Perioperative outcomes in intermediate and high-risk patients after major surgery following introduction of a dedicated perioperative medicine team: A single centre cohort study.

Intermediate and high-risk patients undergoing surgery are often managed on a surgical ward in the absence of haemodynamic or ventilatory support requirements necessitating intensive care unit or high dependency unit admission. We describe a model of care for the multidisciplinary management of selected postoperative patients and the epidemiology of patients managed using this model at a tertiary Australian hospital.Of 25,139 patients undergoing inpatient surgery at our institution over a two-year period, 506 (2%) were referred to the Perioperative Medicine team. The median age of patients referred was 74 years; 85% had an American Society of Anesthesiologists physical status ≥3, and 44% underwent emergency surgery. Major complication or death within 30 days was 44.2% (213/482). The most common complications, as defined by the American College of Surgeons National Surgical Quality Improvement Program were transfusion within 72 h (17.4%), pneumonia/aspiration pneumonitis (11.3%), and acute renal failure (10.6%); median time to Medical Emergency Team call was 146 (interquartile range 77-279) h.Sixty-six percent of referred patients (280/423) required an intervention during their time under the service. This high incidence indicates that this population of patients merits closer attention, including routine measurement and reporting of postoperative outcomes to monitor and improve quality of care at our institution as part of an integrated perioperative service. We believe that with so much current focus on perioperative medicine, it is important we translate this to clinical care by evolving traditional models of management into more innovative strategies to meet the complex demands of today's surgical patients.

Towards a national perioperative clinical quality registry: The diagnostic accuracy of administrative data in identifying major postoperative complications.

Accurately measuring the incidence of major postoperative complications is essential for funding and reimbursement of healthcare providers, for internal and external benchmarking of hospital performance and for valid and reliable public reporting of outcomes. Actual or surrogate outcomes data are typically obtained by one of three methods: clinical quality registries, clinical audit, or administrative data. In 2017 a perioperative registry was developed at the Alfred Hospital and mapped to administrative and clinical data. This study investigated the statistical agreement between administrative data (International Statistical Classification of Diseases and Related Health Problems (10th edition) Australian Modification codes) and clinical audit by anaesthetists in identifying major postoperative complications. The study population included 482 high-risk surgical patients referred to the Alfred Hospital anaesthesia postoperative service over two years. Clinical audit was conducted to determine the presence of major complications and these data were compared to administrative data. The main outcome was statistical agreement between the two methods, as defined by Cohen's kappa statistic. Substantial agreement was observed for five major complications, moderate agreement for three, fair agreement for six and poor agreement for two. Sensitivity and positive predictive value ranged from 0 to 100%. Specificity was above 90% for all complications. There was important variation in inter-rater agreement. For four of the five complications with substantial agreement between administrative data and clinical audit, sensitivity was only moderate (61.5%-75%). Using International Statistical Classification of Diseases and Related Health Problems (10th edition) Australian Modification codes to identify postoperative complications at our hospital has high specificity but is likely to underestimate the incidence compared to clinical audit. Further, retrospective clinical audit itself is not a highly reliable method of identifying complications. We believe a perioperative clinical quality registry is necessary to validly and reliably measure major postoperative complications in Australia for benchmarking of hospital performance and before public reporting of outcomes should be considered.

Development and psychometric evaluation of a postoperative quality of recovery score: the QoR-15.

BACKGROUND: Quality of recovery (QoR) after anesthesia is an important measure of the early postoperative health status of patients. The aim was to develop a short-form postoperative QoR score, and test its validity, reliability, responsiveness, and clinical acceptability and feasibility. METHODS: Based on extensive clinical and research experience with the 40-item QoR-40, the strongest psychometrically performing items from each of the five dimensions of the QoR-40 were selected to create a short-form version, the QoR-15. This was then evaluated in 127 adult patients after general anesthesia and surgery. RESULTS: There was good convergent validity between the QoR-15 and a global QoR visual analog scale (r = 0.68, P < 0.0005). Construct validity was supported by a negative correlation with duration of surgery (r = -0.49, P < 0.0005), time spent in the postanesthesia care unit (r = -0.41, P < 0.0005), and duration of hospital stay (r = -0.53, P < 0.0005). There was also excellent internal consistency (0.85), split-half reliability (0.78), and test-retest reliability (ri = 0.99), all P < 0.0005. Responsiveness was excellent with an effect size of 1.35 and a standardized response mean of 1.04. The mean ± SD time to complete the QoR-15 was 2.4 ± 0.8 min. CONCLUSIONS: The QoR-15 provides a valid, extensive, and yet efficient evaluation of postoperative QoR.

What is the value of professional opinion? The current medicolegal application of the "peer professional practice defence" in Australia.

Under state laws, a medical practitioner will not be found negligent if they acted in a manner that was widely accepted in Australia, by a significant number of respected practitioners in the field, as competent professional practice in the circumstances. This is known as the "peer professional practice defence". The professional opinion being relied on must not be unreasonable (Victoria and Western Australia) or irrational (New South Wales and other states). The peer professional practice defence does not apply to claims of negligence arising from failure to warn patients about risks associated with medical treatment. This reinforces the importance of warning patients of material risks as determined by the High Court of Australia in Rogers v Whitaker. Recent cases demonstrate the successful operation of the peer professional practice defence, but also highlight its limitations. In practice, the legislation may not shield doctors from negligence claims as fully as originally intended.