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Proposed Perioperative Medicine Service Model in a Teaching Hospital in Hong Kong
Danny Ip Department of Anaesthesiology
Queen Mary Hospital (HKWC)
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Perioperative Care Past, Present and Future
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A Paradigm Shift
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Endemic Burden of Surgery
• 66 countries
• Between 2005 - 2013
• 312.9 millions operations in 2012
• 33.6% increase over 8 years
The Lancet, Volume 385, Special Issue S11, 27 April 2015
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Endemic Burden of Surgery
United Nations Department of Economic and Social Affairs
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Endemic Burden of Surgery
PEW Research Center
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Are we doing GOOD enough ?
British Journal of Anaesthesia, Volume 117, Issue 5, 1 November 2016, Pages 601–609
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Are we doing GOOD enough ?
50%
Knowing the Risk A Report by the National Confidential Enquiry into Patient Outcome and Death (2011)
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Local Burden of Surgery
Census & Statistical Department, HKSAR
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Local Burden of Surgery
‧
Statistics and Workforce Planning Department, Hospital Authority Census and Statistical Department, HKSAR
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Are we doing GOOD enough ?
Surgical Outcomes Monitoring & Improvement Program Report, Hospital Authority
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Can we do EVEN better ?
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Perioperative Medicine
‘The care of patients from the time they contemplate surgery through the operative period to full recovery at home’
The Royal College of Anaesthetists
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Care Model - does it exist ? UK Experience
Perioperative Medicine : The Pathway to Better Surgical Care The Royal College of Anaesthetist
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Care Model - does it exist ? UK Experience • University College London
Hospital
• Consultant-led Perioperative Medicine Unit
• Stand alone unit
• Preoperative Risk Assessment
• Postoperative Ward Round
• Extended Post-anaesthetic care ward
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Perioperative Medicine Service Model
1. Preoperative phase • Risk stratification • Risk modification • Multidisciplinary Interventions
2. Intraoperative phase • Evidence-based Practice • Patient and surgical safety
3. Postoperative phase • Enhanced Recovery • Early detection of Complications
Perioperative Medicine
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Perioperative Medicine Service in QMH
Ultramajor Surgery
Total number of Surgery
2014-2015 4816
(21%) 22869
2015-2016 4662
(18%) 25294
2016-2017 4981
(17%) 28567
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Preoperative Phase
Perioperative Medicine
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1. Electronic PreAnaesthetic Assessment Record
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1. Electronic Preanaesthetic Assessment Record
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2. Develop a more comprehensive Risk Stratification System • American Society of
Anaesthesiologists (ASA) Grading System
• Since 1963
• Simple and easy to use
• Too subjective
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2. Develop a more comprehensive Risk Stratification System
The UCL/UCLH Surgical Outcomes Research Centre (SOuRCe)
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2. Develop a more comprehensive Risk Stratification System
• ? Direct adoption of established scoring system
• ? Importance of just knowing mortality
• Future direction
• Own scoring system
• Mortality / morbidity
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3. Anaesthetist-led Preanaesthetic talk • Twice a week
• One-hour talk
• Before Preanaesthetic clinic
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4. High Risk Preanaesthetic Assessment Clinic • Role of Preanaesthetic clinic
(PAC)
• One-stop preanesthetic assessment
• Allow identification and optimization of medical conditions before surgery
• Nurse-led clinic
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4. High Risk Preanaesthetic Assessment Clinic
• Features of High Risk clinic (every Friday)
1. Consultation before decision of surgery
• Minimize routine in-patient consultations
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4. High Risk Preanaesthetic Assessment Clinic • Allow share decision
(surgeon + anaesthetist + patients) making to be made for very high risk cases
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4. High Risk Preanaesthetic Assessment Clinic 2. Initiation of investigations and treatments for appropriate cases
• Investigate and diagnose iron deficiency anaemia
• Treat or titrate medications for uncomplicated hypertension and diabetes
• Perform targeted Echocardiography
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5. Blood Management Program • Preoperative anaemia is common
• Anaemia Audit (QMH) in 2015
• 34 %
• Preoperative anaemia is associated with adverse perioperative outcomes
• Length of stay • ICU admission • In hospital mortality
British Journal of Anaesthesia 113 (3): 416-23 (2014)
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5. Blood Management Program • Blood transfusion
• Supply could be unstable
• Association with various complications
• Financial implications
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5. Blood Management Program • Preoperative anaemia as a potential
modifiable risk factor for adverse outcome
• Investigate and diagnose iron deficiency anaemia
• Actively treated before surgery
• Regular audit and monitor the outcome
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Intraoperative Phase
Perioperative Medicine
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1. Difficult Case Conference
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2. Towards better Patient’s Safety
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Postoperative Phase
Perioperative Medicine
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1. Enhanced Recovery Program • Enhanced Recovery After
Surgery (ERAS) Program
• Joint replacement
• Upper GI
• Lower GI
• Urology
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2. Extended Post-anaesthetic Care Unit (PACU) • Functions of a PACU
• Close monitoring of physiological parameters right after anaesthesia/surgery
• Make sure no immediate surgical complications
• Ensure reasonable pain control is achieved
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2. Extended Post-anaesthetic Care Unit • Principles - UK Experience
• Normal PACU stay
• Extended PACU stay
• 4 hours / < 24 hours
• Protocols driven
• Haemodynamic optimisation
• Close monitoring
• Warm awake extubation
• Exclude : • Expected PACU stay > 24 hours • Patients with Multiorgan failure
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2. Extended Post-anaesthetic Care Unit • How an Extended PACU
could be beneficial ?
• ICU beds is in scarcity
• Costs of an ICU bed
• Unplanned ICU admission
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Perioperative Medicine in QMH • Regular Audit • Education & Training
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Perioperative Medicine Service - Ways ahead
1. Preoperative phase • Risk stratification • Cardiopulmonary Exercise Testing • Risk modification • Organ Protection Strategies • Multidisciplinary Interventions • Prohabilitation
2. Intraoperative phase • Evidence-based Practice • Patient and surgical safety
3. Postoperative phase • Enhanced Recovery • Early detection of Complications • Post Op ward round by
Anaesthetist • Patient Reported Outcomes
Measurement
Perioperative Medicine
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Thank you very much