Abstract
These abstracts are published as supplied and have not been subject to editorial review or correction.
Operation Clean Up in Australian Operating Theatres – A Quality Improvement program by TRA2SH
Dr Davies Jess1,2, Dr Grobler Sophia1,2, Professor Story David1,3
1University of Melbourne, Melbourne, Victoria, Australia
2Royal Darwin Hospital, Darwin, Northern Territory, Australia
3Austin Health, Melbourne, Victoria, Australia
TRA2SH (Trainee-led Research and Audit in Anaesthesia for Sustainability in Healthcare) is a sustainability research network. On March 4th 2020 TRA2SH ran a Clean Up Theatres Day, inspired by Australia’s Clean Up Australia Day campaign. The aim of the day is to encourage departments to reflect, engage and discuss their anaesthetic practice and find ways of reducing theatre waste and their carbon footprint. TRA2SH decided on a theme “Reduce Bluey Use” as the disposable absorbent underpads (DAP, “Blueys/Greenies”) are a high-use, non-recyclable, non-compostable item that are thought to be used for indications other than their intended purpose and contribute to preventable waste.
Methods
TRA2SH recruited anaesthetic trainees via a presentation at the 2019 Victorian Registrar Scientific Meeting, posts in the ANZCA eNewsletter and on Twitter. Trainees hosted Clean Up Theatres Day which included a DAP procurement audit, presenting information to their department, engaging with all theatre staff, and stimulating discussions around theatre waste production. Trainees were encouraged to use ‘reduce, reuse and recycle’ principles to find department-relevant alternatives to DAPs. TRA2SH supported trainees with an information document, posters, advice and promotion of Clean Up Theatres Day via social media, contacts and ANZCA publications.
Results
Of the 19 trainees who responded, seven ran Clean Up Theatres Day in March 2020 in seven theatre departments in Australia. Follow-up surveys indicated that some trainees did not feel empowered to lead an engaging Clean Up Theatre Day, due to a departmental rotation just one month earlier or their “rank” in the department. Others expressed a keenness to participate but not to lead. Enablers included engagement by nursing staff and theatre technicians, presence of established sustainability theatre groups, support from senior staff, presentations and meetings to give context and posters in the surgical office and toilets. Follow-up indicated that after 6 months, posters may still be displayed but be ignored by new rotating staff. One department resisted displaying posters due to “cluttered” walls and infection control. One trainee suggested displaying posters where DAPs are taken from. In one hospital, wards joined the “Reduce Bluey Use” campaign showing the power of word-of mouth and collective action. Resources provided by TRA2SH were found to be useful, especially a Frequently Asked Questions page. The COVID-19 pandemic caused major disruption to theatre activity and waste practices and was a barrier to reducing DAP use.
Discussion
The inaugural Clean Up Theatre Day demonstrated that trainee-led sustainability projects are feasible and that there is an appetite for more sustainable practices. Department-level initiatives can provide opportunities for trainees to practice their non-clinical skills such as leadership, engagement, teaching and professional development. Collectively we can tackle the burden of operating waste and achieve cost savings in procurement, waste management and carbon footprint.
Clean Up Theatres Day will be hosted on 22 April 2021.
Acknowledgements
TRA2SH trainees who participated
Departmental funding
None
Comparing thoracic epidural analgesia (TEA) with continuous wound infusion catheters (CWIC) in simultaneous pancreas kidney (SPK) transplantations.
Dr Reed Isabelle1, Dr Falko Adermann1, Dr Alan Bullingham1
1Westmead Hospital, Sydney, New South Wales, Australia
SPK transplants require midline incisions and are often performed on complex patients with multiple comorbidities. In the past post-operative pain was often managed with TEA. The transplant surgeons had expressed dissatisfaction with TEA for two reasons: time to insert a TEA was felt to contribute to increasing cold ischaemic time potentially impacting graft survival and subsequent post-operative hypotension may encourage administration of large volumes of intravenous fluids increasing complications such as wound breakdown. This initiated a change in practice utilising CWIC as routine regional anaesthesia for SPK transplants. We decided to investigate outcomes between the different regional analgesia techniques in our population of SPK transplant patients.
Methods
Ethics committee approval was obtained. A retrospective cohort-controlled study comparing verbal response pain scores (VRS), perioperative fluid administration, lowest systolic blood pressure and urine output (UO) in patients undergoing a SPK transplant at Westmead Hospital (25–30 SPK transplants done per year). 16 patients who had a TEA were compared to the same number of patients with CWIC. All patients in the CWIC group had a PCA and 0.2% ropivacaine either as an infusion or programmable intermittent bolus via the wound catheters. The TEA group had 0.125% bupivacaine with 2.5mcg/ml fentanyl via the epidural and only received a PCA if the epidural was deemed inadequate. Patients who required admission to the Intensive Care Unit (ICU) post-operatively or required a return to theatre were excluded. Continuous variables were compared with Mann-Whitney U test and proportions were compared with Chi square test. p < 0.05 was accepted to indicate clinical significance.
Results
VRS both at rest and on movement were significantly lower in the epidural group at 1, 6, 12 and 24 hours post-operatively. At 48 and 72 hours there was no difference in VRS at rest or movement between the two groups. At six hours the difference was most marked (mean VRS at rest TEA 1.8 vs CWIC 4.0 (p < 0.001), mean VRS on movement TEA 3.5 vs CWIC 5.9 (p < 0.001)). At 24 hours total urine output was more in the CWIC group than TEA (Mean UO CWIC 7969mls vs TEA 5828mls p < 0.05). Both groups received considerable amounts of post-operative fluid according to the SPK transplant protocols. CWIC group received more fluid although not significantly in the first 48 hours (mean total fluids TEA 16624mls vs CWIC 20139mls p = 0.070). There were no significant differences in other outcomes although there were trends for less blood loss with TEA (TEA 533mls vs CWIC 843mls p = 0.5), higher ICU admission rates for CWIC (CWIC 16% vs TEA 8% p = 0.3) and longer hospital stay with TEA (TEA 9.3 days vs CWIC 8.5 days p = 0.065). There was no difference in mean lowest systolic blood pressure for any time period.
Discussion
TEA provided better analgesia for SPK transplant patients with midline incision for the first 24 hours post-operatively, which is consistent with findings in larger studies [1,2]. TEA was not associated with greater cardiovascular instability or ICU admission rates nor did it result in infusion of greater amounts of fluid administered intravenously. CWIC analgesia did result in better urine output and analgesia was similar after 24 hours. Our other results were not significant but were reassuring that change from TEA to CWIC analgesia would not negatively impact outcomes.
References
Surgical day care unit (SDCU) fasting clock – an initiative to reduce prolonged preoperative fasting times in patients undergoing elective colorectal and bariatric surgery.
Dr Joanna Yu1,2, Dr Carin Lye3, Dr Gerard Eames3
1Rockhampton Hospital, Rockhampton, Queensland, Australia
2University of Queensland, St Lucia, Queensland, Australia
3Royal Brisbane and Women’s Hospital, Herston, Queensland, Australia
Current evidence-based fasting guidelines recommend the intake of clear fluids (CF) up to 2 hours prior to the induction of anaesthesia. Optimising preoperative fasting times is one of the key strategies in enhanced recovery protocols for gastrointestinal surgery. Despite this, a pre-intervention audit showed that over 65% of elective colorectal and bariatric patients were fasting for prolonged periods of time (i.e. more than 6 hours). This quality improvement project aimed at reducing prolonged CF fasting times in patients presenting for elective colorectal and bariatric surgery at the Royal Brisbane and Women’s Hospital (RBWH). Exemption from full ethical review was obtained from the RBWH Human Research Ethics Committee (HREC) before commencement of this project (Ref no: LNR/2019/QRBW/57022).
