The accuracy of trained nurses in pre-operative health assessment: results of the OPEN study

We quantified the accuracy of trained nurses to correctly assess the pre‐operative health status of surgical patients as compared to anaesthetists. The study included 4540 adult surgical patients. Patients' health status was first assessed by the nurse and subsequently by the anaesthetist. Both needed to answer the question: ‘is this patient ready for surgery without additional work‐up, Yes/No?’ (primary outcome). The secondary outcome was the time required to complete the assessment. Anaesthetists and nurses were blinded for each other's results. The anaesthetists' result was the reference standard. In 87% of the patients, the classifications by nurses and anaesthetists were similar. The sensitivity of the nurses' assessment was 83% (95% CI: 79–87%) and the specificity 87% (95% CI: 86–88%). In 1.3% (95% CI: 1.0–1.6%) of patients, nurses classified patients as ‘ready’ whereas anaesthetists did not. Nurses required 1.85 (95% CI: 1.80–1.90) times longer than anaesthetists. By allowing nurses to serve as a diagnostic filter to identify the subgroup of patients who may safely undergo surgery without further diagnostic workup or optimisation, anaesthetists can focus on patients who require additional attention before surgery.     

A retrospective observational study of pre-operative sickle cell screening

The aim of this study was to determine the ethnic mix of those patients being pre-operatively screened for sickle cell disease in a London teaching hospital and to determine the rate of carriage of sickle haemoglobin amongst those tested. We retrospectively studied 1879 patients undergoing surgery over a 2-month period. Two hundred and thirteen (11%) were screened for sickle cell disease and of these, 12 (5%) tested positive for sickle cell trait (HbAS). There were no patients homozygous for sickle cell disease (HbSS) or with haemoglobin SC disease (HbSC). Screening rates varied widely in different ethnic groups from 0% of the Chinese population to 85.2% of the Afro-Caribbean population. We conclude that at present there is no coherent pre-operative screening policy for sickle cell disease in our institution. Sickle cell disease poses unique anaesthetic risks and with a rapidly expanding 'mixed race' population high-risk patients are difficult to identify phenotypically. We propose a universal screening policy be implemented in high-risk areas.     

Validation of a pre-anaesthetic screening questionnaire

Summary We developed a screening questionnaire to be used by nurses to decide which patients should see an anaesthetist for further evaluation before the day of surgery. Our objective was to measure the accuracy of responses to the questionnaire. Agreement between questionnaire responses and the anaesthetist's assessment was assessed. For questions with a prevalence of 5 to 95%, the Kappa coefficient was used; percentage agreement was used for all other questions. Criterion validity was excellent/good for all questions with a prevalence between 5 and 95%, except for the question ‘Do you have kidney disease?’ For questions with prevalence < 5%, all demonstrated adequate criterion validity except the questions ‘Has anyone in your family had a problem following an anaesthetic?’ and ‘If you have been put to sleep for an operation were there any anaesthetic problems?’ Therefore, it is reasonable for nurses to use this questionnaire to determine which patients an anaesthetist should see before the day of surgery.     

Current practice in the pre-operative assessment of patients for elective repair of abdominal aortic aneurysmA survey of UK hospitals

A postal survey of 100 hospitals throughout the United Kingdom and Ireland was conducted to assess current practice in the pre-operative assessment and use of pulmonary artery catheters in patients undergoing elective abdominal aortic aneurysm repair. Seventy-four completed questionnaires were received. The survey revealed that 53% of respondents hold designated pre-operative assessment clinics, attended by anaesthetists in 54% and cardiologists in 26%. However, only 4% of respondents have a written protocol for stratifying patients and assessing peri-operative risk. By far the commonest investigation of choice for further cardiological assessment is transthoracic echocardiography (67%). Other investigations of choice are multiple update gated acquisition (MUGA) scan (13%), dipyridamole thallium imaging (9%), exercise ECG (6%), stress echocardiography (1%) and stress MUGA (1%). Two units (3%) never undertook further investigation. Pulmonary artery flotation catheters are used as a routine by 9% of respondents, dependent upon left ventricular ejection fraction by 65%, dependent on other factors by 7% and not used at all by 19%. The survey reveals widespread variation in pre-operative assessment of patients undergoing elective repair of abdominal aortic aneurysm.     

