Enhanced peri-operative care to improve outcomes for high-risk surgical patients in Brazil: a single-centre before-and-after cohort study

A Stahlschmidt, S C Passos, G R Cardoso, G J Schuh, C S Gutierrez, S M J Castro, W Caumo, R M Pearse, Ex-Care collaborative, L C Stefani, K Moraes, H D Santos, T Dalcin, A Caberlon, E Felix, A Aguzzoli, G Braulio, P Gamermann, C Schiavo, V Alves, A Sturm, A Martins, A Schmit, A Schwalbert, A Prates, A Wolmeister, P de Oliveira, B Novelo, B Borges, J Neto, M Bortolini, C Bressan, C Bortolozzo, C Alboim, C Mendanha, C Pando, C Filho, T Bevilacqua, C Abel, E Vicente, E Mallmann, F Petry, F Vieira, A de Feijo, F Paniz, F Lima, F Grillo, D Lemmertz, F Fritz, G Somm, G Bauzon, A Migliore, G Sá, G Somm, G Dos Santos, I Dornelles, I Sirtoli, H Ribeiro, J Correa, J Viesi, J Crestani, J Ebersol, J Pasa, J Guimarães, K Biavatti, L Schneider, L Schultz, L Oliveira, L da Rosa, L Sachett, L Schönell, L Fernandes, L Borges, L Monteiro, M Bravo, M Souza, L Menezes, M Jacobsen, M Ferreira, N Pereira, N Dotto, N Savaris, O Brathwaite, P Barone, P Faccin, P Homrich, R Coral, R Vidal, R Franco, R Martin, R da Costa, R Minuzzi, S Passos, S Molin, S Petry, M Guske, S Morisso, T Lima, T Schuch, V Moreira, V Piccoli, V Damiani, V Rocha, V Nogueira, W Vieira, C da Rosa, C Evaldt, D Deggerone, G Martins, L da Silva, L Ferreira, L Nabarros, M Guimarães, M Nolasco, N Paludo, N Júnior, V Rodríguez, A Vilaverde, A Henkemaier, J Blanco, L Barbosa, L Okabayashi, M Spader, M Lizott, O Gastal, R Kliemann, R Schlosser, R Brandão, S Coelli, V Giaretta, B Neto, L Cavazzola, A Osvaldt, T Gurski, R Contu, C Polanczyk, A Biolo, N Clausell, T Buttelli, M Boniatti, T Furian, A Azeredo, P Neto, C Pando, C Medanha, I Sirtoli, T Soares, D Dornelles, M Brandão, G Marangon, G Sbrissa, M Dasqueve, T da Costa, F Almeida, N Travi, A Geronimo, D Trost, N Volkmer, N Rauber, L Oliveira, L Brito, C Souza, C Guzinski, C Riboldi, K Silva, M Borges, T Melo, A Mandicaju, F Schnath, M Trasel, G Dreyer, C Brandolt, S Pereira, C Oliveira, A Silva, F Costa, F Martins, D Rodrigues, F Antunes, M Dalmoro, G Camargo, A Stahlschmidt, S C Passos, G R Cardoso, G J Schuh, C S Gutierrez, S M J Castro, W Caumo, R M Pearse, Ex-Care collaborative, L C Stefani, K Moraes, H D Santos, T Dalcin, A Caberlon, E Felix, A Aguzzoli, G Braulio, P Gamermann, C Schiavo, V Alves, A Sturm, A Martins, A Schmit, A Schwalbert, A Prates, A Wolmeister, P de Oliveira, B Novelo, B Borges, J Neto, M Bortolini, C Bressan, C Bortolozzo, C Alboim, C Mendanha, C Pando, C Filho, T Bevilacqua, C Abel, E Vicente, E Mallmann, F Petry, F Vieira, A de Feijo, F Paniz, F Lima, F Grillo, D Lemmertz, F Fritz, G Somm, G Bauzon, A Migliore, G Sá, G Somm, G Dos Santos, I Dornelles, I Sirtoli, H Ribeiro, J Correa, J Viesi, J Crestani, J Ebersol, J Pasa, J Guimarães, K Biavatti, L Schneider, L Schultz, L Oliveira, L da Rosa, L Sachett, L Schönell, L Fernandes, L Borges, L Monteiro, M Bravo, M Souza, L Menezes, M Jacobsen, M Ferreira, N Pereira, N Dotto, N Savaris, O Brathwaite, P Barone, P Faccin, P Homrich, R Coral, R Vidal, R Franco, R Martin, R da Costa, R Minuzzi, S Passos, S Molin, S Petry, M Guske, S Morisso, T Lima, T Schuch, V Moreira, V Piccoli, V Damiani, V Rocha, V Nogueira, W Vieira, C da Rosa, C Evaldt, D Deggerone, G Martins, L da Silva, L Ferreira, L Nabarros, M Guimarães, M Nolasco, N Paludo, N Júnior, V Rodríguez, A Vilaverde, A Henkemaier, J Blanco, L Barbosa, L Okabayashi, M Spader, M Lizott, O Gastal, R Kliemann, R Schlosser, R Brandão, S Coelli, V Giaretta, B Neto, L Cavazzola, A Osvaldt, T Gurski, R Contu, C Polanczyk, A Biolo, N Clausell, T Buttelli, M Boniatti, T Furian, A Azeredo, P Neto, C Pando, C Medanha, I Sirtoli, T Soares, D Dornelles, M Brandão, G Marangon, G Sbrissa, M Dasqueve, T da Costa, F Almeida, N Travi, A Geronimo, D Trost, N Volkmer, N Rauber, L Oliveira, L Brito, C Souza, C Guzinski, C Riboldi, K Silva, M Borges, T Melo, A Mandicaju, F Schnath, M Trasel, G Dreyer, C Brandolt, S Pereira, C Oliveira, A Silva, F Costa, F Martins, D Rodrigues, F Antunes, M Dalmoro, G Camargo

