Development, implementation and evaluation of high-quality virtual preoperative anaesthetic assessment during COVID-19 and beyond: a quality improvement report.

BACKGROUND: Preoperative risk factor identification and optimisation are widely accepted as the gold standard of care for elective surgery and are essential for reducing morbidity and mortality. COVID-19 public health restrictions required a careful balance between ensuring best medical practices and maintaining safety by minimising patient face-to-face attendance in the hospital. Based on the successful implementation of telemedicine (TM) in other medical specialties and its feasibility in the preoperative context, this study aimed to develop, implement and evaluate a high-quality virtual preoperative anaesthetic assessment process. METHODS: The three-step model for improvement was used. The specific, measurable, actionable, relevant, time aim (step 1) and measures for improvement (step 2) were defined at the onset of the project. The plan-do-study-act tool was used for the structured implementation of improvement interventions (step 3) in three phases. Data relating to virtual and in-person referrals, assessments, did-not-attend (DNA) rate, consultation time, day of surgery delays and cancellations, and service-user and provider experience surveys were recorded prospectively. RESULTS: A total of 2805 patients were assessed in the preoperative anaesthetic assessment clinic between July 2020 and March 2021. The mean rate of virtual preoperative assessments was 50% (SD ±10) (1390/2805). 0.1% (30/2805) were inappropriately referred on the alternative pathway. The DNA rate was 0.4% (8/1398) and 3% (43/1458) for virtual and in-person pathways, respectively. The mean consultation times for virtual and in-person attendance were 19 (SD ±7) and 31 (SD ±13) min, respectively. There were five same-day surgery cancellations and one delay due to medical reasons. When asked about their experience with the virtual assessment, both service users and providers reported high satisfaction, minimal technical difficulties and shared concerns about limited opportunities for physical examination. CONCLUSION: This is one of the first implementational studies to comprehensively outline the feasibility of TM in preoperative anaesthetic assessment during COVID-19.

Chewing Gum for Prevention of Nausea and Vomiting After Elective Caesarean Section: a Pilot Randomised Controlled Trial.

Nausea and vomiting are common complications in patients undergoing caesarean delivery under regional anaesthesia. When experienced after surgery, they may delay recovery, reduce patient satisfaction and affect the bonding between mother and baby. Various pharmacological and non-pharmacological approaches for prophylaxis and treatment of postoperative nausea and vomiting (PONV) have been employed with different degree of efficacy. In this pilot randomised controlled trial, we aimed to determine the possible preventative effects of chewing gum on the rate of PONV in expectant mothers undergoing neuraxial anaesthesia for elective lower segment caesarean section. All participants underwent spinal anaesthesia with administration of 10-11.5 mg of intrathecal heavy Bupivicaine 0.5% according to anaesthetists' preference, Morphine 100 µg and Fentanyl 25 µg. Postoperative analgesia regimen was also standardised. Two hundred ninety-six patients were randomised to an intervention arm to receive chewing gum in addition to standard therapy and to a non-intervention arm to receive standard therapy. After exclusions, 258 patients were followed up 24 h postoperatively. Standard therapy is defined as Ondansetron 4 mg IV intra-operatively. The primary outcomes were the incidences of nausea and vomiting in the first 24 h postoperatively. Secondary outcomes were the number of episodes of nausea or vomiting in the recovery room and on the ward 24 h postoperatively, use of anti-emetics postoperatively, severity of nausea and patient satisfaction with the intervention. Our study revealed no significant differences in rates of postoperative nausea and vomiting between the intervention and standard therapy groups (41.4% v 36.9% p = 0.461). There were no significant differences in secondary outcomes between groups. Chewing gum does not reduce the incidence of PONV after elective LSCS under spinal anaesthesia. Our trial was registered with clinicaltrials.org (NCT04191694).

Maternal near miss: what lies beneath?

OBJECTIVE: Capturing 'near miss' and severe maternal morbidity using standard definitions is challenging. Information about levels of care required by ill pregnant or recently pregnant women may be more informative. The aim of this study was to prospectively audit incidence, causes, categorisation of maternal morbidity and level of care required by patients admitted to a labour ward high dependency unit (HDU) in a stand-alone obstetric hospital. STUDY DESIGN: All women admitted to HDU from May 5th to November 5th 2014 were identified prospectively and morbidity was categorised according to the Scottish Audit of Severe Maternal Morbidity (SAMM) and World Health Organisation (WHO) definitions of 'near miss' (NM), and 'severe maternal complications' (SMC). Level of care was determined by the RCOG Maternal critical care working group recommendations [1]. RESULTS: There were 128 admissions to HDU with 4502 live births (2.8%) during this period. There were 16 (12.5%) cases of NM; 83 (64.8%) of SMC and 29 'others' not meeting either criteria. Direct obstetric causes accounted for 79% of admissions. NM cases were more likely to be caused by haemorrhage (56.3%, p=0.009), postpartum (75%, p<0.05) and require blood transfusion (56.4%) compared to SMC cases, more likely to result from hypertension (39.8%, p=0.018) and be admitted antenatally (66.3%, p=0.039). Those admitted in the beneath NM and SMC group were more likely to be admitted antenatally (89.7%, p=0.039) and require specialist consultation (31%, p=0.022). Mean duration of HDU stay was 26.6 (±17 SD) hours. The perinatal mortality rate was 39/1000 total births. There were no maternal deaths. Level 2 care was required by 40 women (NM 25%; SMC 39% and others 14%) and two women required ICU transfer for Level 3 care. CONCLUSIONS: Approximately one quarter of women requiring HDU care 'lie beneath' criteria for near miss or severe maternal complications. One third of women admitted to the HDU require Level 2 care and the remainder require higher levels of monitoring only. The majority of cases are antepartum and delivery is integral in their care. HDU care in a labour ward setting is a good model for care of the ill pregnant or recently pregnant woman.