after elective surgery in Australia and New Zealand: A point prevalence study

Objective

We aimed to describe the characteristics, outcomes and resource utilisation of patients being cared for in an ICU after undergoing elective surgery in Australia and New Zealand (ANZ).

Methods

This was a point prevalence study involving 51 adult ICUs in ANZ in June 2021. Patients met inclusion criteria if they were being treated in a participating ICU on he study dates. Patients were categorised according to whether they had undergone elective surgery, admitted directly from theatre or unplanned from the ward. Descriptive and comparative analysis was performed according to the source of ICU admission. Resource utilisation was measured by Length of stay, organ support and occupied bed days.

Results

712 patients met inclusion criteria, with 172 (24%) have undergone elective surgery. Of these, 136 (19%) were admitted directly to the ICU and 36 (5.1%) were an unplanned admission from the ward. Elective surgical patients occupied 15.8% of the total ICU patient bed days, of which 44.3% were following unplanned admissions. Elective surgical patients who were an unplanned admission from the ward, compared to those admitted directly from theatre, had a higher severity of illness (AP2 17 vs 13, p<0.01), require respiratory or vasopressor support (75% vs 44%, p<0.01) and hospital mortality (16.7% vs 2.2%, p < 0.01).

Conclusions

ICU resource utilisation of patients who have undergone elective surgery is substantial. Those patients admitted directly from theatre have good outcomes and low resource utilisation. Patient admitted unplanned from the ward, although fewer, were sicker, more resource intensive and had significantly worse outcomes.

Does preoperative multidisciplinary team assessment of high-risk patients improve the safety and outcomes of patients undergoing surgery?

BACKGROUND

International guidelines recommend preoperative multidisciplinary team (MDT) assessment for high-risk surgical patients. Preoperative MDT meetings can help to improve surgical care, but there is little evidence on whether they improve patient outcomes.

METHODS

This paper aims to share our experience of MDT meetings for high-risk surgical patients to underline their added value to the current standard of care. An observational study of a retrospective cohort of preoperative high-risk MDT meetings of a tertiary referral hospital between January 2015 and December 2020. For 249 patients the outcomes preoperative data, MDT decisions, and patient outcomes were collected from electronic health records.

MAIN RESULTS

A total of 249 patients were discussed at high-risk MDT meetings. Most of the patients (97%) were assessed as having an American Society of Anesthesiology score ≥ 3, and 219 (88%) had a European Society of Cardiology and European Society of Anaesthesiology risk score of intermediate or high. After MDT assessment, 154 (62%) were directly approved for surgery, and 39 (16%) were considered ineligible for surgery. The remaining 56 (23%) patients underwent additional assessments before reconsideration at a high-risk MDT meeting. The main reason for patients being discussed at the high-risk MDT meeting was to assess the risk-benefit ratio of surgery. Ultimately, 184 (74%) patients underwent surgery. Of the operated patients, 122 (66%) did not have a major complication in the postoperative period, and 149 patients (81%) were alive after one year.

CONCLUSIONS

This cohort study shows the vulnerability and complexity of high-risk patients but also shows that the use of an MDT assessment contributes too improved peri- and postoperative treatment strategies in high-risk patients. Most patients underwent surgery after careful risk assessment and, if deemed necessary, preoperative and perioperative treatment optimization to reduce their risk.

Preoperative multidisciplinary team decisions for high-risk patients scheduled for noncardiac surgery-a retrospective observational study

PURPOSE

Preoperative multidisciplinary team (MDT) meetings are recommended for patients at high risk for perioperative complications and mortality, although the underlying evidence is scarce. We aimed to investigate the effect of MDT decisions on patient management and patient outcome.

METHODS

We conducted a single-centre retrospective cohort study including all noncardiac surgical patients selected for discussion at preoperative MDT meetings from January 2017 to December 2019 (N = 120). We abstracted preoperative data, MDT decisions, and patient outcomes from the electronic health records for analysis.

RESULTS

Of the 120 patients registered for an MDT meeting, 43% did not undergo their initially planned surgery. Only 27% of patients received perioperative management as planned before the MDT meeting. Most surgery cancellations were the MDT's decision (22%) or the patient's decision before or after the MDT discussion (10%). Postoperative complications occurred in 28% of operated patients, and postoperative mortality was 4% at 30 days and 10% at three months, most of which was attributable to postoperative complications. Non-operated patients had a 7% mortality rate at 30 days and 9% at three months. Alterations of perioperative management following MDT discussion were associated with fewer cases of extended length of hospital stay (> ten days).

CONCLUSION

This study shows that preoperative MDT meetings for high-risk noncardiac surgical patients altered the management of most patients. Management alterations were associated with fewer hospital admissions of long duration. These results should be interpreted with appropriate caution given the methodological limitations inherent to this small study.