Smoothing out the ride for surgical patients

Bruce Waxman examines the drivers of change in perioperative care and the effects on patient outcomes

Whether a patient is having an elective or emergency procedure, ideally their journey will follow a pathway that has been mapped out from the time of entering the hospital until their discharge summary is generated.

Recent changes in perioperative patient management have been described as a “paradigm” shift in surgical care — from traditional models (largely dictated by individual surgeons or surgical units) to a multidisciplinary team approach (including planned protocols, policies and guidelines with accountability governed by audit and peer review, the outcomes of which are used to formulate recommendations that effect change).1 The driver is a synergy between a quest for improving quality and safety and the desire to be more efficient with diminishing resources — where the objective is to reduce patient morbidity and mortality.

Here, I outline an ideal model of care — although, even with the best intentions, pragmatic deviations can occur. While it is most relevant to Australia, similar models exist overseas.2

For patients who undergo elective procedures, the journey starts in the pre-admission clinics, which have been around for a couple of decades but are now better integrated. Today, pre-admission clinics combine pre-anaesthetic and presurgical assessments of risk with allied health and nursing interventions that commence the discharge planning process and allow day-of-surgery admissions. They also provide the opportunity to commence the most exciting intervention of the journey — the accelerated recovery pathways, or enhanced recovery after surgery (ERAS). ERAS programs have led to halving the 30-day morbidity and reducing the length of hospital stay by at least 2 days.2,3 The success of ERAS programs depends not only on a committed clinical team, but also on a well prepared and informed patient who has realistic expectations about standardised discharge criteria and planning, and has adequate social support. The programs use a combination of strategies, such as reducing nausea and vomiting with pre-emptive multimodal non-opioid analgesia (which allows the patient to tolerate three meals a day and promotes early return of gastrointestinal function) and judicious use of intravenous fluids. When increasing use of laparoscopic or minimally invasive surgery is added to the equation, the result is further reduction in length of stay, smaller incisions and fewer adhesions.2

When the patient arrives in the operating theatre, the World Health Organization’s Surgical Safety Checklist swings into action. Often referred to as “time out”, it uses a similar model to the preflight checklist used by airline pilots. The aim is to not only ensure the correct patient and the correct operative site, but also to ensure that the team members are familiar with each other, the objectives of the operation are clear to all and potential complications have been pre-empted — true crew resource management. In addition, the team checks and implements the plan for venous thromboembolism prophylaxis, if not already commenced before surgery, and commences the “bundle of care” to prevent surgical site infection. This bundle includes: maintaining normothermia and ensuring adequate oxygenation in the operating theatre, recovery room and ward; administering prophylactic antibiotics; monitoring and managing blood glucose levels; using drain tubes judiciously in patients with obesity; and preparing skin with a chlorhexidine-based agent. These initiatives have also led to better outcomes.2,4

Perioperative care continues in the ward, intensive care unit or high dependency unit. Patient outcomes are likely to be better if a perioperative medical service is in place which integrates well with the surgical team. Any deterioration is detected early and handled by the hospital acute response or medical emergency team. Regular multidisciplinary meetings with allied health professionals and the rehabilitation team drive early assessment and discharge through rehabilitation wards or programs such as hospital in the home. Communication and clinical handover are increasingly being managed with computer-based programs and electronic medical records, part of the e-health revolution, which enables online delivery of discharge summaries to general practitioners.

Similar principles apply to patients who undergo emergency surgery, although the planning cannot be so strategic. Introduction of the 4-hour rule in emergency departments and acute surgical units means that patients are seen by the surgical team within 2 hours of arrival and enter the operating theatre within 24 hours, leading to reduced length of stay and better outcomes. A driver of the acute surgical unit concept is the 12 point plan of General Surgeons Australia.5

These changes in perioperative care mean that patients will be well informed and well managed, and should have a smooth perioperative journey, rather than a “roller-coaster” ride.

