Prof. Dr. med. Andreas Hoeft (University Hospital Bonn, Germany)
Prof. Dr. med. Hugo K. Van Aken (University Hospital Münster, Germany)
with contributions from PD Dr. med. Sven Staender (District Hospital Männedorf, Switzerland)

 

In Europe, overall mortality of surgical patients ranges between 0.8 and almost 4%. Recent evidence suggests that this mortality to a considerable degree is caused by complications, which might not optimally be managed. This phenomenon is called “Failure to Rescue (FTR)” and up to one third or even half of the surgical mortality might therefore be preventable. With approximately 40 Million surgeries in Europe per year, a conservative estimate would be that more than 500.000 patients death might be preventable by best practice perioperative medicine and in particular by best practice complication management. FTR is therefore a major issue of patient safety, which most likely has a much higher impact on patient outcomes than other commonly known problems in patient safety, and which has been underestimated in the past and only recently recognized in its dimension. The aim of the task force for “Optimizing Patients Undergoing Surgery” (OPUS) is to establish recommendations of best practice patterns for optimal management of patients undergoing surgery. Anaesthesiologists are in a key position to coordinate such a task force, as they are involved in the perioperative treatment of nearly all surgical patients. The task force should comprise members from all major surgical disciplines in a particular general surgery, orthopaedic and trauma surgery, gynaecology and obstetrics, urology, ENT, neuro- and cardiac surgery, possibly also smaller disciplines such as oral-fascial surgery, eye surgery and plastic surgery under the umbrella of the European Patient Safety Foundation (EUPSF). The final goal is to optimize treatment of patients undergoing surgery and to avoid all preventable deaths due to FTR, basically, to save 500.000 lives per year.

Surgical Outcomes in Europe and evidence for Failure to Rescue.

The European Society of Anaesthesiology (ESA) has recently performed a large observational study on outcome of surgical patients. Within one week 46,539 patients were recruited in 498 hospitals across 28 European countries3. Surprisingly, the mortality of surgical patients was higher than expected (4%) and notably 85% deaths occurred outside intensive care units, i.e. on normal surgical wards. Even more surprising was the observation, that the average mortality rate of elective patients with planned admission to critical care was only 2%, whereas the mortality rate of elective patients with no admission to critical care was 3%. This observation was totally counterintuitive to the assumption that patients with higher risks would be those with planned admission to critical care. This observation would be compatible with the hypothesis of a significant contribution of “Failure to Rescue” to overall mortality.

Interestingly, in another ESA study with similar inclusion criteria and a large number of the same hospitals a remarkably lower mortality of only 0.9% was observed2. Also, less patients died outside the ICU. As this study aimed to detect postoperative pulmonary complications all patients were routinely visited on the first postoperative day primarily for assessment of pulmonary complications. Although not an absolute proof, this observation adds to the hypothesis, that some degree of postoperative mortality might have been avoided by earlier detection of postoperative complications, more secondary admission to critical care and thereby less mortality.

The hypothesis of “Failure to Rescue” has also been raised by other clinical studies. Ghaferi et al. demonstrated in a retrospective study with data from the “American College of Surgeons National Surgical Quality Improvement Program” (NSQIP) that the variation of hospital mortality in high risk surgical patients is closely associated with variation of rates of deaths after major complications1. This study also provides some data on the nature of major complications. Leading causes of death were septic shock, acute renal failure, pneumonia and organ space infection, whereas myocardial  infarction and stroke were only minor contributors to overall mortality. Again, these data add to the evidence, that a major cause of post-surgical death are complications with a relatively slow onset. Thus, there might be an opportunity to prevent these by optimal perioperative management of surgical patients in order to avoid intra- and postoperative complications as well as early detection an early adequate treatment of complications, in general by avoidance of “Failure to Rescue”.

Failure to rescue – a neglected problem of patient safety

It is well known that surgical mortality varies between hospitals and that hospitals with large volume of surgery tend of have lower mortality rates. Intuitively, this leads to the hypothesis, that in hospitals with higher case load fewer complications occur. In fact, this is not the case. It has been shown, that in hospitals with low mortality rates less deaths occur after major complications, where-as the complication rates are similar. The aim of OPUS is to optimize perioperative management of surgical patients in order to identify patients at risk, avoid intra- and postoperative complications, and to detect complications early and to treat these early, adequately and aggressively.

Taskforce for Optimizing Patients Undergoing Surgery (OPUS)

The goal of the task force for “Optimizing Patients Undergoing Surgery” (OPUS) is to establish recommendations of best practice patterns for optimal management of patients undergoing surgery. In order to achieve this goal an interdisciplinary taskforce should be convened. The recommendations can, but might not necessarily have the character of guidelines. In many areas the recommendations might have more the character of “practice advisories”, in particular in those areas where evidence for best practice is scare. The major focus of OPUS should be on:

  • Identifying patients at risk for development of complications
  • Avoiding complications in general and in particular in patients at risk
    • by optimal preoperative preparation of the patient
    • by optimal intraoperative management
    • by optimal perioperative adjuvant protective therapy
  • Optimal postoperative management
    • Pain therapy
    • Hemodynamic and Fluid Management
    • Respiratory  Management
  • Detecting postoperative complications early
    • by stratified postoperative surveillance and care
    • with high dependency units
    • with postoperative SOPs for surveillance
    • with postoperative visits
    • with extended monitoring
  • Treating postoperative complications

