Proposed Perioperative Medicine Service Model in a Teaching Hospital in Hong Kong

Danny Ip Department of Anaesthesiology

Queen Mary Hospital (HKWC)

Perioperative Care Past, Present and Future

A Paradigm Shift

Endemic Burden of Surgery

• 66 countries

• Between 2005 - 2013

• 312.9 millions operations in 2012

• 33.6% increase over 8 years

The Lancet, Volume 385, Special Issue S11, 27 April 2015

Endemic Burden of Surgery

United Nations Department of Economic and Social Affairs

Endemic Burden of Surgery

PEW Research Center

Are we doing GOOD enough ?

British Journal of Anaesthesia, Volume 117, Issue 5, 1 November 2016, Pages 601–609

Are we doing GOOD enough ?

50%

Knowing the Risk A Report by the National Confidential Enquiry into Patient Outcome and Death (2011)

Local Burden of Surgery

Census & Statistical Department, HKSAR

Local Burden of Surgery

‧

Statistics and Workforce Planning Department, Hospital Authority Census and Statistical Department, HKSAR

Are we doing GOOD enough ?

Surgical Outcomes Monitoring & Improvement Program Report, Hospital Authority

Can we do EVEN better ?

Perioperative Medicine

‘The care of patients from the time they contemplate surgery through the operative period to full recovery at home’

The Royal College of Anaesthetists

Care Model - does it exist ? UK Experience

Perioperative Medicine : The Pathway to Better Surgical Care The Royal College of Anaesthetist

Care Model - does it exist ? UK Experience • University College London

Hospital

• Consultant-led Perioperative Medicine Unit

• Stand alone unit

• Preoperative Risk Assessment

• Postoperative Ward Round

• Extended Post-anaesthetic care ward

Perioperative Medicine Service Model

1. Preoperative phase • Risk stratification • Risk modification • Multidisciplinary Interventions

2. Intraoperative phase • Evidence-based Practice • Patient and surgical safety

3. Postoperative phase • Enhanced Recovery • Early detection of Complications

Perioperative Medicine

Perioperative Medicine Service in QMH

Ultramajor Surgery

Total number of Surgery

2014-2015 4816

(21%) 22869

2015-2016 4662

(18%) 25294

2016-2017 4981

(17%) 28567

Preoperative Phase

Perioperative Medicine

1. Electronic PreAnaesthetic Assessment Record

1. Electronic Preanaesthetic Assessment Record

2. Develop a more comprehensive Risk Stratification System • American Society of

Anaesthesiologists (ASA) Grading System

• Since 1963

• Simple and easy to use

• Too subjective

2. Develop a more comprehensive Risk Stratification System

The UCL/UCLH Surgical Outcomes Research Centre (SOuRCe)

2. Develop a more comprehensive Risk Stratification System

• ? Direct adoption of established scoring system

• ? Importance of just knowing mortality

• Future direction

• Own scoring system

• Mortality / morbidity

3. Anaesthetist-led Preanaesthetic talk • Twice a week

• One-hour talk

• Before Preanaesthetic clinic

4. High Risk Preanaesthetic Assessment Clinic • Role of Preanaesthetic clinic

(PAC)

• One-stop preanesthetic assessment

• Allow identification and optimization of medical conditions before surgery

• Nurse-led clinic

4. High Risk Preanaesthetic Assessment Clinic

• Features of High Risk clinic (every Friday)

1. Consultation before decision of surgery

• Minimize routine in-patient consultations

4. High Risk Preanaesthetic Assessment Clinic • Allow share decision

(surgeon + anaesthetist + patients) making to be made for very high risk cases

4. High Risk Preanaesthetic Assessment Clinic 2. Initiation of investigations and treatments for appropriate cases

• Investigate and diagnose iron deficiency anaemia

• Treat or titrate medications for uncomplicated hypertension and diabetes

• Perform targeted Echocardiography

5. Blood Management Program • Preoperative anaemia is common

• Anaemia Audit (QMH) in 2015

• 34 %

• Preoperative anaemia is associated with adverse perioperative outcomes

• Length of stay • ICU admission • In hospital mortality

British Journal of Anaesthesia 113 (3): 416-23 (2014)

5. Blood Management Program • Blood transfusion

• Supply could be unstable

• Association with various complications

• Financial implications

5. Blood Management Program • Preoperative anaemia as a potential

modifiable risk factor for adverse outcome

• Investigate and diagnose iron deficiency anaemia

• Actively treated before surgery

• Regular audit and monitor the outcome

Intraoperative Phase

Perioperative Medicine

1. Difficult Case Conference

2. Towards better Patient’s Safety

Postoperative Phase

Perioperative Medicine

1. Enhanced Recovery Program • Enhanced Recovery After

Surgery (ERAS) Program

• Joint replacement

• Upper GI

• Lower GI

• Urology

2. Extended Post-anaesthetic Care Unit (PACU) • Functions of a PACU

• Close monitoring of physiological parameters right after anaesthesia/surgery

• Make sure no immediate surgical complications

• Ensure reasonable pain control is achieved

2. Extended Post-anaesthetic Care Unit • Principles - UK Experience

• Normal PACU stay

• Extended PACU stay

• 4 hours / < 24 hours

• Protocols driven

• Haemodynamic optimisation

• Close monitoring

• Warm awake extubation

• Exclude : • Expected PACU stay > 24 hours • Patients with Multiorgan failure

2. Extended Post-anaesthetic Care Unit • How an Extended PACU

could be beneficial ?

• ICU beds is in scarcity

• Costs of an ICU bed

• Unplanned ICU admission

Perioperative Medicine in QMH • Regular Audit • Education & Training

Perioperative Medicine Service - Ways ahead

1. Preoperative phase • Risk stratification • Cardiopulmonary Exercise Testing • Risk modification • Organ Protection Strategies • Multidisciplinary Interventions • Prohabilitation

2. Intraoperative phase • Evidence-based Practice • Patient and surgical safety

3. Postoperative phase • Enhanced Recovery • Early detection of Complications • Post Op ward round by

Anaesthetist • Patient Reported Outcomes

Measurement

Perioperative Medicine

Thank you very much