Should hospitals have intensivist consultants in-house 24 hours a day? – Yes

Onsite intensivist support is needed to improve clinical decisions and safety

An intensive care unit (ICU) is only as good as the care and decision making provided at 2 am. If we believe that intensivists really make a difference to patient outcomes, surely extended hours of onsite intensivist cover are necessary? A patient-centred approach to staffing that takes into account the potential for human error is needed. Most Australian ICUs are staffed after-hours by registrars. Some are not vocational trainees. Experience and clinical skill is variable. Onsite intensivist support tends to be concentrated throughout the day, with the on-call specialists often required to be onsite for 12 hours or more and on-call overnight. Challenges exist in providing uniform levels of clinical expertise around the clock to ICU patients while maintaining a healthy and safe work routine for clinicians.

The ICU is a complex operating environment that requires high-risk decision making day and night. Early work on errors in the ICU emphasised adverse incidents; current research concentrates on diagnostic error. A recent systematic review of autopsy studies on ICU patients found an important incidence of critical misdiagnosis including vascular events and infections.1 Other missed diagnoses included pulmonary embolus, myocardial infarction, pneumonia and aspergillosis. Perhaps extended onsite intensivist cover would help reduce misdiagnoses?

Acute care hospital intensive care services are not only provided within increasingly large ICUs (30 plus beds are not uncommon), but many ICUs also provide rapid response to the wards. Night duty is associated with an increased risk of error because it coincides with the circadian nadir of medical staff and is associated with mild-to-moderate sleep deprivation. A study that examined sleep patterns in a tertiary Australasian ICU found that many registrars were sleep deprived while working on night duty (45% had woken before 16:00 and 48% had less than 5 hours’ sleep before shifts).2 It has been shown that even a modest sleep deficit can impair waking neurobehavioural functions.3

A recent study examined cognitive errors in the ICU and reviewed current research on dual process theory in relation to diagnostic error.4 In essence there are considered to be two types of clinical thinking: pattern recognition (intuitive thinking) and analytical thinking. An experienced clinician mainly uses intuitive thinking, and only uses analytical reasoning when encountering a new situation. Clinical reasoning is often influenced by cognitive bias. Many such biases have been described, including confirmation bias (selecting information to confirm the diagnosis), anchoring heuristic (relying on initial impression despite subsequent information) and framing effects (diagnostic information biased by inappropriate information).

It follows that intuitive thinking is where most cognitive error occurs. Individuals with sleep deprivation and task saturation are more likely to revert to intuitive thinking, which requires less effort than thinking analytically.

It can thus be argued that what is needed is an environment that promotes optimal decision making 24 hours a day. Specialists working extended days and on-call overnight to support junior onsite medical staff is not optimal. While all clinicians will be subject to the pressures of night duty outlined earlier, ICUs need a senior clinician who is awake and immediately available.

There have been arguments for and against intensivist staffing of ICU after-hours with no clear resolution.5 Those opposing 24-hour intensivist staffing have made arguments on the basis of no discernible difference in outcome, intensivist lifestyle and burnout, the need for registrars to have a degree of autonomy in their training, and cost. There are practical difficulties in moving to this system including night duty fatigue and clinical handover. Importantly, it requires a shift from continuity of care provided by individuals to one of system-based continuity. Market forces may eventually drive change towards 24-hour in-house specialist staffing. Increasing numbers of trained specialists and a limited pool of specialist positions has the potential to decrease the demand for intensive care training. Another problem is the smaller ICUs, where 24-hour specialist cover is impractical — although the remote telemedicine model with 24-hour intensivist supervision of multiple ICUs may be the answer here.

Hospitals have a duty to provide safe care. Ideally there should be a specialist awake and available to the ICU at all times. This is a major change in intensivist work practices. Evening shift rostering for intensivists may provide a transition to safer cover for ICUs as well as optimising clinician work routines. Most tertiary hospitals now have specialist anaesthetists and emergency physicians working evening shifts. It might be naive to think that intensive care, which is so closely affiliated to these acute care specialties, should be different.