Within all topics above the following areas need to be covered

  • Preoperative  assessment
  • Preoperative preparation (NPO, fluid restriction, preop. nutrition, preop sedation, prewarming, etc.)
  • Anaesthetic techniques including regional, balanced, multimodal and total intravenous anaesthesia, as well as use of muscle relaxants
  • Postop management including pain management, PONV, delirium, other complications.
  • Post PACU management and surveillance

The following outcomes should receive special attention:

  • Postoperative pulmonary complications
  • Infectious complications like organs space infection, deep wound infection, sepsis
  • Major adverse cardiac events and stroke
  • Deep vein thrombosis and Pulmonary embolism
  • Bleeding
  • Delirium

In addition to these ‚best practice patterns’, established tools and strategies for patient safety should be included in these recommendations4. These should include at least the following:

  • Preoperative checklists and anaesthesia checklists to prevent operative and postoperative  events
  • Bundles that include checklists to prevent central line–associated bloodstream infections
  • Interventions to reduce urinary catheter use, including catheter reminders, stop orders, or nurse-initiated removal protocols
  • Bundles that include head-of-bed elevation, sedation vacations, oral care with chlorhexidine, and subglottic suctioning endotracheal tubes to prevent ventilator- associated  pneumonia
  • Hand hygiene
  • The do-not-use list for hazardous abbreviations
  • Multicomponent interventions to reduce pressure ulcers
  • Barrier precautions to prevent health care–associated infections
  • Use of real-time ultrasonography for central line placement
  • Interventions to improve prophylaxis for venous thromboembolisms

Composition of OPUS

The OPUS task force should comprise members from all disciplines involved in the perioperative care of patients. Anaesthesiologist might coordinate these activities as they are involved in the perioperative management of nearly all surgical patients. Therefore, Anaesthesiologists have the highest case load in most hospitals and are overseeing more patients compared to a singular surgical discipline. Moreover, in many hospitals postoperative intensive care is managed by Anaesthesiologists as well, and the rescue teams (CPR-teams) or other forms of rapid response teams are also often run by Anaesthesiologists. Anaesthesiologists are therefore predestined to coordinate activities to optimize perioperative management of surgical patients. However, a close cooperation and input from all major surgical disciplines is essential. The taskforce should therefore comprise members from all major surgical disciplines, in particular general surgery, orthopaedic and trauma surgery, gynaecology and obstetrics, urology, ENT, neuro- and cardiac surgery, possibly also smaller disciplines such as oral-fascial surgery, eye surgery and plastic surgery. The umbrella for all these disciplines will be the European Patient Safety Foundation.

Structure of OPUS

The OPUS task force should be led by an interdisciplinary steering committee. The number of the members of the steering committee should not exceed 15, preferably smaller. The steering committee should be led by a chair accompanied by a co-chair. The steering committee should convene at least twice a year. Due to the complex nature of the task several subgroups (8 – 12) should be established. Size of subgroups might depend on the topic and vary between four and up to twenty. Members of OPUS taskforce should be selected by an open, transparent process. The EUPSF board should select the steering committee first, subgroups should be constituted by OPUS steering committee and approved by OPUS board. The process of committee member selection with open advertisement and open application forms, which has been developed by the ESA might be adopted (see attachment). The application form should be promoted and advertised by all major European societies involved.

In addition to the experts a basic infrastructure is required, i.e. at least 1½ FTE accompanying the work of OPUS by administrative support, including accounting, preparation and arrangement of meetings, managing an OPUS website, etc.. The administration should be located in EUPSF headquarters. Meetings should preferably take place in Brussels.

Work packages and timeline for OPUS

OPUS should start latest beginning of next year. The OPUS task force should comprise members from all disciplines involved in the perioperative care of patients. The work of OPUS will extend over at least two years. Results should be published in the major journals of societies involved.

Financial needs of the OPUS campaign

It is estimated that the following resources will be required for OPUS:
Office: 1½ FTE administrative support: 150.000 € per year
Office space: 12.000 € per year
Office supplies including hardware and software 20.000 € per year Meetings: 70.000 € per year
Total 252.000 € per year

References

  1. Ghaferi, Amir A., John D. Birkmeyer, und Justin B. Dimick. 2009. „Variation in hospital mortality associated with inpatient surgery“. New England Journal of Medicine 361 (14): 1368–75.
  2. Mazo, Valentín, Sergi Sabaté, Jaume Canet, Lluís Gallart, Marcelo Gama de Abreu, Javier Belda, Olivier Langeron, Andreas Hoeft, und Paolo Pelosi. 2014. „Prospective External Validation of a Predictive Score for Postoperative Pulmonary Complications.“ Anesthesiology 121 (2).
  3. Pearse, Rupert M., Rui P. Moreno, Peter Bauer, Paolo Pelosi, Philipp Metnitz, Claudia Spies, Benoit Vallet, Jean-Louis Vincent, Andreas Hoeft, und Andrew Rhodes. 2012. „Mortality after surgery in Europe: a 7 day cohort study“. The Lancet 380 (9847): 1059–65.
  4. Shekelle PG, Pronovost PJ, Wachter RM, et al. The top patient safety strategies that can be encouraged for adoption now. Ann Intern Med 2013; 158:365–368.