Performance and usability of pre-operative prediction models for 30-day peri-operative mortality risk: a systematic review

Estimating pre-operative mortality risk may inform clinical decision-making for peri-operative care. However, pre-operative mortality risk prediction models are rarely implemented in routine clinical practice. High predictive accuracy and clinical usability are essential for acceptance and clinical implementation. In this systematic review, we identified and appraised prediction models for 30-day postoperative mortality in non-cardiac surgical cohorts. PubMed and Embase were searched up to December 2022 for studies investigating pre-operative prediction models for 30-day mortality. We assessed predictive performance in terms of discrimination and calibration. Risk of bias was evaluated using a tool to assess the risk of bias and applicability of prediction model studies. To further inform potential adoption, we also assessed clinical usability for selected models. In all, 15 studies evaluating 10 prediction models were included. Discrimination ranged from a c-statistic of 0.82 (MySurgeryRisk) to 0.96 (extreme gradient boosting machine learning model). Calibration was reported in only six studies. Model performance was highest for the surgical outcome risk tool (SORT) and its external validations. Clinical usability was highest for the surgical risk pre-operative assessment system. The SORT and risk quantification index also scored high on clinical usability. We found unclear or high risk of bias in the development of all models. The SORT showed the best combination of predictive performance and clinical usability and has been externally validated in several heterogeneous cohorts. To improve clinical uptake, full integration of reliable models with sufficient face validity within the electronic health record is imperative.     

Daycase anaesthesia and anxiety A study of anxiety profiles amongst patients attending a Day Bed Unit

Two hundred adult patients aged 16-65 years scheduled to undergo operation under general anaesthesia in a Day Bed Unit were assessed for anxiety at the time of booking and on the day of operation. The nature of previous anaesthetic experience was the prime determinant of the anxiety scores obtained at booking. The score at booking was the prime determinant of the score on the day of operation, with previous experience and type of operation as secondary independent factors. Patients scheduled to undergo oral surgery were particularly anxious. Nineteen percent of patients would have liked to have received something to relieve their anxiety.     

Anaesthetic adverse incident reports: an Australian study of 1,231 outcomes

While there have been previous studies looking at patterns of litigation against anaesthetists overseas, there is little reported on the trends in Australia. This study was performed to ascertain current reporting rates of anaesthetic incidents, and from what areas these reports arise. Over the five years spanning January 1999 until December 2003, 1,231 adverse anaesthetic outcomes were reported to United Medical Protection by Australian anaesthetists. As in other studies, damage relating to airway instrumentation was the most frequently reported, comprising 261 incidents (21.8%). Complications related to epidural blockade were the next most common, accounting for 182 outcomes (15.2%). Other common areas generating incident reports included nerve injuries, respiratory complications, drug side-effects and death. To date 147 claims (12.3%) have arisen from these incident reports. Knowledge of these areas of risk should translate into more effective risk management with reduction in claims and adverse patient outcomes.     

Recovery room incidents: a review of 419 reports from the Anaesthetic Incident Monitoring Study (AIMS)

Four hundred and nineteen incidents that occurred in the recovery room were extracted from the Anaesthetic Incident Monitoring Study database, representing 5% of the total database of 8372 reports. Incidents were reported mainly in daylight hours, with over 50% occurring in ASA 1-2 patients. The most common presenting problems related to respiratory/airway issues (183; 43%), cardiovascular problems (99; 24%) and drug errors (44; 11%). One hundred and twenty-two events (29%) led to a major physiological disturbance and required management in the High Dependency Unit or Intensive Care Unit. Contributing factors cited included error of judgement (77; 18%), communication failure (57; 14%) and inadequate pre-operative preparation (29; 7%), whilst factors minimising the incident included previous experience (97; 23%), detection by monitoring (72; 17%) and skilled assistance (54; 13%). Staffing and infrastructure of the recovery room needs to be supported, with ongoing education and quality assurance programmes developed to ensure that such events can be reduced in the future.     