Should hospitals have intensivist consultants in-house 24 hours a day? – No

Twenty-four-hour coverage is costly, has not demonstrated benefit and diminishes the quality of intensivists’ training

At first glance, proposals for having an in-house consultant intensivist providing 24-hour care have some appeal. It has been suggested that because daily intensivist input improves outcomes in the critically ill, moving from an after-hours consultation service to a 24-hour presence onsite would improve the quality of health care.1 However, this belief is purely speculative and is not supported by data. It is important to recognise that in other areas of medicine, treatments require a certain “dose”, and when given in excess of this dose there is no further improvement. For example, excessive administration of what some may consider relatively benign therapies, such as oxygen, intravenous fluid and enteral nutrition, has no benefit and indeed can be harmful beyond a certain dose. The optimal “dose” of an intensivist remains uncertain.

Before introducing major structural changes to a system, its problems should be identified, and the solution provided should have the potential to fix or ameliorate the problems. Accordingly, if onsite intensivists are the solution, there must be a problem with the current level of care provided to the critically ill, and the problem must be one that intensivists have the capacity to address. Recently, Bhonagiri and colleagues evaluated more than 200 000 patient admissions to Australian intensive care units (ICUs) and observed that after adjusting for severity of illness, patients admitted unexpectedly have similar mortality regardless of whether the admission occurs in-hours or after-hours.2 The investigators did report that patients with planned admissions after undergoing elective surgery were at greater risk of death if they were admitted after-hours when compared with those admitted in-hours. However, a prolonged time spent in theatre (and later admission as a result) is more likely to reflect surgical problems. It is therefore unlikely that an onsite intensivist will influence outcomes in these patients.

A number of ICUs overseas have adopted the model of having a consultant intensivist onsite 24 hours a day. We propose that data from these ICUs will be biased to observe associations with reduced mortality even in the absence of causality. This is based on the likelihood that refusal to admit to ICU on the grounds of futility will be more frequent when intensivists are onsite, thereby reducing ICU mortality while hospital mortality remains unaffected. Further, most studies from these ICUs have evaluated mortality using a before-and-after intervention design. However, ICU mortality appears to be falling over time,3 so using such a study design is biased toward observing a reduction in mortality even when the intervention is ineffective.

Despite these inherent biases, every published study has reported that ICU mortality is unaffected by the presence of 24-hour onsite intensivists. Moreover, the pivotal study in this area evaluated staffing across 49 United States ICUs and 65 752 patient admissions.4 This study reported that in “closed” ICUs (the model used in Australia), mortality was similar whether intensivists were onsite after-hours or available as a consultative service.

An important part of medical training is the progression to independent decision making that is developed when a senior registrar has responsibility for some decisions, but is supported as required by a consultant. In our opinion this skill is a fundamental determinant of subsequent success as an intensivist. The presence of consultant intensivists in-house 24 hours a day will “protect” senior registrars from making independent decisions. Indeed, the whole premise on which this endeavour is based is that all clinical decision making should be effected by the onsite consultant. Junior consultants will subsequently need to acquire these skills without the benefit of senior support.

Australian health care expenditure continues to rise at a rate greater than gross domestic product.5 The cost implication of introducing intensivists onsite 24 hours a day would be substantial, as salary costs for the increased number of consultant intensivists are fixed, whereas any potential reduction in patient bed-days is unrealised unless beds and smaller ICUs are closed. Such closures are often unpopular and may have unforeseen consequences. For these reasons rigorous cost–benefit modelling must be done, particularly as to date there is no sign of benefit from 24-hour onsite intensivists.

In summary, while the mechanisms underlying any proposed benefit of increasing intensivist “dose” are questionable, the intervention will be costly and may adversely affect training. Unless future well designed studies show an actual benefit for patients, hospitals and health care policymakers should resist any attempts to enforce this potentially expensive and ineffective practice.

Neuroplasticity and pain: what does it all mean?