Methods
A CF fasting clock trial was implemented in the SDCU of RBWH over a five-week period between 18/2/20 to 23/3/20. The trial included all elective adult outpatients booked on a public bariatric or colorectal surgical list. Patients who were scheduled for an early 8:00am surgery start time, or those flagged as a high aspiration risk were excluded from this trial. Upon arrival to SDCU, pre-identified eligible patients were given a questionnaire to document their current fasting time, as well as hunger and thirst scores (on a scale of 0–10 with 10 being the most hungry or thirsty). Following communication with the patient’s anaesthetist, SDCU nurses offered patients up to 200ml of clear fluids if they were expected to be waiting a minimum of two hours before their scheduled surgery. A new fasting time was then calculated by subtracting the anaesthesia induction time from the time the patient received CF in SDCU. The patient’s hunger and thirst scores were again recorded after receiving CF.
Results
Over the five-week period, a total of 22 patients qualified and participated in the fasting clock trial. Of these, 10 (45%) patients successfully received CF in SDCU. The mean ( ± standard deviation) baseline CF fasting time for this group was 10 ( ± 4.25) hours, which was subsequently reduced to 4 ( ± 1.25) hours after receiving CF in SDCU (p < 0.05). The median baseline thirst and hunger score was 5.5 and 3.5 respectively. After receiving CF, the median hunger and thirst scores were both reduced to 2.5. An appropriate reason was documented for most of the remaining patients who did not receive CF during the trial (n = 8 [out of 12], 67%), with the most common explanation being inadequate time before surgery to offer CF. There was no evidence that the SDCU fasting clock trial caused any list delays or compromise to patient safety.
Discussion
The SDCU fasting clock trial has proven to be a safe and effective method of optimising preoperative CF fasting times in elective bariatric and colorectal patients. The improvement of patients’ hunger and thirst scores may also be an indicator of enhanced patient satisfaction. The fact that most patients could not receive CF in SDCU due to inadequate time, emphasises the importance of patient education regarding optimal fasting times at an earlier stage in the surgical journey (i.e. preanaesthesia clinic). Future fasting clock trials should expand to involve all elective surgical patients, and include the consumption of carbohydrate rich fluids, as this may improve gastric emptying whilst potentially mitigating some of the deleterious metabolic and psychological effects of fasting.
Acknowledgements
We would like to acknowledge Dr Kate McCrossin who championed the original RBWH fasting clock initiative and for her help overseeing this project, and Dr Tommy Lam for his help with the pilot audit which helped to identify the issue of prolonged fasting times in elective colorectal patients.
Postoperative opioid requirement in elective primary unilateral knee replacement surgery at Alfred Health: a follow-up retrospective cohort study.
Dr Alexandra Bolger1, Dr Jennifer Reilly1, Dr Jonathan Nicholson1, Dr Alex Konstantatos1, Dr Kerry McLaughlin1, Dr Dr Carolyn Arnold1
1Alfred Health, Melbourne, Victoria, Australia
Background
At Alfred Health, ERAS protocols for knee replacement surgery include slow release (SR) opioids for postoperative analgesia. Our retrospective cohort study conducted on postoperative analgesia after total knee joint replacement (TKR) in 2017–18 found that 98.4% of patients received SR opioids postoperatively, SR opioids were rarely tapered during admission and 86% of previously opioid naïve patients were discharged on SR opioids. The ERAS protocol was subsequently updated to limit SR opioid use. In July 2019, a protocolised electronic prescribing plan (“Power Plan”) for TKR was introduced in the Cerner electronic medical record. We conducted a follow-up study to assess the change in pattern of SR opioid prescription after introduction of the Power Plan.
Methods
We studied the 64 primary unilateral elective TKR surgeries that were performed at Alfred Health between July and December 2019. Primary outcomes were; duration of SR opioid prescription, number of doses administered, total daily opioid requirement (Oral Morphine Equivalents – OME), and average daily pain scores. Secondary outcomes included safety indicators (lowest daily respiratory rate, sedation score, MET calls and naloxone use) and quality of recovery indicators (length of stay).
Results
Median patient age was 71 with a range of ASA-PS scores; 1–2 (62.5%), 3 (35.9%) and 4 (1.6%). These patient demographics paralleled those in the original study. 98.4% of patients in the follow up study were prescribed the TKR Power Plan. 78.1% of patients were opioid naïve and received SR opioids for a median of 4 days, with a median of 6 doses. Median OME on the first 3 postoperative days were 38, 45 and 30mg respectively. Average maximum pain score on the first 3 postoperative days were 6, 5.3 and 5 out of 10 respectively. 21.9% of patients were opioid tolerant with a baseline preoperative opioid requirement of 32mg OME. This group received SR opioids for a median of 3.5 days with a median of 5.5 doses. Median OME on the first 3 postoperative days was 46.5, 60 and 30mg. The average maximum pain score on the first 3 postoperative days was 5.64, 6.5 and 5.6.
Preoperative opioid tolerance was 26.2% in our original study and 21.9% in the follow up study. The introduction of an electronic prescribing plan was associated with a significant reduction in postoperative SR opioid prescription, daily OME and number of opioid doses. Additionally, there was a large reduction in discharge prescription of SR opioids; from 86.1% to 44% for opioid naïve patients, and from 88% to 50% in opioid tolerant patients.
There was no instance of respiratory depression in either study. There was a reduction in MET calls from 9.7% of patients in the original study to 1.6% in the follow-up and a reduction in ward naloxone administration from 2.6% to 0% of patients.
Conclusion
Our data demonstrated a significant reduction in postoperative SR opioid prescription in hospital and on discharge with the use of an electronically prescribed protocolised postoperative opioid analgesia plan. There was no acute harm detected relating to opioid administration in this small sample size.
References
Does the transfusion of perioperative blood products influence outcomes following orthotopic liver transplantation?
Dr Timothy Duong1, Dr Michael Paleologos1, Professor Peter Kam1
1Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
Introduction
Conflicting results have been reported concerning the effects of transfusion of blood products on several outcomes in liver transplantation. De Boer et al. found that intraoperative platelet transfusion was associated with an increased mortality in liver transplant patients [1]. An increase in mortality associated with intraoperative transfusion of packed red blood cells in liver transplant patients has been reported [2].
The aim of this retrospective cohort study was to assess the independent effects of perioperative transfusion of blood products on outcomes in liver transplant recipients.
Methods
Four hundred and thirty-three patients underwent orthotopic liver transplantation between 2002 to 2011 at the Royal Prince Alfred Hospital (RPAH). Data from a prospective database of the Australian National Liver Transplantation Unit at RPAH were analysed. Patient demographics, Model for End Stage Liver Disease (MELD) score and the amount and type of blood product transfused were evaluated with univariate and multivariate analysis of outcomes. These included mortality rates 1 and 5 years after transplantation, postoperative infections, and organ rejection.