The developing world of pre-operative optimisation: a systematic review of Cochrane reviews

Pre-operative optimisation is a heterogenous group of interventions aimed at improving peri-operative outcomes. To understand the evidence for pre-operative optimisation in the developing world, we systematically reviewed Cochrane reviews on the topic according to the Human Developmental Index (HDI) of the country where patient recruitment occurred. We used summary statistics and cartograms to describe the HDI, year of publication, timing of pre-operative intervention and risk of bias associated with each included trial. We assessed the impact of multinational trials on the risk of bias introduced by countries of differing HDI. Four-hundred and nine trials representing 51 countries and 89,389 randomly allocated participants were summarised in this review. Four-hundred and nineteen out of 451 (93%) trial populations (i.e. a group of study participants from one country) were from high and very high HDI countries. The median (IQR [range]) HDI of countries were 0.862 (0.806–0.892 [0.445–0.949]). Three of the 409 included trials were multinational, representing 32 countries and 37,736 out of 89,389 (42.2%) included participants. Africa was the least represented continent, with only 4 included trials and 566 participants, of which 62.3% were from one multinational trial. The overall risk of bias was high or unclear in 381 out of 409 (93%) trials. Inclusion of multinational trials decreased the proportion of trial populations introducing high or unclear risk of bias by 9.4% (95%CI 5.1–13.7; p < 0.0001). Half of the world's population live in low- and middle-HDI countries. This population is poorly represented in systematically reviewed evidence on pre-operative optimisation. Multinational trials increase the knowledge contribution from low- and middle-HDI countries and decrease risk of bias in systematic reviews.     

Categorization of major and minor complications in the treatment of patients with resectable rectal cancer using short-term pre-operative radiotherapy and total mesorectal excision: a Delphi round

Background To properly balance the benefit (reduction of local recurrence) of short‐term pre‐operative radiotherapy for resectable rectal cancer against its harm (complications), a consensus concerning the severity of complications is required. The aim of this study was to reach consensus regarding major and minor complications after short‐term radiotherapy followed by total mesorectal excision in the treatment of rectal carcinoma, using the Delphi technique. Methods A Delphi round was performed in cooperation with 21 colo‐rectal surgeons from the Netherlands, United Kingdom and Sweden. The key‐question was: ‘Which of the predefined complications, caused or substantially aggravated by radiotherapy, are so important (major) that they might lead to the decision to abandon short‐term pre‐operative radiotherapy (5 × 5Gy) when treating patients with resectable rectal cancer (T_1?3N_0?2M₀)?’ Results After three rounds, consensus was reached for 37 (68%) of 54 complications of which 13 were considered major and 24 considered minor. The following complications were considered to be major: mortality, anastomotic leakage managed by relaparotomy, anastomotic leakage resulting in persisting fistula, postoperative haemorrhage managed by relaparotomy, intra‐abdominal abscess without healing tendency, sepsis, pulmonary embolism, myocardial infarction, compartment syndrome of the lower legs, long‐term incontinence for solid stool, long‐term problems with voiding, pelvic fracture with persisting pain, and neuropathy with persisting pain (legs). Three of 17 complications without consensus showed a tendency to be considered as major: perineal wound dehiscence managed by surgical treatment, small bowel obstruction leading to relaparotomy and long‐term incontinence for liquid stool. Conclusion The 13 major and three ‘accepted as major’ complications can be used to properly balance the benefit and harm of short‐term pre‐operative radiotherapy in resectable rectal cancer. This may eventually lead to improved treatment strategies for these patients.     

Tubeless percutaneous nephrolithotomy: a prospective feasibility study and review of previous reports

OBJECTIVE: To evaluate the status of tubeless percutaneous nephrolithotomy (PCNL) in managing renal and upper ureteric calculi, from initial experience and a review of previous reports. PATIENTS AND METHODS: From September 2004 to December 2004, 46 patients were scheduled for tubeless PCNL in a prospective study. Patients with solitary kidney, or undergoing bilateral simultaneous PCNL or requiring a supracostal access were also enrolled. Patients needing more than three percutaneous access tracts, or with significant bleeding or a significant residual stone burden necessitating a staged second-look nephroscopy were excluded. At the end of the procedure, a JJ ureteric stent was placed antegradely and a nephrostomy tube avoided. The patients' demographic data, the outcomes during and after surgery, complications, success rate, and stent-related morbidity were analysed. Previous reports were reviewed to evaluate the current status of tubeless PCNL. RESULTS: Of the 46 patients initially considered only 40 (45 renal units) were assessed. The mean stone size in these patients was 33 mm and 23 patients had multiple stones. Three patients had a serum creatinine level of >2 mg/dL (>177 micromol/L). Five patients had successful bilateral simultaneous tubeless PCNL. In all, 51 tracts were required in 45 renal units, 30 of which were supracostal. The mean decrease in haemoglobin was 1.2 g/dL and two patients required a blood transfusion after PCNL. There was no urine leakage or formation of urinoma after surgery, and no major chest complications in patients requiring a supracostal access tract, except for one with hydrothorax, managed conservatively. The mean hospital stay was 26 h and analgesic requirement 40.6 mg of diclofenac. Stones were completely cleared in 87% of renal units and 9% had residual fragments of < 5 mm. Two patients required extracorporeal lithotripsy for residual calculi. In all, 30% of patients had bothersome stent-related symptoms and 60% needed analgesics and/or antispasmodics to treat them. CONCLUSION: Tubeless PCNL was safe and effective even in patients with a solitary kidney, or with three renal access tracts or supracostal access, or with deranged renal values and in those requiring bilateral simultaneous PCNL. The literature review suggested a need for prospective, randomized studies to evaluate the role of fibrin sealant and/or cauterization of the nephrostomy tract in tubeless PCNL.     

