A multidisciplinary perioperative medicine clinic to improve high-risk patient outcomes: A service evaluation audit.

Various perioperative interventions have been demonstrated to improve outcomes for high-risk patients undergoing surgery. This audit assessed the impact of introducing a multidisciplinary perioperative medicine clinic on postoperative outcomes and resource usage amongst high-risk patients.Between January 2019 and March 2020, our institution piloted a Comprehensive High-Risk Surgical Patient Clinic. Surgical patients were eligible for referral when exhibiting criteria known to increase perioperative risk. The patient's decision whether to proceed with surgery was recorded; for those proceeding with surgery, perioperative outcomes and bed occupancy were recorded and compared against a similar surgical population identified as high-risk at our institution in 2017.Of 23 Comprehensive High-Risk Surgical Patient Clinic referrals, 11 did not proceed with the original planned surgery. Comprehensive High-Risk Surgical patients undergoing original planned surgery, as compared to high-risk patients from 2017, experienced reduced unplanned intensive care unit admission (8% versus 19%, respectively), 30-day mortality (0% versus 13%) and 30-day re-admission to hospital (0% versus 20%); had shorter postoperative lengths of stay (median (range) 8 (7-14) days versus 10.5 (5-28)) and spent more days alive outside of hospital at 30 days (median (range) 18 (0-25) versus 21 (16-23)). Cumulatively, the Comprehensive High-Risk Surgical patient cohort compared to the 2017 cohort (both n=23) occupied fewer postoperative intensive care (total 13 versus 24) and hospital bed-days (total 106 versus 212).The results of our Comprehensive High-Risk Surgical Patient pilot project audit suggest improved individual outcomes for high-risk patients proceeding with surgery. In addition, the results support potential resource savings through more appropriate patient selection.

Gentamicin vestibulotoxicity with modern systemic dosing regimens: a prospective study using video-oculography.

Objectives: To determine the incidence of gentamicin vestibulotoxicity with current dosing regimens, and to evaluate the feasibility of routine video-oculography on all patients given gentamicin. Materials and methods: In this prospective incidence study serial horizontal vestibulo-ocular reflex (HVOR) gain measurements were recorded using video-oculography on adult inpatients receiving intravenous gentamicin. The primary outcome was the proportion of patients developing impairment of their HVOR gain. Results: After exclusions, 42 patients were included in the analysis. Three patients (7.1%) developed asymptomatic vestibulotoxicity, exact 95% confidence interval 1.5-19.5%. In two of these patients the deficit resolved within several hours. No patients developed symptomatic vestibulotoxicity. There was no evidence for a generalised reduction in group HVOR gain with time. HVOR gain was not associated with total gentamicin dose, dynamic visual acuity or subjective imbalance. Conclusions and significance: Gentamicin may cause reversible, asymptomatic vestibulotoxicity. Video-oculography may be useful to monitor for vestibulotoxicity in patients treated with gentamcin; however, testing all patients routinely may be challenging.

Audit to investigate junior doctors' knowledge of how to administer and score the Montreal Cognitive Assessment (MoCA).

AIM: To investigate junior doctors' knowledge of how to conduct the Montreal Cognitive Assessment (MoCA). METHODS: A two-part questionnaire was administered to junior doctors at teaching sessions across three New Zealand district health boards. Part 1 investigated prior experience and knowledge of the MoCA. Part 2 tested junior doctors' ability to identify errors in administration and how to score the test. Several weeks later a brief MoCA teaching session was given followed immediately by a repeat questionnaire. RESULTS: Seventy-one individuals completed the initial audit and 46 did the follow-up audit. The majority of junior doctors carried out the MoCA on a monthly basis. Prior to our teaching session, only 23% of participants had received formal teaching on how to administer and score the MoCA. The majority (89%) of participants thought that the teaching session had improved their ability to conduct the MoCA. Statistically significant changes were seen in participants' ability to administer the trail-making question and to score the example questions of clock faces, naming animals, serial seven subtractions, verbal fluency testing, abstraction and the awareness about the effect of years of education on the MoCA score. CONCLUSION: Junior doctors administer and score the MoCA but many have not received formal teaching on how to do so. A short teaching session improved their ability to conduct the MoCA and identify errors in administration and scoring.