Results
The transfusion of ≥5 units of pooled platelets was associated with decreased 5 year patient mortality (hazard ratio: 0.335, P = 0.009) and 5 year graft failure (hazard ratio 0.359, P = 0.009). Platelet transfusion was also associated with an increased incidence of postoperative infection (odds ratio: 2.50, P = 0.045). Packed red blood cell transfusion (PRBC) was not associated with increased mortality, graft failure or increased postoperative infections in a multivariate logistic regression model. Fresh frozen plasma (FFP) transfusion was associated with increased 5 year patient mortality (hazard ratio: 2.424, P = 0.022) but was not associated with increased postoperative infections. The transfusion of cryoprecipitate was not associated with increased mortality, graft failure or postoperative infection following liver transplantation (P > 0.05). There was no association between the transfusion of any blood product and increased mortality or graft failure at 1 year. MELD score (median = 17.4) was used to adjust for confounding in the multivariate analysis.
Discussion
In contrast to de Boer’s study, this retrospective cohort study demonstrated that perioperative platelet transfusion was associated with decreased 5 yeart mortality and graft failure rate following liver transplantation. Perioperative transfusion of PRBC and cryoprecipitate was not associated with increased patient mortality or graft rejection.. This contrasts to previous studies which linked blood product transfusion to increased patient mortality and graft failure in this cohort of patients. However, transfusion of FFP was associated with an increase in 5-year mortality of the recipients. Animal studies have demonstrated that transfused platelet have a protective immunomodulatory effect mediated by MHC class I [3 ]. This may explain the decreased 5 year mortality and graft failure rates in the patients who had perioperative transfusion of platelets in this study.
References
When all else fails, is COFFEE the solution? (Carbon Offset Funding For Environmental Emissions)
Dr Gregory Leverett1, Dr Nathaniel Hiscock1, Dr Lyndsay Thompson2, Dr John Hay3
1Department of Anaesthesia, Eastern Health, Victoria, Australia, Department of Anaesthesia
2St Vincent’s Hospital, Melbourne, Victoria, Australia
3Department of Anaesthesia, Goulburn Valley, Shepparton, Victoria, Australia
Introduction
Anaesthesia shares a number of similarities with aviation, especially the latter’s influence on anaesthesia’s emergency and safety protocols. A less flattering comparison between the two industries is the significant environmental harm caused by their emissions.
Concerns regarding the evermore apparent effects of volatile agents and nitrous oxide (N2O) on the environment has led anaesthetists down a “greener” path. Although the authors advocate that reducing or replacing these agents should be the priority, we explore an offset model (similar to that used by the aviation industry) as a contingency to neutralise the carbon footprint from their continued use.
Methods
The 20-year Global Warming Potential (GWP20) for the volatile anaesthetics and the 100-year Global Warming Potential (GWP100) for N2O were obtained from previously published data [1,2]. The standard for our analysis was one MAC-hour in a 40-year-old patient with either sevoflurane (2%) or desflurane (6%), or 0.6 MAC-hour with N2O (60%), with fresh gas flows of one litre per minute. These were expressed as their Carbon Dioxide Equivalent (CDE20 for the volatiles, CDE100 for N2O). We compared two different carbon prices and used a comparator that anaesthetists are familiar with – the price of a Melbourne barista coffee, of A$4.20. As of January 2021, exchange rates were A$1 = US$0.77 = €0.64
Results
One MAC-hour of sevoflurane produces 4.3kg CDE20 and desflurane 168.1kg CDE20. One hour of 60% N2O produces 17.1kg CDE100. Using the carbon offsetting price employed by Atmosfair (€23/tonne, A$36.18) the cost to offset one MAC-hour of sevoflurane was A$0.16 compared to A$6.08 for desflurane and $0.61 for 0.6-MAC-hour of N2O. Using the lower end of the proposed international carbon price supported by the World Bank (US$40/tonne, A$51.80 AUD), the offset cost of one MAC-hour of sevoflurane was A$0.22, desflurane A$8.70 and 0.6-MAC-hour of N2O A$0.89. Taking one anaesthetic list’s volatile emissions to be eight MAC-hours, sevoflurane could be offset for the price of 0.30 to 0.42 coffees per day ($1.25 – $1.78), compared to 11.6 to 16.6 coffees per day ($48.65 – $69.66) for desflurane, while eight hours of 0.6-MAC of N2O would require 1.1 to 1.7 coffees ($4.88 – $7.12). Proposed offset funding models include incorporation into the wholesale cost of the agent; hospitals and/or anaesthetists independently offsetting their own emissions; and (similar to the aviation industry) patients voluntarily offsetting their own anaesthetic.
Discussion
Anaesthetists should be encouraged to replace or reduce inhaled anaesthetic agents; however, they still have a fundamental role in everyday practice. We propose a “last resort” financial model to assist in reducing the environmental harm caused by inhaled anaesthetics, and in some cases, “going green” can be for less than the price of a coffee per day.
References
Postoperative recommencement advice for antithrombotic agents
Dr James Cheng Jiang1, Dr Leisa Watson2, Dr Roshan Reginald1, Dr Basel El-Behesy1
1Department of Anaesthesia, Eastern Health, Victoria, Australia
2Faculty of Medicine, Nursing and Health Science, Monash University, Victoria, Australia
Preoperative cessation of oral antithrombotic agents is often indicated to reduce the risk of excessive intraoperative bleeding. Patients that are prescribed such agents have a higher baseline risk of developing thromboembolic events postoperatively. Therefore, recommencement is routinely recommended after achieving postoperative haemostasis [1, 2]. A previous study has suggested that antiplatelet agents are sub-optimally restarted [3]. This study aims to observe the rate of postoperative recommencement advice given to patients who ceased antithrombotic medication/s prior to elective surgery.
Methods
121 patients (>18 years) were recruited over a 2-month period from August to October 2019 in a prospective observational study across 2 hospitals in a metropolitan Victorian health service. Patients undergoing elective surgery that were advised preoperatively to withhold antithrombotic medications were included. Patients with a history of memory or cognitive impairment were excluded. Patients discharged from hospital <72 hours postoperatively were followed up by telephone questionnaire to determine if they had received recommencement advice for their antithrombotic medications and, if they had followed the advice. Patients discharged >72 hours postoperatively had their medical records reviewed for documentation of recommencement plans.
Results
Of 94 patients discharged <72 hours postoperatively, 18 were lost to follow up and 76 were analysed. 18/76 (23.7%) could not recall receiving antithrombotic recommencement advice while 2/76 (2.6%) recalled instructions but had not followed them. 56/76 (73.7%) either had their antithrombotic agent restarted before hospital discharge or followed their provided discharge advice. 11/18 (61.1%) patients who did not recall instructions had already restarted their antithrombotic medication at the time of being called (48–72 hours postoperatively); 9 of whom had not consulted a medical practitioner. A further 3/27 (11.1%) patients discharged >72 hours postoperatively had no documented antithrombotic recommencement plan in their medical records.
Of all 103 patients analysed, 11/29 (37.9%) patients taking antiplatelets and 9/52 (17.3%) taking Direct Oral Anticoagulants (DOACs) were discharged without recommencement advice. The remaining patients, comprising of patients taking warfarin (n = 17), enoxaparin (n = 1) or multiple classes of antithrombotic agents (n = 4), all received adequate recommencement instructions.
