Perioperative Pathways
Thinking about the perioperative route of a patient is important in allowing the optimal provision of care to our patients.
There is a clear difference between elective and emergency surgical care, but some of the principles overlap.
There is currently a drive to change such pathways to optimise the delivery of care for our patients, particularly those within an increasing burden of chronic disease.
More can be seen about this at the Royal College of Anaesthetists site on perioperative medicine. (http://www.rcoa.ac.uk/perioperativemedicine)
There is a clear difference between elective and emergency surgical care, but some of the principles overlap.
There is currently a drive to change such pathways to optimise the delivery of care for our patients, particularly those within an increasing burden of chronic disease.
More can be seen about this at the Royal College of Anaesthetists site on perioperative medicine. (http://www.rcoa.ac.uk/perioperativemedicine)
Traditional Model
The surgeon acts as the current lead for patient care.
Anaesthetic team provide input to the patient's peri-operatively at varying levels:
Postoperative care in critical care environment or surgical ward.
Care managed by surgical team, often rotating junior doctors.
Anaesthetic input not usual beyond the immediate perioperative period (e.g. 24 hours).
Complications are managed in a reactive manner.
Follow up after discharge in by the patient’s primary care team and in the surgical outpatient clinic.
Discharge communication is often usually provided by the surgical team.
Advantages:
Disadvantages:
Anaesthetic team provide input to the patient's peri-operatively at varying levels:
- Traditionally seen on the day of surgery
- Increased use of nurse led preoperative assessment of patients.
- Some patients are seen by anaesthetists preoperatively as well, guided by risk assessment
Postoperative care in critical care environment or surgical ward.
Care managed by surgical team, often rotating junior doctors.
Anaesthetic input not usual beyond the immediate perioperative period (e.g. 24 hours).
Complications are managed in a reactive manner.
Follow up after discharge in by the patient’s primary care team and in the surgical outpatient clinic.
Discharge communication is often usually provided by the surgical team.
Advantages:
- Efficient in terms of workload (volume and flow) and cost
- Clear leadership and accountability (lead surgeon)
- Optimises the skills and knowledge of the surgical team
- Works well for low risk patients
Disadvantages:
- Relatively fragmented - delays in surgical pathway possible (for example whilst awaiting correspondence)
- Little opportunity for nuanced discussion of risk or optimisation of patients
- May miss out on the skills and knowledge of other clinicians e.g. medical
- Can work less well for more complex patients.
A Need for Change
The changing nature of healthcare is driving a need for change to this model.
This is particularly due improvements of general medical care resulting in an older population with more medical comorbidities.
This is combined with ongoing surgical innovations that allow greater options for provision of surgery to patients who would not previously have been considered for this.
Data suggests that current model is not best designed to manage this changing picture.
Important documents:
Key points:
This is particularly due improvements of general medical care resulting in an older population with more medical comorbidities.
This is combined with ongoing surgical innovations that allow greater options for provision of surgery to patients who would not previously have been considered for this.
Data suggests that current model is not best designed to manage this changing picture.
Important documents:
- National Confidential Enquiry into Patient Outcomes and Death (NCEPOD). An age old problem: a review of the care received by elderly patients undergoing surgery. 2010. Available at: http://www.ncepod.org.uk/2010report3/downloads/EESE_fullReport.pdf
Key points:
- Of the 170,000 patients undergoing higher risk (non-cardiac surgery) each year, 100,000 will develop complications with 25,000 deaths.
- ‘High risk patients’ account for under 15% of surgical procedures but over 80% of postoperative deaths.
- Care for these patients show a high variability
- The majority of deaths results from postoperative complications
- Delays in provision of care are a significant factor in complications
Links & References
- Whiteman, A. Sherrard P. Perioperative medicine in action. University College London. 2017
- The Royal College of Anaesthetists. Perioperative medicine: the pathway to better surgical care. 2015. Available from: http://www.rcoa.ac.uk/sites/default/files/PERIOP-2014.pdf
- The Royal College of Anaesthetists. Perioperative medicine homepage. http://www.rcoa.ac.uk/perioperativemedicine
- National Confidential Enquiry into Patient Outcomes and Death (NCEPOD). An age old problem: a review of the care received by elderly patients undergoing surgery. 2010. Available at: http://www.ncepod.org.uk/2010report3/downloads/EESE_fullReport.pdf