Review of the Australian incident monitoring system

BACKGROUND: A survey was conducted to assess the benefits and limitations of the Australian Incident Monitoring System (AIMS) as a programme to improve patient safety. METHODS: A 12-point questionnaire was sent to 12 current users of AIMS in November 2002. RESULTS: The AIMS provides a consistent system of coding, trending and monitoring of incident data. It promotes a patient safety culture and an awareness of system error. Other benefits include the building of teamwork and the implementation of strategies to reduce the prevalence and severity of incidents. The majority of respondents (83%) reported that AIMS investigations resulted in significant changes to equipment usage, medication prescribing or administration, clinical protocols, training programmes and falls risk assessment tools. Although 75% of users reported improvements in patient outcomes, these were difficult to measure. A major limitation of AIMS was the low rate of incident reporting by medical staff. Voluntary reporting systems did not capture all incident data and the information was often too generic for root cause analysis. There were difficulties benchmarking data and concerns were raised regarding the ownership of information. The programme requires ongoing resources to implement change strategies and to maintain incident reporting levels. On a scale of 1 (poor rating) to 10 (excellent rating) the mean benefit rating was 7.6. CONCLUSION: The Australian Incident Monitoring System is beneficial as a component of a clinical risk management strategy. Usefulness could be improved by increased participation by medical staff. The level of resources required should not be underestimated if the programme is to demonstrate improvements to patient outcomes. More recent versions of AIMS promise improved capabilities and will require similar evaluation.     

Incidents relating to arterial cannulation as identified in 7,525 reports submitted to the Australian incident monitoring study (AIMS-ICU)

Arterial cannulation is frequently used in the critical care environment. Literaturefocuses on insertion techniques and complications. This report utilized data from the Australian Incident Monitoring Study (AIMS-ICU) national database to identify common problems and contributing factors associated with the use and maintenance of arterial lines. A review of narratives, keywords and contributing factors yielded 251 reports outlining 376 incidents. Of these, 15% describing line insertion problems, 66% line use and maintenance problems and 19% patient injuries. Inadequate line securing, accidental line dislodgement, incorrect set-up, distal ischaemia and infection featured prominently. As a result of the incident, 49% of patients involved suffered no ill effect, 28% minor physiological complications and 15% suffered major adverse effects. Multiple contributing factors were selected for each report, with lack of knowledge, rule-based errors, high unit activity, and lack of support staff or supervision selected most frequently. This study highlights the need to employ meticulous insertion technique, line set-up, securing, frequent line assessment and the early removal of lines no longer essential to patient care. Support and education of staff as well as the development of protocols are important for the safe use of arterial lines.     

Popliteal aneurysm after total knee arthroplasty: Case reports and review of the literature

Vascular complications after total knee arthroplasty include arterial occlusion, arterial severance, arteriovenous fistula, and arterial aneurysm. Both a false aneurysm and a true aneurysm of the popliteal artery are described. The false popliteal aneurysm resulted from direct surgical trauma and required excision and repair. The true popliteal aneurysm was unsuccessfully treated with excision, transfemoral thrombectomy, and bypass surgery. Many of the vascular complications after total knee arthroplasty may be preventable and the following prudent guidelines are suggested. Careful preoperative evaluation is critical, including past medical history, palpation of pedal pulses, and review of radiographs to identify abnormal calcification in the vessels. Vascular consultation may be necessary. Should a vascular complication occur, immediate intervention with the advice and assistance of a vascular surgeon is imperative.     