Discussion
A significant proportion of patients (20.4%) did not receive adequate instructions to recommence preoperatively withheld antithrombotic agents. Patients taking antiplatelet agents and DOACs were most likely to be discharged without recommencement advice. Patients who had not received advice were likely to restart without seeking medical advice or fail to restart antithrombotic agents, creating potential for postoperative complications.
References
Effects of rotational thromboelastometry-guided transfusion management in patients undergoing surgical intervention for post-partum haemorrhage: an observational study
Dr Yiying (Sally) Tsang1,2, Dr Ade Kurniawan1, Dr Owen Tomasek1, Dr Elizabeth Hessian1, Dr David Bramley1, Dr Oliver Daly3, Dr Koen Simons4,5, Dr Georgina Imberger1
1Department of Anaesthesia, Pain and Perioperative Medicine, Western Health, Victoria, Australia
2Department of Anaesthesia, Perioperative and Pain Medicine, Peter MacCallum Cancer Centre, Parkville, Victoria, Australia
3Department of Obstetrics and Gynaecology, Western Health, Footscray, Victoria, Australia
4Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne
5Western Health Office for Research, Western Health, Victoria Australia
Our observational cohort study, conducted in a 600-bed metropolitan hospital in Melbourne with a level five maternity service, aimed to measure effects of a ROTEM-guided transfusion protocol on transfusion practice and clinical outcomes in patients with PPH managed in the operating theatre. Our hypothesis was that implementation of a ROTEM-guided transfusion protocol would reduce the proportion of patients with PPH managed in the operating theatre who required a packed red blood cell (PRBC) transfusion. Secondarily, we also aimed to measure the effects of ROTEM-guided transfusion on requirement for other blood products (fresh frozen plasma (FFP), platelets and cryoprecipitate), hysterectomy and intensive care unit (ICU) admission.
Study design and methods
We compared data collected from 450 consecutive patients treated from July 2015 to May 2016 (‘pre-ROTEM cohort’) and 450 consecutive patients from September 2017 to April 2018 (‘post-ROTEM cohort’), following approval by our hospital ethics committee in October 2017. The inclusion criterion was all women managed for PPH in the operating theatre, with no exclusions. The intervention was the introduction of ROTEM in the operating suite in June 2016, alongside a transfusion algorithm and clinical education on ROTEM-guided transfusion management. Multivariate regression was used to evaluate the effect of ROTEM introduction on the primary outcome, proportion of patients requiring a PRBC transfusion, adjusting for demographic and obstetric confounders, as well as secondary outcomes as described above. Pre-planned subgroup analysis was performed according to mode of delivery (vaginal vs caesarean).
Results
90 (20%) of patients treated prior to ROTEM introduction received a PRBC transfusion, compared with 102 (22.7%) of those treated after ROTEM introduction (adjusted odds ratio (OR) 1.4, p = 0.04). This was not supportive of our hypothesis. There was no significant difference in PRBC transfusion in patients undergoing caesarean section (adjusted OR 0.9, p = 0.78). In the post-ROTEM cohort, there was increased use of cryoprecipitate (3.3% vs 2.4%) and reduced use of platelets (5% vs 9%) and FFP (1.3% vs 2.9%) compared to the pre-ROTEM cohort, although these were not statistically significant. There were no significant differences in proportions of patients requiring hysterectomy or ICU admission.
Conclusion
In our institution, the introduction of ROTEM-guided transfusion did not reduce the percentage of patients with PPH treated in the operating theatre who received PRBC transfusion. There was a suggestion of increased cryoprecipitate and reduced FFP and platelet use in the post-ROTEM group, however small numbers of coagulopathic patients precluded statistical significance. Larger multi-centre studies are likely required to further explore areas of uncertainty and clarify the role of ROTEM in PPH.
References
Anaesthetists are primed to leap into action on climate change.
Dr Maximilian Benness1, Dr Matthew Doane1
1Royal North Shore Hospital, St Leonards, New South Wales, Australia
Currently 7% of Australia’s carbon emissions are from healthcare and anaesthetic gases likely comprise ≥5% of this output [1, 2]. Desflurane is a particularly potent greenhouse gas (GHG), which creates an opportunity for significantly reducing GHG emissions (and cost) by more conscious management of Desflurane use and limiting fresh gas flows (FGF) to reduce its consumption. A baseline audit into our department’s volatile usage calculated that the use of Desflurane accounted for roughly 80% of our volatile carbon footprint. With relative equipoise across the department regarding the use of Desflurane vs other available volatile agents, a potential for significant reduction in our carbon footprint was identified via minimising Desflurane use. Motivated hospitals have repeatedly demonstrated significant reductions in GHG emissions through rationalisation of inhalational anaesthesia practices. In keeping with current ANZCA and international society recommendations, we sought to promote clinically appropriate, yet more socially responsible usage of volatile anaesthetics and assess the impact on our carbon footprint.
Methods
A simple, staged, multimodal intervention, was designed, with an aim of promoting culture change over a 6-month period. This program constituted a brief departmental presentation, followed by further promotion via departmental newsletters and finally placement of educational posters across targeted areas of the operating theatre complex. All three interventions were geared at staff education and encouraged alternatives to Desflurane, combined with practices to minimise Desflurane consumption when utilised. A follow-up audit of volatile consumption after 9 months created a month-on-month comparison from the previous year, which was adjusted by the volume of cases to compensate for any alterations due to the pandemic.
RESULTS
Following this simple, three-staged, intervention our department achieved >58% reduction in Desflurane use (despite adjusting for lower case volumes). This equated to >$46,000 in cost savings and a 360 tonne eCO2 reduction over the 9 months since implementation.
DISCUSSION
These results are particularly encouraging given the ease and simplicity of our interventions. This quality improvement project affirms that educational interventions can drive practice change to achieve significant environmental and financial impacts. Our results highlight that the anaesthetic community is primed to move in leaps and bounds in response to the climate change emergency. It is clear from this project that targeted educational interventions (at least in key areas such as this) do not require extensive or expensive campaigns to be successful.
Analysis of the monthly volatile usage demonstrates the impact of each interventional stage in driving continued practice change. Our results support the benefits of targeted, repeated promotion to achieve meaningful culture change. We therefore encourage other departments to consider similar multi-dosed interventions to address their environmental impacts and join a growing number of institutions that are responsibly bounding towards a better future.
REFERENCES
Influence of metabolic syndrome and hypercoagulability on post-operative troponin levels in patients undergoing major orthopaedic surgery
Dr Usha Gurunathan1,3, Dr Scott Mckenzie1, Associate Professor Victoria Eley2,3, Mr Joel Hines1, Mrs Bronwyn Pearse1, Dr Karen Hay4, Professor Harshal Nandurkar5
1The Prince Charles Hospital, Brisbane, Queensland, Australia
2Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia
3University of Queensland, Brisbane, Queensland, Australia
4Queensland Institute of Biomedical Research, Brisbane, Queensland, Australia
5Alfred Health and Monash University, Melbourne, Victoria, Australia
The proinflammatory, prothrombotic state of obesity increases the risk of perioperative cardiovascular complications. We aimed to explore the association between hypercoagulability and metabolic syndrome with elevated post-operative troponin levels in patients undergoing elective hip or knee replacements (THR, TKR).
