An audit of pre-operative optimization Derriford Hospital

Abstract

Pre-operative optimization (PO) has been shown to reduce mortality, duration of hospital stay and hospital costs.1 2 The Intensive Care National Audit and Research Centre (ICNARC) data base shows that 3.4% of all patients are admitted for PO in contrast to 1.9% at our centre. The effective provision of PO requires a bed on the intensive care unit (ICU)–high dependency unit (HDU) with appropriate levels of staffing. There are suggested guidelines for identifying the high-risk surgical population based on surgical categories, underlying medical conditions and HDU admission criteria. At Plymouth there is a nine-bedded ICU and a four-bedded HDU which admit 1200 patients per year, of which, 58% are surgical cases. We performed a prospective audit of 100 consecutive surgical admissions to ICU–HDU assessing whether current resources are sufficient to provide PO. Demographic data were collected and the surgical category noted. The availability of a bed in the 3 h preceding surgery for each admission was recorded. Pre-operative clinical and biochemical data were collected from the notes in accordance with admission criteria used in previous studies. The APACHE II scores, diagnostic and outcome data were obtained using the ICNARC database. The majority of patients underwent vascular or abdominal surgery (laparotomyn = 40, vascularn = 26, orthopaedicsn = 13, othern = 21). A bed was available pre-operatively for all booked admissions (n = 26). Of the remaining non-booked admissions (n = 74), 61% had a bed available for PO without transferring a patient off ICU/HDU. Two patients were admitted specifically for PO. There was no difference in APACHE II scores or outcome between booked and non-booked cases. Eight patients were identified who required admission by recognized criteria. However, data were rarely complete with certain variables seldom recorded (respiratory rate 13%, urine output 15%, temperature 72%, blood gases 11%). Only nine patients had complete basic observations documented in the notes and more patients might have satisfied the criteria if documentation was complete. The low frequency of PO and availability of beds indicates that we should be aiming to increase the number of patients admitted pre-operatively. The ICNARC data for the subgroup of elective vascular case clearly illustrates this (10.2%vs 2.5% Derriford). This audit demonstrates the difficulty in identifying high-risk surgical patients. Poor data collection is a major contributor. A dramatic change in ward care and use of single referral criteria would improve this.