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BACKGROUND: Patients undergoing surgery deserve the best possible peri-operative outcomes. Each stage of the peri-operative patient journey offers opportunities to improve care delivery, with shorter lengths of stay, less complications, reduced costs and better value. METHODS: These opportunities were identified through narrative review of the literature, with consultation and consensus at the hidden pandemic (of postoperative complications) summit 2, July 2023 in Adelaide, Australia RESULTS: Before surgery: Some patients who receive timely alternative treatments may not need surgery at all. The period of waiting after listing should be a time of preparation. Risk assessment at the time of surgical listing facilitates recognition of need for comorbidity optimisation and identifies those who will most benefit from prehabilitation, particularly frail and deconditioned patients. DURING SURGERY: During the surgical admission, ERAS programs result in less postoperative complications, shorter length of stay and better patient experience but require agreement between clinicians, and coordinated monitoring of delivery of the elements in the ERAS bundle of care. AFTER SURGERY: At-risk patients need to have the appropriate levels of monitoring for cardiovascular instability, renal impairment or respiratory dysfunction, to facilitate timely, proactive management if they develop. Access to allied health in the early postoperative period is also critical for promoting mobility, and earlier discharge, particularly after joint surgery. Where appropriate, provision of rehabilitation services at home improves patient experience and adds value. The peri-operative patient journey begins and ends with primary care so there is a need for clear communication, documentation, around sharing of responsibility between practitioners at each stage. CONCLUSION: Identifying and mitigating risk to reduce complications and length of stay in hospital will improve outcomes for patients and deliver the best value for the health system.
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BACKGROUND: Surgical audit is key in upholding the standards of surgical care but may be inadequate in capturing morbidity experienced by patients being transferred across different health systems. The aim of this study was to assess the utility of an objective framework in the evaluation of clinical issues surrounding interhospital transfers (IHTs). METHODS: A retrospective cohort study was conducted at a Victorian state bariatric hospital. Patients transferred with bariatric surgery related complications between 2014 and 2021 were included. Each case was reviewed by two surgeons using an objective framework developed via a modified Delphi-process. Key issues and preventability surrounding each transfer were evaluated. Inter-observer agreement was assessed using weighted Cohen's Kappa coefficient. RESULTS: Seventy-three patients were included. The most common indication for transfer was proximal staple line leak post sleeve gastrectomy (34/73, 46.6%). Length of stay was 38.3 ± 58.8 days. Cost of care amounted to AUD $110 666.18 per patient. Delay in transfer and complication recognition were present in 20% of cases (Cohen's Kappa 0.51;0.61). Human factors and patient related factors were the most common principal underlying causes (Cohen's Kappa 0.59). A third of the complications (n = 25/73, 34.2%), were potentially preventable (Cohen's Kappa 0.58) and more than half (39/73, 53.4%) did not have documented objective feedback to referring clinicians. CONCLUSION: IHTs associated with bariatric surgery complications have significant morbidity and costs. A structured framework in reviewing IHT can consistently identify potentially modifiable factors that improve clinical outcomes, and constructive feedback to the referring clinician should be actively facilitated and documented.
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BACKGROUND: Colonic diverticular disease is common and its incidence increases with age, with uncomplicated diverticulitis being the most common acute presentation (1). This typically results in inpatient admission, placing a significant burden on healthcare services (2). We aimed to determine the safety and effectiveness of using intravenous or oral antibiotics in the treatment of uncomplicated diverticulitis on 30-day unplanned admissions, c-reactive protein (CRP), White Cell Count (WCC), pain resolution, cessation of pain medication, return to normal nutrition, and return to normal bowel function. METHODS: This single centre, 2-arm, parallel, 1:1, unblinded non-inferiority randomized controlled trial compared the safety and efficacy of oral antibiotics versus intravenous antibiotics in the outpatient treatment of uncomplicated colonic diverticulitis. Inclusion criteria were patients older than 18 years of age with CT proven acute uncomplicated colonic diverticulitis (Modified Hinchey Classification Stage 0-1a). Patients were randomly allocated receive either intravenous or oral antibiotics, both groups being treated in the outpatient setting with a Hospital in the Home (HITH) service. The primary outcome was the 30-day unplanned admission rate, secondary outcomes were biochemical markers, time to pain resolution, time to cessation of pain medication, time to return to normal function and time to return to normal bowel function. RESULTS: In total 118 patients who presented with uncomplicated colonic diverticulitis were recruited into the trial. Fifty-eight participants were treated with IV antibiotics, and 60 were given oral antibiotics. We found there was no significant difference between groups with regards to 30-day unplanned admissions or inflammatory markers. There was also no significant difference with regards to time to pain resolution, cessation of pain medication use, return to normal nutrition, or return to normal bowel function. CONCLUSION: Outpatient management of uncomplicated diverticulitis with oral antibiotics proved equally as safe and efficacious as intravenous antibiotic treatment in this randomized non-inferiority control trial.