Methods
With individual written informed consent and ethics approval (HREC/15/QPCH/123) perioperative troponin changes were analysed in 177 adult patients enrolled in RETHInK-O study. This is an ongoing prospective observational study investigating the association between hypercoagulability and thrombotic complications in THR and TKR patients. Participants were obese, defined as a body mass index (BMI) ≥ 25kg/m2 and/or waist circumference ≥ 94 cm (males) and 80 cm (females). Presence of metabolic syndrome (MetS) was documented [1]. Other documented measures of obesity were waist-hip ratio and neck circumference. Troponins were measured pre-operatively and on post-operative days (POD) 1, 2 and 3 on all patients regardless of symptoms. Myocardial injury was defined as (1) postoperative hs-cTnI >99th percentile of upper reference limit: females: ≥ 10 ng/L, males ≥ 20ng/L with atleast 5 ng/L elevation from the baseline concentration (2) or any value > 0.04 µg/L for cTnI. Preoperative hypercoagulability was measured using ROTEM and was defined as a G score of ≥11 dynes/cm2. [G score for ExTEM MCF = (5000 x MCF) /100-MCF]. Logistic regression modelling was used to explore the associations between hypercoagulability and MetS with increased post-operative troponin levels.
Results
Of 177 patients, 175 with preoperative and at least one post-operative troponin level were included in this analysis. 50 patients had cTn and 125 patients had hs-cTnI measured. Overall, 26 patients (15%, 5 with cTn and 21 with hs-cTnI) had at least one elevated postoperative troponin level consistent with myocardial injury. Elevated troponin levels were found in five patients preoperatively, nine, 18 and 25 on POD 1, 2 and 3 respectively.
Significantly higher postoperative troponin levels were observed in those with MetS than those without MetS (42% vs 19%; p = 0.02). With logistic regression modelling adjusting for gender, MetS was found to be a strong and independent predictor of myocardial injury (OR: 3.4; 95% CI: 1.4–8.3; p = 0.008). There was no association between elevated post-operative troponins and preoperative hypercoagulability or individual obesity measures.
Discussion
Metabolic syndrome but not hypercoagulability was associated with elevated post-operative troponin levels in patients undergoing major lower limb orthopaedic surgery.Postoperative troponin elevations can be associated with significant mortality within 30 days following non-cardiac surgery [2]. Our findings allude to a possible role for postoperative cardiac troponin measurement in patients with metabolic syndrome.
References
MEasuring the impact of Anaesthetist-administered medications volumeS on intraoperative flUid balance duRing prolonged abdominal surgEry (MEASURE study)
Associate Professor Laurence Weinberg1,2, Dr Dong-Kyu Lee3, Dr Hannah Bergin1, Dr Anoop Koshy4, Dr Patrick Tully1, Dr Joshua Meyerov1, Dr Maleck Louis1, Dr Bobby Ou Yang1, Dr Olivia Grover Johnston1, Dr Nick Scurrah1, Professor Luka Cosic1, Dr David Story1,5, Dr Rinaldo Bellomo1,5
1Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
2Department of Surgery, The University of Melbourne, Heidelberg, Victoria, Australia
3Department of Anesthesiology and Pain Medicine, Korea University Guro Hospital, Guro-Gu, Seoul
4Department of Cardiology, Austin Health, Melbourne, Victoria, Australia
5Centre for Integrated Critical Care (CICC), The University of Melbourne, Melbourne, Victoria, Australia
Background
Intraoperative delivery of anaesthetic medication volumes may be important in patients having major pancreatic surgery. However, their contribution to the total volume of intraoperative intravenous (IV) fluid therapy and their association with postoperative outcomes have not been assessed. The aims of this study were to evaluate the contribution of intraoperative anaesthetist-administered medications (IAAMs) to the total volume of intraoperative intravenous (IV) fluid therapy and their association with postoperative outcomes.
Methods
Consecutive patients undergoing open pancreaticoduodenectomy between January 2011 and October 2020 were included in this study. Detailed information about the volume of IAAMs, crystalloids and colloids, blood and blood products, blood loss, urine output and intraoperative fluid balance were collected. Complications were graded according to the Clavien Dindo classification. We then quantified the contribution of IAAMs to the total intraoperative IV fluid volume and assessed their association with postoperative complications.
Results
A total of 152 consecutive patients (mean age 63.7 (12.5) years, 69.1% male) were included. The median volume of IAAMs was 363.8 mL (interquartile range [IQR], (241.0 – 492.5) delivered at a median rate of 0.61 mL/kg/hr (0.40–0.87) over a median duration of surgery of 489 min (416.3‒605.3). This increased the total administered fluid volume by 5.2% (95% confidence intervals [CI]: 4.6, 5.9%) (Cohen’s d = 1.33, p < 0.001). The volume of IAAMs was comparable to the intraoperative colloid volume administered (median colloid volume, 400 mL). Overall, fluid volumes correlated significantly with the severity of complications (Spearman’s rho = 0.207, p = 0.011), and the correlation strength increased when the IAAMs volume was included (Spearman’s rho = 0.226, p = 0.005). On addition of IAAMs, the area under the receiver operator characteristic (ROC) curve for prediction of postoperative complications increased from 0.580 (95%CI: 0.458, 0.701) to 0.603 (95%CI: 0.483, 0.723). p = 0.041).
Conclusion
In patients undergoing open pancreaticoduodenectomy, IAAMs significantly increased the total administered fluid volume. Their inclusion increases the accuracy of postoperative complications predictions. These findings support their inclusion in fluid volumes and balances in future interventional studies. Registered with the Australian New Zealand Clinical Trials Registration (no: ACTRN12620001208998; registered 13th November 2020).
Reported definitions of intraoperative hypotension in surgical patients under general anaesthesia
Ms Stephanie Li1,2, Dr Maleck Louis1, Mr Jadon Karp1, Dr Nadia Poci1, Dr Patrick Tully1, Associate Professor Laurence Weinberg1,3
1Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
2Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
3Department of Surgery, The University of Melbourne, Austin Health, Victoria, Australia
Intraoperative hypotension (IOH) is a common intraoperative complication that has been associated with postoperative morbidity and mortality [1]. Despite its importance as a modifiable risk factor, there is no consensus definition of intraoperative hypotension [1, 2]; varying definitions give rise to incidences anywhere between 5 and 99% of surgical patients [2]. This study aims to review reported definitions for intraoperative hypotension in studies of adult and paediatric patients undergoing surgery with general anaesthesia. Key elements of a definition were chosen to be: (1) choice of blood pressure for optimisation (i.e. mean arterial pressure (MAP), systolic blood pressure (SBP) or diastolic blood pressure (DBP)); (2) numerical threshold for defining hypotension; (3) baseline blood pressure definition for relative thresholds; and (4) methodology for ascribing severity.
Methods
A search of the literature from 2000 to 2020 was conducted in the Medline (OVID), Embase (OVID) and the Cochrane Library databases. Broad search criteria using a combination of targeted keywords and medical subject headings (MeSH) were used. Primary research studies, including randomised and non-randomised controlled trials, case-control studies and cohort studies, that reported a definition of intraoperative hypotension were included, as were conference abstracts meeting inclusion criteria. All surgical techniques were included, but anaesthetic techniques were limited to studies reporting outcomes for patients under general anaesthesia. The PRISMA criteria and the Covidence platform were used to select articles and extract data for analysis. The study was prospectively registered with the National Institute of Health Research International prospective register of systematic reviews (PROSPERO no: CRD42020204661).