Recent findings have implications for how we conceptualise, assess and treat pain

The concept of neuroplasticity — the ability of the nervous system to change its structure and function — has captured the imagination of clinicians, researchers and the general public.1 The ability of the brain to reorganise itself is remarkable. For example, people who are visually impaired engage their visual cortex for fine sensory discrimination when using their hands. In these situations, neuroplasticity appears to be a positive adaptation to loss of function.

Recent neuroplasticity studies have shown that pain is associated with a host of functional, anatomical and chemical changes at many levels of the nervous system.2,3 The most intriguing and dramatic example of functional changes is the reorganisation that occurs at a cortical level, particularly in association with major trauma to the nervous system such as limb amputation or spinal cord injury.4,5 In these situations, it has been shown that regions of the cortical homunculus that normally respond to inputs from a part of the body that has been denervated can be activated by stimuli that would normally activate an adjacent region of the sensory cortex. For example, stimulation of the lip in people with an amputated arm will activate the lip region as well as the adjacent sensory cortex normally activated by inputs from the hand. This reorganisation has been shown to be important in pain medicine. Although the direction of causality is unclear, the reorganisation is strongly linked to the presence of pain. Therefore, neuroplasticity may be an attempt by the nervous system to adapt to injury in a positive way. But in the case of pain, neuroplasticity appears to be maladaptive.

Chemical and structural changes which occur in the presence of pain and injury include receptor and neurotransmitter changes that flow through to physiological phenomena such as alterations in pain modulation6,7 and sensitisation of central neurones involved in the transmission of nociceptive signals.3,8 These changes amplify signals arising from tissue damage and can increase the intensity of experienced pain.

Understanding neuroplasticity has put paid to the old concept that pain is merely another sensation transmitted along hard-wired pathways. Findings regarding the complexity of pain processing, including neuroplasticity, show that the experience of pain engages an entire orchestra of pathophysiology. This means that the best chance of success in treating pain occurs when assessment and treatment address these many factors. For example, treating persistent low back pain means not just trying to determine which structures in the back may be contributing to pain — it also means identifying any psychological factors that may alter the responsiveness of the nervous system and amplify incoming signals.

However, these findings provide reasons for hope. The first reason is that, although it may sound strange, neuroplasticity is by nature plastic.9 This means that although nervous system changes can occur, they are not necessarily irreversible. Some authors have adopted the view that central processes can become so dominant and fixed that they generate pain in the absence of peripheral input. Fortunately, there is not a great deal of evidence to support this view. Although nervous system injury such as damage to the spinal cord may give rise to structural changes that are extremely resistant to change, activity-dependent neuroplasticity (central changes that are dependent on the level of incoming signals to the spinal cord and brain) in response to nociceptive inputs is not so resistant. Clinically, this is seen by the large number of people with osteoarthritis of the hip who experience relief of pain following total hip replacement, no matter how severe the pain or how long it has been present. It has been shown that people who have pain associated with osteoarthritis of the hip have neuroplastic changes, including a reduction in grey matter volume in some brain regions. Importantly, these changes have been shown to reverse following successful hip surgery and a decrease in pain.10 This suggests that neuroplasticity is dependent on pain rather than the other way around.

The other reason for hope is that the findings provide us with a much better understanding of the role of psychological factors in pain and the potential for treatment. There is no room for the old dualist view of pain being either real or psychological. Cognitive and emotional processes strongly engage brain and spinal cord pathways that are directly involved in altering the responsiveness of pain pathways. By doing so, psychological factors influence neuroplastic processes and thus directly modify the pain experience.7

The role of mood and thought processes in modifying neuroplastic changes builds further support for the role of psychological interventions in treating pain, not just as a way of being able to cope with pain, but as an important and effective option for relieving pain.

Effective pain management therefore relies on judicious use of treatments that, as far as possible, reduce inputs from the periphery, and on the wide and growing range of pharmacological, physical and psychological approaches that are known to modify central pain processing and reduce pain.

Neuroplasticity research has opened our eyes to a whole new world of mechanisms underlying pain and given us a greater appreciation of the complex interaction between the mind and body. It has provided important keys that hold promise and hope for the future.