Abstract

Mortality and morbidity for high-risk surgical patients are often high, especially in low-resource settings. Enhanced peri-operative care has the potential to reduce preventable deaths but must be designed to meet local needs. This before-and-after cohort study aimed to assess the effectiveness of a postoperative 48-hour enhanced care pathway for high-risk surgical patients ('high-risk surgical bundle') who did not meet the criteria for elective admission to intensive care. The pathway comprised of six elements: risk identification and communication; adoption of a high-risk post-anaesthesia care unit discharge checklist; prompt nursing admission to ward; intensification of vital signs monitoring; troponin measurement; and prompt access to medical support if required. The primary outcome was in-hospital mortality. Data describing 1189 patients from two groups, before and after implementation of the pathway, were compared. The usual care group comprised a retrospective cohort of high-risk surgical patients between September 2015 and December 2016. The intervention group prospectively included high-risk surgical patients from February 2019 to March 2020. Unadjusted mortality rate was 10.5% (78/746) for the usual care and 6.3% (28/443) for the intervention group. After adjustment, the intervention effect remained significant (RR 0.46 (95%CI 0.30-0.72). The high-risk surgical bundle group received more rapid response team calls (24% vs. 12.6%; RR 0.63 [95%CI 0.49-0.80]) and surgical re-interventions (18.9 vs. 7.5%; RR 0.41 [95%CI 0.30-0.59]). These data suggest that a clinical pathway based on enhanced surveillance for high-risk surgical patients in a resource-constrained setting could reduce in-hospital mortality.

Trial registration: ClinicalTrials.gov NCT04187664.

Keywords: failure-to-rescue; high-risk surgical patient; outcome assessment; patient care team; postoperative care.

© 2022 Association of Anaesthetists.