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Doença Diverticular do Colo , Diverticulite , Diverticulose Cólica , Humanos , Doença Diverticular do Colo/tratamento farmacológico , Antibacterianos/uso terapêutico , Dor , Doença Aguda , Resultado do TratamentoRESUMO
Emergency and essential surgery is a critical component of universal health coverage. Session three of the three-part virtual meeting series on Strategic Planning to Improve Surgical, Obstetric, Anaesthesia, and Trauma Care in the Asia-Pacific Region focused on strategic partnerships. During this session, a range of partner organisations, including intergovernmental organisations, professional associations, academic and research institutions, non-governmental organisations, and the private sector provided an update on their work in surgical system strengthening in the Asia-Pacific region. Partner organisations could provide technical and implementation support for National Surgical, Obstetric, and Anaesthesia Planning (NSOAP) in a number of areas, including workforce strengthening, capacity building, guideline development, monitoring and evaluation, and service delivery. Participants emphasised the importance of several forms of strategic collaboration: 1) collaboration across the spectrum of care between emergency, critical, and surgical care, which share many common underlying health system requirements; 2) interprofessional collaboration between surgery, obstetrics, anaesthesia, diagnostics, nursing, midwifery among other professions; 3) regional collaboration, particularly between Pacific Island Countries, and 4) South-South collaboration between low- and middle-income countries (LMICs) in mutual knowledge sharing. Partnerships between high-income countries (HIC) and LMIC organisations must include LMIC participants at a governance level for shared decision-making. Areas for joint action that emerged in the discussion included coordinated advocacy efforts to generate political view, developing common monitoring and evaluation frameworks, and utilising remote technology for workforce development and service delivery.
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BACKGROUND: Failure to rescue (FTR) is increasingly recognised as a measure of the quality care provided by a health service in recognising and responding to patient deterioration. We report the association between a patient's pre-operative status and FTR following major abdominal surgery. METHODS: A retrospective chart review was conducted on patients who underwent major abdominal surgery and who suffered Clavien-Dindo (CDC) III-V complications at the University Hospital Geelong between 2012 and 2019. For each patient suffering a major complication, pre-operative risk factors including demographics, comorbidities (Charlson Comorbidity Index (CCI)), American Society of Anaesthesiology (ASA) Score and biochemistry were compared for patients who survived and patients who died. Statistical analysis utilised logistic regression with results reported as odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS: There were 2579 patients who underwent major abdominal surgery, of whom 374 (14.5%) suffered CDC III-V complications. Eighty-eight patients subsequently died from their complication representing a 23.5% FTR and an overall operative mortality of 3.4%. Pre-operative risk factors for FTR included ASA score ≥ 3, CCI ≥ 3 and pre-operative serum albumin of < 35 g/L. Operative risk factors included emergency surgery, cancer surgery, greater than 500 ml intraoperative blood loss and need for ICU admission. Patients who suffered end-organ failure were more likely to die from their complication. CONCLUSION: Identification of patients at high risk of FTR should they develop a complication would inform shared decision-making, highlight the need for optimisation prior to surgery, or in some cases, result in surgery not being undertaken.
