The Case for Perioperative Care

Safe surgery is one of the greatest successes of modern healthcare. The challenge of care during surgery is now to improve the quality of patient care, as well as preventing medical error. The presence of an experienced anaesthetist supported by a multi-disciplinary team, provides an opportunity for the delivery of treatments which need significant medical input, without disrupting the surgical care pathway.

Maintaining standards, improving quality

Permanent harm caused by technical errors during surgery is now considered to be rare. Whilst the need to maintain the highest safety standards will never cease, the greatest challenge of care during surgery has now become the need to improve the quality of patient care. There are numerous examples of developments in perioperative care which are based on interventions started in the operating theatre.

The presence of a highly-trained anaesthetist, supported within a multi-disciplinary team, provides an easy opportunity for the delivery of treatments which are complex or need significant medical input, without disrupting the surgical care pathway. It is increasingly necessary to see the care provided during surgery, not as an isolated episode, but as part of a continuum starting with the decision to operate.

Reducing the impact of acute pain after surgery

Despite the efforts of doctors and nurses, many patients still experience acute pain after surgery. For these patients, pain is much more than an unpleasant experience. Severe pain delays patient recovery, and prevents adequate breathing leaving patients more at risk of pneumonia and myocardial infarction, and in some cases it develops into chronic pain which can cause life-long disability. As many as one in ten patients having a knee replacement experience long-term pain afterwards.

Perioperative physicians are ideally placed to prevent and treat pain following surgery. The anaesthetist takes primary responsibility for assessing the risk of acute and chronic pain and for developing a robust plan for pain management. In almost all NHS hospitals, patients at risk of severe pain are reviewed on the surgical ward by a multi-disciplinary acute pain team, providing expert advice and training for the doctors and nurses from the surgical team. This approach to effective pain management helps to reduce the risk of complications such as pneumonia, and speeds patient recovery. It also reduces the risk of debilitating chronic pain problems.

The prevention and treatment of pain is an excellent example of perioperative care. Whilst not a fundamental part of treating the index disease (such as cancer or arthritis), we all recognise that it is essential to treat this consequence of surgery in order to give the patient the best chance of a safe and speedy recovery. Acute pain teams also offer a model of care for the multi-disciplinary perioperative medicine team early after surgery. Whilst not leading the care of every patient, they provide expert advice and guidance as well as seamless continuity of care from surgery to patient discharge.

Simple tools to make surgery safer

Although harm due to medical error during surgery is now rare, it remains important. There is growing recognition that safety and quality of care are at two ends of a single continuum that ensures the best possible outcomes for patients. Research led by the World Health Organisation (WHO), suggested that adverse incidents in the operating theatre may be reduced by a simple checklist to confirm that basic safety procedures are complete before surgery begins. The Department of Health then directed that the WHO Surgical Safety Checklist was to be used in all NHS hospitals.

During implementation, local variation of the layout and content of the checklist allowed hospitals to tackle their individual needs, promoting a sense of ownership, and improving adoption. The three core components of the checklist are: the sign in before anaesthesia, time out before surgery begins and sign out before any member of the surgical team leaves the operating theatre. Participation in the WHO checklist is now included in the curriculum for anaesthesia, in good practice guidelines and in the Anaesthesia Clinical Services Accreditation (ACSA) standards.

Recent research across Europe has shown significant international variation in use of the surgical checklist, and vitally that exposure to a checklist is associated with reduced mortality after surgery. Compliance with the checklist in the NHS is greater than 90% although regulators sometimes report some variability. We don’t know whether the checklist itself prevents frequent harm, or that it is used more commonly where the quality of care is higher. However, it is clear that the need to improve the quality of perioperative care is as important as maintaining high standards of safety.