References

    1. Weiser TG, Regenbogen SE, Thompson KD, et al. An estimation of the global volume of surgery: a modelling strategy based on available data. Lancet 2008; 372: 139-44.
    1. Lloyd C, Proctor L, Au M, Story D, Edwards SLG. Incidence of early major adverse events after surgery in moderate-risk patients: early postoperative adverse events. British Journal of Anaesthesia 2020; 124: e9-10.
    1. Bhangu A, Fitzgerald JEF, Fergusson S, et al. Mortality of emergency abdominal surgery in high-, middle- and low-income countries. British Journal of Surgery 2016; 103: 971-88.
    1. Knight SR, Shaw CA, Pius R, et al. Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries. Lancet 2021; 397: 387-97.
    1. Castro MC, Massuda A, Almeida G, et al. Brazil's unified health system: the first 30 years and prospects for the future. Lancet 2019; 394: 345-56.
    1. Santhirapala V, Peden CJ, Meara JG, et al. Towards high-quality peri-operative care: a global perspective. Anaesthesia 2020; 75: e18-27.
    1. Ahmad T, Bouwman RA, Grigoras I et al. Use of failure-to-rescue to identify international variation in postoperative care in low- , middle- and high-income countries : a 7-day cohort study of elective surgery. British Journal of Anaesthesia 2017; 119: 258-66.
    1. Kahan BC, Koulenti D, Arvaniti K, et al. Critical care admission following elective surgery was not associated with survival benefit: prospective analysis of data from 27 countries. Intensive Care Medicine 2017; 43: 971-9.
    1. Morton B, Banda NP, Nsomba E, et al. Establishment of a high- ­ dependency unit in Malawi. BMJ Global Health 2020; 5: 1-6.
    1. Peden CJ, Stephens T, Martin G, et al. Effectiveness of a national quality improvement programme to improve survival after emergency abdominal surgery (EPOCH): a stepped-wedge cluster-randomised trial. Lancet 2019; 393: 2213-21.
    1. Biccard BM, du Toit L, Lesosky M, et al. Enhanced postoperative surveillance versus standard of care to reduce mortality among adult surgical patients in Africa (ASOS-2): a cluster-randomised controlled trial. Lancet Global Health 2021; 9: e1391-401.
    1. Hollis RH, Graham LA, Lazenby JP, et al. A role for the early warning score in early identification of critical postoperative complications. Annals of Surgery 2016; 263: 918-23.
    1. Turan A, Chang C, Cohen B, et al. Incidence, severity, and detection of blood pressure perturbations after abdominal surgery: a prospective blinded observational study. Anesthesiology 2019; 130: 550-9.
    1. Gutierrez CS, Passos SC, Castro SMJ, et al. Few and feasible preoperative variables can identify high-risk surgical patients: derivation and validation of the Ex-Care risk model. British Journal of Anaesthesia 2021; 126: 525-32.
    1. Stefani LC. ExCare app. Porto Alegre - RS - Brazil: Ricardo Bertoglio Cardoso, 2020. (accessed 21/12/2021).
    1. Stefani LC. ExCare app IOS. Porto Alegre - RS - Brazil: Ricardo Bertoglio Cardoso, 2020. (accessed 21/12/2021).
    1. Passos SC, Stalschmidt A, Blanco J, Spader M, Brandão RB SL. Derivation and validation of a national multicenter mortality risk stratification model - the ExCare model: a study protocol. Brazilian Journal of Anesthesiology 2021. Epub 26 July; S0104-0014(21)00283-9.
    1. Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. New England Journal of Medicine 2009; 360: 491-9.
    1. de Souza GC, Bottega K, de Jezus Castro SM, et al. The impact of the incorporation of a feasible postoperative mortality model at the post-Anaesthestic care unit (PACU) on postoperative clinical deterioration: A pragmatic trial with 5,353 patients. PLoS One 2021; 16: 1-11.
    1. Langley GL, Moen R, Nolan KM, Nolan TW, Norman CL, Provost LP. The improvement guide: a practical approach to enhancing organizational performance. 2nd ed. San Francisco: Jossey-Bass; 2009.
    1. Gumbert SD, Kork F, Jackson ML, et al. Perioperative acute kidney injury. Anesthesiology 2020; 132: 180-204.