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Falha da Terapia de Resgate , Complicações Pós-Operatórias , Humanos , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Austrália , Fatores de Risco , Mortalidade HospitalarRESUMO
Victoria suffered three major waves during the first two years of the COVID-19 pandemic. Melbourne became the longest locked down city in the world at 267 days. This narrative review documents the chronological waves of COVID-19 in Victoria and key themes influencing the State-wide surgical response. In 2020, Victoria needed to secure supplies of personal protective equipment (PPE) and later, recognizing the importance of aerosol transmission, introduced a respiratory protection program to protect health care workers (HCWs) with fit-tested N-95 masks. It established routine preoperative PCR testing for periods when community prevalence was high and developed strategies to restrict elective surgery when hospital capacity was limited. In 2021, three short-term outbreaks were contained and eliminated whilst vaccination of HCWs and the vulnerable was taking place. A third major wave (Delta) occurred July to November 2021, succeeded by another involving the Omicron variant from December 2021. Planned surgery waiting list numbers, and waiting times for surgery, doubled between March 2020 and March 2022. In early 2022, almost 300 patients underwent surgery when infected with Omicron, with a low mortality (2.6%), though mortality was significantly higher in the unvaccinated (7.3% versus 1.4%). In conclusion, the Victorian response to COVID-19 involved tight state-wide social restrictions, contact tracing, furlough, escalating PPE guidance and respiratory protection. HCW infections were greatly reduced in 2021 compared with 2020. Pre-operative PCR testing gave confidence for emergency and urgent elective surgery to proceed during pandemic waves. Other elective cases were performed as health system capacity allowed, without compromising outcomes.
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COVID-19 , Humanos , COVID-19/epidemiologia , SARS-CoV-2 , Pandemias/prevenção & controle , Aerossóis e Gotículas RespiratóriosRESUMO
Post-acute COVID-19 condition (PACC) - also known as long COVID - is a serious and growing problem in primary health. This letter describes the work of the Victorian Post-Acute COVID-19 Study (VPACS) group, which comprises clinician researchers, basic scientists and consumers. Two key priorities for PACC research in Australia are identified and discussed: (1) the establishment of COVID-19 patient registries and data linkage; and (2) the consolidation of clinical guidelines. Collaboration between consumers, researchers, clinicians and institutions must be the foundation of PACC management in Australia. Ongoing research should focus on large, multicentre controlled studies, the protective effect of vaccination, differential impacts from variants, pathobiological underpinnings, disease mechanisms to avoid severe and enduring impacts on the Australian economy. The lived experience of people with PACC is also essential to enable the design and implementation of effective models of care. VPACS brings a diverse group of people together to work on a shared vision of holistic and high-quality care, and collectively maximise their impact on outcomes for patients and the broader community.
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COVID-19 , Síndrome de COVID-19 Pós-Aguda , Humanos , Austrália/epidemiologia , Qualidade da Assistência à Saúde , Estudos LongitudinaisAssuntos
Divertículo , Embolização Terapêutica , Doenças do Jejuno , Humanos , Jejuno/cirurgia , Hemorragia/complicações , Embolização Terapêutica/efeitos adversos , Divertículo/complicações , Divertículo/cirurgia , Isquemia/etiologia , Isquemia/cirurgia , Hemorragia Gastrointestinal/terapia , Hemorragia Gastrointestinal/cirurgia , Doenças do Jejuno/etiologia , Doenças do Jejuno/cirurgiaAssuntos
Hérnia Inguinal , Laparoscopia , Hérnia Inguinal/cirurgia , Herniorrafia , Humanos , Telas CirúrgicasRESUMO
BACKGROUND: This paper describes the development of learning from novice to expert in Stage 4: Clinical Decision Making (CDM) in surgery: Postoperative reflection and review. It also outlines some or the assessment and teaching approaches suitable to facilitate that transition in skill level. METHODS: This paper is drawn from a much broader study of learning and teaching CDM, that used qualitative methodology based on Constructivist and Grounded Theory. Data was collected in individual interviews and focus groups. Using thematic analysis the data were analysed to identify key ideas. All participants worked in the Department of Surgery at one large regional hospital in Victoria. RESULTS: For each stage there is a sequence of learning beginning from relying on external resources, gradually developing internal resources to guide and direct the learner's CDM. Those internal resources built through experience include multisensory and kinaesthetic memories that expand to facilitate the ability to cope with complexity. DISCUSSION: Armed with the mind-map and rubric table included in this paper it should be possible for any senior clinician or teacher to diagnose their trainees' progression in Stage 4 CDM. This will enable them to tailor their teaching to best match the capabilities of the trainee and to enable to be more effectively targeted. CONCLUSION: CDM can be taught and both trainees and senior clinicians can benefit from understanding the processes involved.