Development and evaluation of a novel pre-operative surgery school and behavioural change intervention for patients undergoing elective major surgery: Fit-4-Surgery School

Group pre-operative education has usually been limited to conditioning expectations and providing education. Prehabilitation has highlighted modifiable lifestyle factors that are amenable to change and may improve clinical outcomes. We instituted a pre-operative ‘Fit-4-Surgery School’ for patients scheduled for major surgery, to educate and promote healthy behaviour. We evaluated patients’ views having attended the school, and after surgery we asked how it had changed their behaviour with a lifestyle questionnaire. The school was launched in May 2016 and was attended by 586/1017 (58%) of invited patients. Patients who did not attend: lived further away, median (IQR [range]) 8 (4–19 [0–123]) miles vs. 5 (3–14 [0–172]) miles, p < 0.001; and were more deprived, Index of Multiple Deprivation Rank decile median (IQR [range]), 6 (4–8 [1–10]) vs. 7 (4–9 [1–10]), p = 0.04. Of the 492/586 (84%) participants who completed an evaluation questionnaire, 462 (94%) would recommend the school to a friend having surgery and 296 (60%) planned lifestyle changes. After surgery, 232/586 (40%) completed a behavioural change questionnaire, 106 (46%) of whom reported changing at least one lifestyle factor, most commonly by increasing exercise. The pre-operative school was acceptable to patients.     

Tracheo-innominate artery fistula after percutaneous tracheostomy: three case reports and a clinical review

Tracheo-innominate artery fistula (TIF) is an uncommon yet lifethreatening complication after a tracheostomy. Rates of 0.1–1%after surgical tracheostomy have been reported, with a peakincidence at 7–14 days post procedure. It is usually fatalunless treatment is instituted immediately. Initial case reportsof TIF resulted from surgically performed tracheostomies. Wepresent three fatalities attributable to TIF, confirmed by histopathology,after percutaneous dilatational tracheostomy (PDT). The useof PDT has resulted in tracheostomies being performed by specialistsfrom different backgrounds and the incidence of this complicationmay be increasing. Pressure necrosis from high cuff pressure,mucosal trauma from malpositioned cannula tip, low trachealincision, radiotherapy and prolonged intubation are all implicatedin TIF formation. Massive haemorrhage occurring 3 days to 6weeks after tracheostomy is a result of TIF until proven otherwise.We present a simple algorithm for management of this situation.The manoeuvres outlined will control bleeding in more than 80%of patients by a direct tamponade effect. Surgical stasis isobtained by debriding the innominate artery proximally, thentransecting and closing the lumen. Neurological sequelae arefew. Post-mortem diagnosis of TIF may be difficult, but specificpathology request should be made to assess innominate arteryabnormalities.     

Screening and treating pre-operative anaemia and suboptimal iron stores in elective colorectal surgery: a cost effectiveness analysis

Our study investigated whether pre-operative screening and treatment for anaemia and suboptimal iron stores in a patient blood management clinic is cost effective. We used outcome data from a retrospective cohort study comparing colorectal surgery patients admitted pre- and post-implementation of a pre-operative screening programme. We applied propensity score weighting techniques with multivariable regression models to adjust for differences in baseline characteristics between groups. Episode-level hospitalisation costs were sourced from the health service clinical costing data system; the economic evaluation was conducted from a Western Australia Health System perspective. The primary outcome measure was the incremental cost per unit of red cell transfusion avoided. We compared 441 patients screened in the pre-operative anaemia programme with 239 patients not screened; of the patients screened, 180 (40.8%) received intravenous iron for anaemia and suboptimal iron stores. The estimated mean cost of screening and treating pre-operative anaemia was AU$332 (£183; US$231; €204) per screened patient. In the propensity score weighted analysis, screened patients were transfused 52% less red cell units when compared with those not screened (rate ratio = 0.48, 95%CI 0.36–0.63, p < 0.001). The mean difference in total screening, treatment and hospitalisation cost between groups was AU$3776 lower in the group screened (£2080; US$2629; €2325) (95%CI AU$1604–5947, p < 0.001). Screening elective patients pre-operatively for anaemia and suboptimal iron stores reduced the number of red cell units transfused. It also resulted in lower total costs than not screening patients, thus demonstrating cost effectiveness.