    1. Stevens P, Levin A, Kidney Disease: Improving Global Outcomes Chronic Kidney Disease Guideline Development Work Group Members. Evaluation and management of chronic kidney disease: synopsis of the kidney disease: improving global outcomes 2012 clinical practice guideline. Annals of Internal Medicine 2013; 158: 825-30.
    1. Jammer I, Wickboldt N, Sander M, et al. Standards for definitions and use of outcome measures for clinical effectiveness research in perioperative medicine: European perioperative clinical outcome (EPCO) definitions: a statement from the ESA-ESICM joint taskforce on perioperative outcome measur. European Journal of Anaesthesiology 2015; 32: 88-105.
    1. Ghaferi AA, Birkmeyer JD, Dimick JB. Complications, failure to rescue, and mortality with major inpatient surgery in medicare patients. Annals of Surgery 2009; 250: 1029-34.
    1. Ferraris VA, Bolanos M, Martin JT, Mahan A, Saha SP. Identification of patients with postoperative complications who are at risk for failure to rescue. Journal of the American Medical Association Surgery 2014; 149: 1103-8.
    1. Victora C, Huttly S, Fuchs S, Olinto M. The role of conceptual frameworks in epidemiological analysis: a hierarchical approach. International Journal of Epidemiology 1997; 26: 224-7.
    1. Stefani LC, Gutierrez CDS, Castro SM, et al. Derivation and validation of a preoperative risk model for postoperative mortality (SAMPE model): an approach to care stratification. PLoS One 2017; 12: e0187122.
    1. Pearse RM, Harrison DA, James P, et al. Identification and characterisation of the high-risk surgical population in the United Kingdom. Critical Care 2006; 10: R81.
    1. Vickery N, Stephens T, du Toit L, et al. Understanding the performance of a pan-African intervention to reduce postoperative mortality: a mixed-methods process evaluation of the ASOS-2 trial. British Journal of Anaesthesia 2021; 127: 778-88.
    1. Burgoine K, Ikiror J, Akol S, et al. Staged implementation of a two-tiered hospital-based neonatal care package in a resource-limited setting in Eastern Uganda. British Medical Journal Global Health 2018; 3: e000586.
    1. Aggarwal G, Peden CJ, Mohammed MA, et al. Evaluation of the collaborative use of an evidence-based care bundle in emergency laparotomy. Journal of the American Medical Association Surgery 2019; 154: 1-9.
    1. Stephens TJ, Peden CJ, Pearse RM, et al. Improving care at scale: process evaluation of a multi-component quality improvement intervention to reduce mortality after emergency abdominal surgery (EPOCH trial). Implementation Science 2018; 13: 142.
    1. Ruetzler K, Smilowitz N, Berger J, et al. Diagnosis and management of patients with myocardial injury after noncardiac surgery: a scientific statement from the American Heart Association. Circulation 2021; 144: e287-305.
    1. Devereaux PJ, Chan MT, Alonso-Coello P, Walsh M, Berwanger O, Villar JC. Association between postoperative troponin levels and 30-day mortality among patients undergoing noncardiac surgery. Journal of the American Medical Association 2012; 307: 2295-304.
    1. van Waes JA, Grobben RB, Nathoe HM, et al. One-year mortality, causes of death, and cardiac interventions in patients with postoperative myocardial injury. Anesthesia and Analgesia 2016; 123: 29-37.
    1. Yeung J, Gillies MA, Pearse RM. Pragmatic trials in peri-operative medicine: why, when and how? Anaesthesia 2018; 73: 799-803.
    1. Portuondo JI, Shah SR, Singh H, Massarweh NN. Failure to rescue as a surgical quality indicator: current concepts and future directions for improving surgical outcomes. Anesthesiology 2019; 131: 426-37.
    1. Ghaferi AA, Dimick JB. The importance of teamwork, communication, and culture in failure to rescue in the elderly. British Journal of Surgery 2017; 103: e47-51.

Source: PubMed

Sponsor e collaboratori

Condizioni mediche

Interventi farmacologici

3
Sottoscrivi