Results
After applying the selection criteria, 401 studies were included in this review of the initial 3,204 that were identified. Studies included were heterogeneous in their population, surgical procedure and objective. There was considerable variability in the definition of hypotension used in the literature. Commonly, single studies reported multiple definitions. Definitions of hypotension were largely based on either SBP or MAP with few studies using DBP alone. The most frequently used definitions of hypotension were absolute; either an SBP less than 80–90mmHg or MAP less than 60mmHg. Where a relative definition was used, a 20% decrease from the baseline measurement of either MAP or SBP was most frequently seen. Studies in paediatric populations were more likely to use a relative definition of hypotension. Where a relative definition of hypotension was used, a baseline blood pressure was necessary for reference. Studies reporting a baseline commonly used pre-induction blood pressure. The majority of studies did not apply a measure of duration or severity to their IOH calculation. Reported methodologies included measurement of the number of episodes of hypotension, total duration, lowest blood pressure and a time-weighted sum or area under the curve.
Discussion
This is the largest synthesis of reported definitions of intraoperative hypotension to date. There remains no consensus definition of intraoperative hypotension in the literature. Our results reflect a change to more conservative blood pressure targets over the last decade, perhaps as the association between intraoperative hypotension and poor postoperative prognosis has become more widely studied. Standardisation of a definition is necessary to support clinical practice and comparability between studies examining associations between intraoperative hypotension and postoperative outcomes.
References
Intraoperative hypotension in elder patients (iHypE): a retrospective cohort study of hypotension treatment thresholds in Queensland.
Dr Stefan Saric1, Dr Adeel Aftab1,2, Dr David Highton1,2
1Queensland Anaesthetic Registrars’ Research Collaborative (QARRC), Queensland, Australia
2PA Southside Clinical Unit, University of Queensland, Brisbane, Queensland, Australia
Intraoperative hypotension (IOH) is associated with organ injury (1) and mortality in older patients (2). Maintaining mean arterial pressure (MAP) > 65mmHg or avoiding a >20% drop from baseline systolic blood pressure (SBP) are suggested targets, as morbidity is associated with IOH beyond these boundaries (1). The clinically applied IOH treatment threshold has not been defined in Australian practice, and this is essential to inform future research and quality improvement. The aim of this study was to identify the prevalence and treatment thresholds for IOH in Queensland.
Methods
This study was conducted by the Queensland Anaesthetic Registrars’ Research Collaborative (QARRC). Following ethical approval (LNR/2019/QMS/51569) data were retrospectively collected over 30 consecutive days from 10 Queensland hospitals for patients aged ≥65 years who underwent non-cardiac surgery. IOH was defined as MAP <65mmHg or >20% reduction from preinduction SBP. Postoperative morbidity was defined via KDIGO criteria for AKI and elevated serum troponin for myocardial injury. Data on administration of vasopressor therapy, stroke, and death at 30 days were also collected. Anaesthetists at each site were concurrently invited to complete an anonymous survey on their intended treatment thresholds for IOH.
Results
There were 1707 patients included (44.7% female; 58.6% aged 65–74 years; 50.1% ASA 3; 93.5% general anaesthesia; 25.5% invasive blood pressure monitoring). IOH was extremely common, with 90.5% of patients experiencing a >20% drop in SBP, and 58.4% having a MAP <65mmHg during their procedure. Nadir blood pressure most frequently occurred during the first 30mins of surgery (56.3%).
A composite adverse outcome of postoperative myocardial injury, AKI, stroke, or death within 30 days occurred in 139 patients (8.1%). This comprised: myocardial injury 28 (1.6%), 30 day mortality 25 (1.5%), AKI 99 (5.8%), stroke 0 (0%). AKI was associated with an intraoperative MAP <65mmHg (OR = 1.772, p = 0.018, 95% CI [1.104, 2.845]).
The survey was completed by 237 anaesthetists (64.6% consultants). Most anaesthetists reported that they used SBP (71.3%) or MAP (93.2%) to titrate fluid and vasopressor therapy intraoperatively. The intended treatment threshold (survey) was <65mmHg MAP for 51% of respondents and below the 20% SBP drop threshold for 29% of respondents. In observed instances of intraoperative vasopressor use, 55% of anaesthetists treated at a MAP ≥65mmHg, but only 22% treated above a 20% drop in SBP.
Discussion
Most patients aged ≥65 years are exposed to IOH during surgery in this Australian cohort. The majority of anaesthetists aimed to treat a MAP <65mmHg and this lower target could contribute to the high prevalence of IOH observed using the study definitions. Tighter control of IOH has substantial potential as a treatment target, however clinical trials are awaited to directly inform the impact of IOH treatment on patient outcomes.
Acknowledgements
QARRC (full contributor list at qarrc.org).
References
Development of a paediatric quality of recovery score
Dr Cameron Graydon1,2, Dr Paul Lee-Archer1,2, Associate Professor Wallis T Muhly3, Associate Professor Paul Stricker3, Dr Elsa Taylor4, Dr Joseph Cravero5
1Queensland Children’s Hospital, South Brisbane, Queensland, Australia
2University of Queensland, St Lucia, Brisbane, Queensland, Australia
3Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States of America
4Starship Children’s Hospital, Auckland, New Zealand
5Boston Children’s Hospital, Boston, Massachusetts, United States of America
Quality of recovery after anaesthesia is an important, multi-faceted end-point that represents the overall health status of a patient after surgery and anaesthesia. It encompasses a patient’s perception of return to ‘well-being’, a combination of physical, psychological, emotional and social factors. In the field of adult perioperative medicine, a quality of recovery tool has been developed and extensively validated (the QoR-40 andQoR-15)[1]. It is now one of the standardised outcome measures included in the Standardised Endpoints in Perioperative Medicine (StEP) initiative. To date, no such instrument exists in paediatric perioperative medicine, however the Paediatric Perioperative Outcomes Group has been established to identify and create standardised instruments to report outcomes in children.
The aim of this project was to develop a pilot quality of recovery tool, responsive and relevant to paediatric patients’ recovery.
Methods
Item generation
1. Literature review for key constructs and existing instruments used in the assessment of recovery.
2. Free-thought brainstorming with health care experts and parents for concepts, themes and endpoints relevant to postoperative recovery.
3. Semi-structured interviews with patients and families to identify important aspects of recovery.
Selection of items
1. Thematic classification of the items into domains and sub-domains
2. Delphi process to create a shortlist of approximately 50 items to use as a pilot tool to undergo psychometric testing.
Results
The literature review of PubMed, search of the grey literature and snowballing references from systematic reviews resulted in the inclusion of 41 adult and paediatric instruments. Free-thought brainstorming with a range of health literate experts was used to expand for missing items or concepts. A sub-group of the authors (WM, PS) conducted semi-structured interviews with stakeholders and focus groups[2]. Information from these steps was assimilated into an item list.
215 items were thematically analysed and matched to 26 conceptual unidimensional sub-domains using the International Classification of Functioning Disability and Health and prior validated instruments. These items were reduced to 92 items (patient/proxy paired questions) after independent review by a sub-group of authors (CG, PLA) evaluating for face validity, ambiguity and responsiveness.
A Delphi exercise with 27 respondents (46 invites to health care experts and health literate parents) was conducted asking respondents to rank each of the items in the sub-domains according to: validity, reliability, feasibility, readability/ambiguity and patient centredness.
The pilot tool was reduced to 48 items by excluding poorly ranked items (or sub-domains if single items).
