The Operating Theatre Journal - Flipbook - Page 8
New research highlights opportunities to
improve care of patients having major surgery
New research from the Royal College of Anaesthetists and University
College London shows that while some progress is being made in
improving perioperative care for patients undergoing major surgery,
more focus is needed on ensuring all patients receive an individualised
risk assessment, effective postoperative pain management and support
with DRinking, EAting and Mobilising (also known as DREAMING) within
24 hours of surgery.
The fourth report of the Perioperative Quality Improvement Programme
(PQIP) analyses data from a cohort of 11,926 patients from 135 hospitals
who had surgery between July 2021 and March 2023, as well as data
from three previous cohorts dating back to December 2016. In total,
data from 44,114 patients across 168 hospitals is included in the PQIP
research. The cohort in the new report is the first to include data from
patients in Scotland, as well as England and Wales.
PQIP is designed to help improve patient outcomes from major noncardiac surgery by supporting clinicians to use local data to enhance
perioperative care. This is important for better outcomes for individual
patients and for the recovery of the NHS after the pandemic. The PQIP
report identifies five priorities for reducing complications and length
of stay after surgery, simplifying enhanced recovery and promoting
teamwork, including with patients.
The report identifies individualised risk assessment as the foundation of
later high-quality patient care, facilitating shared decision making and
open communication, which may help to improve patients’ adherence
to treatment. Approximately 1 in 3 patients having major high-risk noncardiac surgery did not have an individualised risk assessment, despite
this being recommended by case law (Montgomery, 2015) and subject
to a recent Prevention of Future Deaths review.
Drinking, Eating and Mobilising (DrEaMing) within 24-hours of surgery is
associated with reduced length of stay in hospital and fewer inpatient
complications. Analysis of 22,218 patients in the PQIP cohort between
December 2016 and November 2020 found that only 17% of patients who
‘DrEaM’ experienced a major complication, compared to 37% who did
not DrEaM.
While DrEaMing compliance has increased year on year since PQIP
began, from 54% in cohort 1(2016-2018) to 67% in the current cohort
(2021-2023), progress has slowed.
Increasing rates of DrEaMing can also have financial benefits for NHS
trusts due to its status as an NHS England Commissioning for Quality
and Innovation Indicator (CQUIN) for a second year. The report makes
a number of recommendations for how teams can improve, including
through collaboration with patients.
Further improvements in clinical outcomes can be achieved through
better individualised pain management and addressing perioperative
anaemia. Unfortunately, a significant proportion of patients continue
to report severe pain within 24 hours of surgery (12-18% of patients).
The report recommends having a multi-modal analgesic plan in place,
postoperative acute pain team follow-up for at risk patients, and
processes to ensure the transition of this plan to the postoperative care
destination.
Addressing perioperative anaemia requires both preoperative detection
and management of anaemia and measures to reduce blood loss during
surgery, such as administration of the cheap, safe and effective drug
tranexamic acid. This is particularly pertinent given recent NHS
shortages in blood products.
70% of anaemic patients having surgery in this PQIP cohort did not
receive treatment for their anaemia in the months before surgery,
including 31% of patients with severe anaemia. Additionally, tranexamic
was administered to only 54% of patients where intraoperative blood
loss was 500 – 1000ml and only 61% of patients where blood loss was
>1000ml. The report highlights perioperative blood management
guidance published by the Centre for Perioperative Care.
The PQIP team continue to innovate in the methods used to help
hospitals embed quality improvement practices into their multidisciplinary team working. This includes near real-time reporting of
risk-adjusted outcome data, and other new online dashboards. The
study is still recruiting new hospitals and more information is available
at www.pqip.org.uk
8
Professor Ramani Moonesinghe, Chief Investigator, Perioperative
Quality Improvement, said:
“Our clinical community has delivered a remarkable achievement,
recruiting almost 12,000 patients to PQIP in this cohort, despite the
pressures on the service everyone is experiencing.
“As always, the report highlights multiple opportunities for
improvement. Now it is up to local teams to examine their own data
and their own processes to see if there are any gaps which could be
addressed.
“My thanks to all our hundreds of local collaborators, and to the PQIP
team who have worked so hard to produce this report.”
Dr Fiona Donald, President of the Royal College of Anaesthetists said:
“The report highlights the opportunities for improving perioperative
care, which start with a high-quality preoperative assessment process.
Despite the hard work of clinicians involved in perioperative care,
significant numbers of patients are going into major, elective high-risk
surgery without an individualised risk assessment or optimisation
of their long-term conditions such as anaemia or diabetes. Changes
to preoperative pathways which will be implemented by the NHS in
England this year may help to address these challenges, and resources
should be made available to local clinical and managerial teams to
support implementation.
“Wider implementation of surgery schools and better information for
patients such as through the RCoA’s “Fitter, Better, Sooner” initiative
should encourage better patient engagement with DrEaMing early
after surgery, also supported by financial incentives from the NHS.
“I would like to thank everyone who has contributed to PQIP so
far and we look forward to continuing the work of the study and
implementing the evidence-based recommendations of the report.”
9th Annual FPC Conference: The Role of the
Extended Surgical Team in the Digital World
Course/Event Details
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Course/Event Date: Sat, 7 October 2023
Course/Event Status: Places available
Location: Birmingham - Other
Convenor: -Ms Susan Hall, Associate Lecturer in Surgical Care Practice, Anglia
Ruskin University -Prof. Bhuvaneswari Krishnamoorthy, Professor in Nursing
and Surgical Practice, The University of Salford.
CPD Points: 6
Fee Structure
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Full Conference and Workshop fee: £100.00
Full Conference only fee: £90.00
FPC Members Conference and Workshop fee: £80.00
FPC Members Conference only fee: £70.00
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Contact
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Education Section
education@rcsed.ac.uk
0131 527 1600
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Relevant Grades
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Consultant
ODP
Surgical Care Practitioner (SCP)
Advanced Care Practitioners
Advanced Clinical Practitioners (ACP)
Physician Associates (PA)
Book Now
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https://www.rcsed.ac.uk/events-courses/event-entry?diaryId=3337
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