An audit of coagulation screening in patients presenting to the emergency department for potential stroke thrombolysis.

AIM: To assess time to coagulation screening results in patients presenting for potential stroke thrombolysis. METHODS: A retrospective cohort study of patients was assessed for thrombolysis for stroke at Wellington Hospital between January and June 2014. We assessed time from presentation to receipt of laboratory specimen, processing time and total time from presentation to result availability and whether times differed by receipt time. RESULTS: During the audit period, 97 unique patients, and 99 clinical episodes, were assessed for stroke thrombolysis; 20 patients received thrombolysis. In 11of 99 (11%) episodes, no coagulation sample was sent. Sample was unsuitable for processing in 16 episodes (18%), and in four, a further specimen was sent. Median (interquartile range) time from presentation to the emergency department to laboratory report during working hours (n = 55) was 61 (53-77) min and out of hours (n = 33) 64 (50-90) min; Hodges-Lehmann estimator (95% CI) of location shift -1 (-11 to 8) min, P = 0.90. No difference in reporting times was seen whether patients received thrombolysis or not. Seven patients were prescribed warfarin, and one had an international normalised ratio (INR) of 1.7 and was thrombolysed. INR in the other six patients ranged between 1.9 and 3.4. Two patients using dabigatran had prolonged thrombin times and so were not thrombolysed. CONCLUSION: A high proportion of laboratory specimens was unsuitable for testing, and overall samples took an unacceptably long time to process. Point-of-care testing may potentially allow quicker decisions regarding whether thrombolysis is contraindicated but is likely to affect only a small proportion of patients.

Prescriber compliance with renal function monitoring in patients taking dabigatran (Pradaxa).

AIM: To assess whether patients prescribed dabigatran had their renal function monitored in accordance with published guidelines. METHODS: We recruited patients from Hutt Hospital and two large primary care practices if they were prescribed dabigatran between July 2011 and April 2012. We assessed patients prescribed dabigatran for more than a year to ascertain whether renal function was monitored at least annually, in keeping with guidelines. RESULTS: All patients had baseline renal function testing. At baseline, 42 (60%) had an eGFR (estimated Glomerular Filtration Rate) over 60mL/min/1.73m2 and 28 (40%) had eGFR between 30-60mL/min/1.73m2. Median follow up was 46 months. Whilst taking dabigatran, 44 of the 70 patients (63%) had at least annual renal function. CONCLUSIONS: Over one-third of patients taking dabigatran for over a year did not have their renal function monitored in keeping with current guidelines, potentially leading to an increased risk of bleeding. We suggest there is a need for an automated reminder to prompt annual renal function testing.

Clinical audit of stroke thrombolysis in Wellington, New Zealand: disparity between in-hours and out-of-hours treatment time.

AIMS: To report on the safety and efficiency of a comprehensive stroke thrombolysis service and look for evidence of disparity between in-hours and out-of-hours treatment times. METHOD: Clinical audit of patients treated with tissue plasminogen activator, alteplase (rt-PA) for stroke at Wellington Hospital between 1 November 2009 and 31 October 2010. RESULTS: Thirty-one patients were treated with rt-PA. All were treated within agreed clinical eligibility criteria. The median NIHSS score pre-treatment was 10; post treatment 5. Two patients died, both from intracranial haemorrhage. Overall the average time to treatment from symptom onset was 168 minutes. Those treated out-of-hours had an additional delay of 33 minutes compared to in-hours treatment (p=0.03). CONCLUSIONS: Patients admitted out-of-hours had significantly longer delays to rt-PA treatment. Those planning Stroke Services should ensure this source of inequity is addressed within their localities.