Discussion
Quality of recovery is a multidimensional construct covering domains of well-being, functioning and postprocedural symptomatology as perceived by the patient and/or carer This tool will be suitable for 2–17 year old children with significantly different developmental and psychological levels, responsive to the whole recovery process, and applicable to the range of procedures children experience.
Construction of this tool follows established mixed methods approaches to questionnaire development[3].
References
Who Delivers Anaesthesia in Rural Australia?
Dr Greg Coates1, Dr Archibald Collyer2
1Djerriwarrh Health Services, Bacchus Marsh, Victoria, Australia
2Carrier Street Clinic, Victoria, Benalla, Australia
Background
Throughout rural and remote Australia, rural generalists provide not just primary care, but also obstetric, emergency and anaesthetic services. They play an important role in servicing local communities where patients would otherwise need to leave from their home towns to gain access to emergency and elective surgery.
General Practice Anaesthetists (GPAs) practice in rural locations throughout Australia and the authors aim to demystify how and where GPAs work. Rural Anaesthetics Down Under (RADU) as a Facebook community was initially created in 2017 to link and support GPAs throughout Australia. The members of RADU have been surveyed repeatedly and this data has been displayed in the poster. RADU has also enabled an open discussion on GPAs roles, creating cohesion amongst our disparate proceduralists.
Methods
This three-year endeavour represents the most comprehensive workforce database on GPAs in Australia. Data continues to be gathered via surveys of GPAs using Facebook posts, messenger, email, phone calls, texts and face-to-face chats. GPAs and trainees are asked about their age, gender, work locations, where they trained, and their current role.
Results
We have identified 668 GPAs currently working in Australia. There are 177 locations where GPAs work across Australia (including fly in fly out locations). A majority of GPAs work in locations with minimal backup – 40% of GPAs work in towns by themselves or with another GPA. Over 90% of GPAs work in Modified Monash Model category 2 or more remote areas (Australian Government Department of Health, 2020). We present this data on the poster and in an interactive map with real-time updates available at http://map.ruralanaesthesia.com.au/
Discussion
Our data provides a unique insight into the workforce of GPAs and redresses myths about their geographical distribution. We have identified 668 GPAs from all over Australia and we continue to update our database as GPAs relocate, retire and new trainees enter the workforce.
Many medical groups struggle to engage with their workforce. In just three short years, this successful model represents a group of GPAs who have been able to come together and be counted.
This data shows that the vast majority of GPAs work in small towns, and often by themselves, but also in larger regional centers and even in Antarctica. There remain some GPAs who work in metropolitan areas, but their numbers are small and this is an identified pattern for older GPAs to move from rural areas to the city.
References
Bullying in Anaesthesia Registrars Survey (BARS)
Dr Peter Benjamin James Garnett1, Dr Scott Douglas1, Dr Richard Riley1, Dr Lindy Roberts2
1Department of Anaesthesia and Pain Medicine, Royal Perth Hospital, Perth, Australia
2Departments of Anaesthesia and Pain Medicine, Sir Charles Gairdner Hospital, Perth, Australia
The impact and prevalence of bullying within health workplaces is an area of ongoing concern for governing bodies, hospitals, staff and patients. Prior to the present study, assessments of bullying in anaesthesia have utilised self-labelled survey tools in which respondents subjective perception of bullying is central in defining prevalence. This study is the first to apply the validated, revised Negative Acts Questionnaire (NAQ-R) to provide a more objective assessment of bullying experienced by anaesthesia trainees [1].
Methods
With ethics approval, a voluntary and anonymous online questionnaire was distributed by the ANZCA Clinical Trails Network to 990 randomly selected ANZCA trainees in Australia and New Zealand. Bullying prevalence was assessing using both a self-labelled tool and the NAQ-R, allowing comparison of subjective and more objective measures. Sources of bullying, impact on recipients and barriers to reporting were also examined.
Results
The survey response rate was 28%. Almost a quarter of respondents (22%) self-labelled as having experienced bullying in the last six- months, with 8% reporting being bullied at least monthly. Bullying was reportedly witnessed by 73% of respondents. The most common behaviours described were humiliation and intimidation.
In response to the NAQ-R, the vast majority of participants (96%) reported they experienced at least one negative act in the last six- months, with over a third (35%) reporting them on a weekly or daily basis.
Using NAQ-R criteria [2], 36% of respondents experienced occasional bullying and 10% were victims of workplace bullying. There was no significant difference in NAQ-R scores between genders, levels of training or major ethnic groups. Anaesthesia consultants were the most commonly reported perpetrators of negative acts (44%) and bullying (66%).
Common effects of bullying reported in free text were increased stress and anxiety, and decreased confidence. Two respondents indicated they sought psychological support, three reported considering leaving the training program, and one stated they had left training because of bullying.
Of respondents that identified as being bullied, only 23% indicated that they had formally reported the behaviours. The main barrier to reporting was concern that it would impact on the respondent’s career. Almost a quarter of respondents that formally reported bullying felt the issue was not addressed.
Discussion
Bullying and negative behaviours experienced by anaesthesia trainees continues to be a significant problem. The rates of bullying indicated by the NAQ-R are greater than those reported using the self-labelled survey tool, suggesting the more subjective approach may be underestimating actual rates of bullying. In either case, it is clear that bullying is experienced by trainees at all levels, can have a profound negative impact on recipients and barriers to reporting are significant. It remains important for all those involved in the training of anaesthetists to be active in reducing negative behaviours and bullying, minimising barriers to reporting and acting appropriately when formal reports are made.
References
Quality over Frailty: an audit of ‘QFIRST’, a novel multi-disciplinary clinic for high-risk surgical patients at a Queensland Tertiary Hospital.
Dr William Curtis1, Dr Andrew Mitchell1, Dr Alex Grosso1
1Sunshine Coast University Hospital, Birtinya, Australia
Introduction
Major and complex surgery is increasingly being performed in patients of advancing age, co-morbidity and frailty. Surgery in these high-risk perioperative patients has been associated with increased complications, hospital length of stay, disability and mortality [1],[2].
The Quality Focused Interventions for the Relief of Symptoms Team (QFIRST) is a novel model of multidisciplinary perioperative care that was trialled at a tertiary teaching hospital in south east Queensland in 2018. It aims to improve the management of high-risk perioperative patients by ensuring the full range of treatments, risks and outcomes were discussed with patients prior to undergoing elective surgical procedures, ensuring decisions on treatment are informed and aligned with the patient’s life goals.
Aims
To evaluate whether the QFIRST pilot clinic, which occurred between April and December 2018 at the Sunshine Coast University Hospital (SCUH) in Queensland, Australia, improved the delivery of healthcare for its high-risk perioperative patients.
Methods
This study was a retrospective clinical audit comparing patients who attended the QFIRST clinic with a control cohort of similarly high-risk surgical patients who underwent elective surgical procedures prior to the QFIRST clinic in 2017. A total of 27 patients were recruited into QFIRST and were compared with a control cohort of 29 patients (n = 56). Data was collected from patient medical records and analysed using Microsoft Excel software.
Results
The QFIRST pilot clinic improved clinical outcomes in the majority of its target areas. QFIRST patients experienced reductions in intra-operative complications (17.6% vs 27.6%), post-operative renal complications (5.9% vs 17.2%), MET call rates (11.8% vs 13.8%), returns to operating theatre (5.9% vs 6.9%), median ICU length of stay (2.5 vs 3.0), discharges to rehab or respite (11.8% vs 17.2%) and post-operative mortality (in-hospital / 30-day: 0% vs 3.4% and 180-day: 3.7% vs 6.9%). In addition, these patients had more comprehensive advanced health planning, more post-op bed de-escalations (11.8% vs 3.4%), as well as no unplanned ICU admissions or hospital readmissions within 28 days. QFIRST did not meet its targets of reducing median hospital length of stay (5.0 vs 5.0) or reducing overall medical (35.3% vs 31.0%) and surgical (23.5% vs 13.8%) complications.
Discussion
This study assessed and compared a large number of pre-, peri- and post-operative outcomes between the QFIRST and control groups. Despite the limited cohort sizes, this study has provided an objective insight into the predominantly positive impact QFIRST has had on the healthcare of high-risk perioperative patients. It will form the platform for ongoing quality improvement and potential propagation of this novel model of care throughout the state and even nationally or internationally.
References
Regional anaesthesia and its association with Victorian inpatient arteriovenous fistula complication rates
Dr Nathaniel Hiscock1, A/Prof Alexander Clarke1, Dr Michael Barrington2
1Department of Anaesthesia and Acute Pain Medicine, St Vincent’s Hospital Melbourne, Melbourne, Australia
2Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
Introduction
Arteriovenous fistula (AVF) formation is performed to enable long-term haemodialysis in patients with end stage kidney disease. Unfortunately, early complications and failure are common, affecting approximately one third of patients, however regional anaesthesia (RA) has been demonstrated in a randomised controlled trial to improve both immediate and primary patency rates at 3 months when compared to local infiltration [1].
Utilising the Victorian Admitted Episodes Dataset (VAED), a comprehensive de-identified Victorian hospital dataset, we have characterised the anaesthetic practice in an Australian setting, incidence of complications during admission for upper limb AVF formation, and their association with RA [2].
We hypothesised that RA would be associated with lower AVF complication rates through providing a local sympathetic blockade and avoiding the potential harms of general anaesthesia in a comorbid population.
Methods
With the help of the Centre for Victorian Data Linkage, we extracted data from the VAED for the period of January 2007 to December 2017. Patients aged 18 years and older who were coded as having a “arteriovenous anastomosis of upper limb” (ACHI 34509–01) were included.
Postoperative complications were identified using the ICD-10-AM diagnosis codes “T82 – Complications of cardiac and vascular prosthetic devices, implants and grafts” along with the ACHI procedure codes “34518-00 – Repair of surgically created arteriovenous fistula”, “38518-01 – Repair of prosthetic (graft) arteriovenous access device” and “34515-00 – Thrombectomy of arteriovenous fistula”. 30-day mortality and a composite of the above codes and 30-day mortality were determined. Sociodemographic data was presented, and multivariate analysis performed to analyse the associations between sociodemographic data, anaesthetic type and outcomes.
Analysis was performed using R with the tidyverse, data.table and comorbidity packages (Alessandro Gasparini) as well as StataSE 13.1. Ethics approval for this study was provided by the St Vincent’s Hospital Melbourne Human Research Ethics Committee (LNR/17/SVHM/126).
Results
There were 4860 admissions with an AVF formation, comprising 3178 men and 1682 women. The median age group was 70–74. Non-metropolitan hospitals accounted for 748 admissions (15.4%) and 1138 (23.4%) were coded as having a “Regional block, nerve of the upper limb” (ACHI 92511-XX).
The overall 30-day mortality rate was 0.43% with no difference between groups (RA risk ratio 0.87; 95% CI 0.29–2.6, P = 0.636). RA was associated with a 23% lower rate of fistula complications and/or death; 11.5% vs 8.88% (risk ratio 0.77; 95% CI 0.63–0.95, P = 0.013).
Discussion
Our findings add to a body of evidence demonstrating improved outcomes with RA for AVF formation. Despite this, RA was only coded as being performed in 23.4% of admissions with an AVF formation in Victoria over an 11 year period.
References
Postoperative Pulmonary Complication Prevention in Elective Cardiac and Major Abdominal Surgery: a feasibility Study
Dr Brian Chen1, Dr Jennifer Reilly2, Dr Jonathan Nicholson2
1Department of Anaesthesia, Joondalup Health Campus, Perth, Australia
2Department of Anaesthesiology & Perioperative Medicine, Alfred Hospital, Melbourne, Australia
Postoperative pulmonary complications (PPCs) are common (incidence 10–50%), costly and a major cause of morbidity to patients following surgery(1). Evidence suggests simple interventions such as patient education can prevent PPCs in the high-risk surgical patient(1), highlighting the need for an easily reproducible, low-cost educational intervention. We created a preoperative educational video about PPCs for high-risk surgical patients which, if effective, could be translated to other health care settings. We investigated patient recall at key points in the surgical care pathway and the feasibility of targeted implementation among patients undergoing elective cardiac and major abdominal surgery.
Methods
A single-centre prospective observational feasibility study of adults undergoing elective cardiac and major abdominal surgery between May to July 2019 at Alfred Hospital, Melbourne, Australia. A two-minute PPC education video was created, containing information about PPCs and four preventative activities – breathing exercises, early mobilisation, effective analgesia and sitting upright. Patients were shown the video during routine attendance at pre-admission clinic (PAC). Recall of the four preventative activities was assessed at PAC, on day of surgery, and on awake postoperative day 1. Feasibility of targeted implementation was measured by patient recruitment rate and video viewing completion rate.
Results
70 eligible patients were identified during the study period. 48 (68%) eligible patients were recruited and all (100%) completed viewing the video at PAC. Reasons for non-participation included workflow factors (time constraints at PAC, n = 13), study resource factors (absence of study coordinator, n = 8), and patient factors (severe cognitive impairment, n = 1). Patients predominantly watched the video on a desktop computer with the PAC nurse (79%, n = 38), with a minority viewing it on a dedicated television unaccompanied in a separate room (21%, n = 10).
After viewing the educational video at PAC, 96% (n = 46) of patients recalled at least one of four preventative activities, and 88% (n = 42) fully recalled the breathing exercises. The median time between PAC attendance and day of surgery was 21 days (range 4–71 days). 37 patients were followed up on day of surgery with 89% (n = 33) recalling at least one of four interventions, 46% (n = 19) fully recalling the breathing exercises, and 41% (n = 15) partly recalling the breathing exercises. 40 patients were followed up after surgery with 88% (n = 35) recalling at least one of four preventative activities, 35% (n = 14) fully recalling the breathing exercises, and 53% (n = 21) partly recalling the breathing exercises.
Discussion
Recall of at least one of four preventative activities was high at all three key points in the surgical care pathway, with a degradation of recall of the breathing exercises between initial viewing and day of surgery. Further degradation of recall of breathing exercises occurred between day of surgery and postoperative day 1. Given the time lag between PAC attendance and the day of surgery, retention and recall may be able to be improved by showing the educational video at multiple points in the care pathway, such as on a digital screen in the waiting room on day of surgery in addition to at PAC. As a low-cost PPC intervention, this could be further investigated.
If adequate retention is demonstrated, the efficacy of the preoperative education video on reducing incidence of PPCs could be investigated. Based on the results of our small unfunded pilot study, targeted implementation into routine care pathways at PAC appears feasible if appropriately resourced.