Incidence of early major adverse events after surgery in moderate-risk patients: early postoperative adverse events

Abstract

Editor—A high incidence of postoperative complications is recognised, especially in ‘high-risk’ groups,1Petersen Tym M.K. Ludbrook G.L. Flabouris A. Seglenieks R. Painter T.W. Developing models to predict early postoperative patient deterioration and adverse events.ANZ J Surg. 2017; 87: 457-461Crossref PubMed Scopus (14) Google Scholar,2Story D.A. Leslie K. Myles P.S. et al.Complications and mortality in older surgical patients in Australia and New Zealand (the REASON study): a multicentre, prospective, observational study.Anaesthesia. 2010; 65: 1022-1030Crossref PubMed Scopus (145) Google Scholar although recent data suggest this is also an issue for lower- or ‘moderate’-risk patients.3Swart M. Carlisle J.B. Goddard J. Using predicted 30 day mortality to plan postoperative colorectal surgery care: a cohort study.Br J Anaesth. 2017; 118: 100-104Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar As populations become older and sicker, it is expected that this problem will increase substantially for all groups.4Ludbrook G. Hidden pandemic of postoperative complications—time to turn our focus to health systems analysis.Br J Anaesth. 2018; 121: 1190-1192Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar For moderate-risk patients (predicted 30-day mortality of 1–4%), there are retrospective data to suggest that brief higher-acuity care may have lingering effects on postoperative complications and efficiency measures, such as length of stay.3Swart M. Carlisle J.B. Goddard J. Using predicted 30 day mortality to plan postoperative colorectal surgery care: a cohort study.Br J Anaesth. 2017; 118: 100-104Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar An advanced recovery room care (ARRC) model has been proposed for these patients, with the key principles being moderate-risk identification, continuity of care, using existing recovery resources, minimising handovers, structured care and checklists, and Day 1 triage to ongoing care. A multicentre feasibility before-and-after trial, including patient follow-up to 90 days, is ongoing in three hospitals. This will be reported in full on completion, which is anticipated by early 2020. However, because of evidence of a previously unrecognised very high incidence of early postoperative complications from one site revealed by the ARRC, initial data on adverse events are reported here. Because of concerns about postoperative complications, a feasibility trial of an ARRC model for ‘moderate-risk’ patients is being conducted. This is a prospective randomised multicentre before-and-after feasibility trial, with ethics approval (HREC/17/TQEH/104) and prospective registration (ANZCTRN 1261700117338). Eligibility was primarily based on the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) score, a well-validated tool that accounts for patient co-morbidities and the nature of surgery to predict the risk of postoperative adverse events and 30-day mortality.5Eamer G. Al-Amoodi M.J.H. Holroyd-Leduc J. Rolfson D.B. Warkentin L.M. Khadaroo R.G. Review of risk assessment tools to predict morbidity and mortality in elderly surgical patients.Am J Surg. 2018; 216: 585-594Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar Patients studied were those with an NSQIP-predicted 30-day mortality of 1–4% and scheduled for postoperative management on normal postoperative surgical wards. In the ‘before’ period (5 weeks), up to 16 patients were identified weekly and treated with usual recovery and ward care. After 4 weeks of training, the ‘after’ period with the ARRC ran for 5 weeks, with eligible patients treated until the morning of Day 1. The primary endpoint was 80% recruitment and follow-up. Two sites completed the ‘before’ and ‘after’ arms, with one site yet to complete the after arm. The secondary endpoints included quality of recovery; serious adverse events, which would usually precipitate calling of a medical emergency, or rapid response, team (MET-level events)6Chen J. Ou L. Flabouris A. Hillman K. Bellomo R. Parr M. Impact of a standardized rapid response system on outcomes in a large healthcare jurisdiction.Resuscitation. 2016; 107: 47-56Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar; ICU admissions; length of stay; 90-day readmissions; mortality; and quality of life. Case notes and study case report forms were manually examined for events that would meet the hospital's criteria for a medical emergency response (MET call). At the Royal Adelaide Hospital site, the site with the largest data set, MET-level events were collected from the time of arrival in the recovery room, with data analysed using a binary logistic generalised-estimating-equation modelling—events vs interaction of time and period, adjusting for repeated measurements over time (SAS 9.4; SAS Institute Inc., Cary, NC, USA). Observations at one site revealed a high, sustained incidence of adverse events, usually undetected in hospital wards. In total, 126 patients were recruited at the Royal Adelaide Hospital (n=71 ‘before’; n=55 ‘after’) between April and July 2018. Recruitment targets of 71 (89%) and 55 (92%), and follow-up targets of 68 (85%) and 53 (88%) were achieved for the ‘before’ and ‘after’ groups, respectively. The groups were well matched, with age (mean; standard deviation) of 72 (12) and 73 (11) yr (P=0.432), and NSQIP-predicted 30-day mortality (median; inter-quartile range) of 1.5% (1.2; 2.5) and 2.0% (1.4; 2.7) (P=0.0832) for the ‘before’ and ‘after’ groups, respectively. The profiles of the ASA physical status differed between groups: ([‘before’ ASA 1: 0%, ASA 2: 7%, ASA 3: 93%, and ASA 4: 1%; ‘after’ ASA 1: 0%, ASA 2: 20%, ASA 3: 80%, and ASA 4: 0%]; [P=0.0303]). The incidences of MET-level events in both groups are displayed in Figure 1. In both groups, these events were frequently detected during periods of close observation in the recovery room in the initial hours after surgery. In the ‘before’ group managed on surgical wards, the MET-level events were relatively uncommon and declined rapidly over time. In the ‘after’ group, who stayed in recovery with frequent observations and regular care by anaesthetists, the MET-level events were detected very frequently. Of note, these events were very common in the period when patients would usually be managed in surgical wards and commonly after-hours. In the period 24–48 h after surgery, when all patients had been discharged from recovery or ARRC, the frequency of MET-level events was 4.6% (three patients) in the ‘before’ group and 1.9% (one patient) in the ‘after’ group (P=0.421). These MET-level data from one hospital, and the close matching of the ‘before’ and ‘after’ groups, suggest that there is an undetected and unmanaged high incidence of serious adverse events in moderate-risk surgical patients receiving standard postoperative ward care. Frequent observations in a recovery room setting allowed early detection of these events and rapid implementation of care by anaesthetists and surgeons if needed. Data on the association between adverse events, such as hypotension, and poor outcomes are now described,7Sessler D.I. Meyhoff C.S. Zimmerman N.M. et al.Period-dependent associations between hypotension during and for four days after noncardiac surgery and a composite of myocardial infarction and death: a substudy of the POISE-2 trial.Anesthesiology. 2018; 128: 317-327Crossref PubMed Scopus (138) Google Scholar, 8McEvoy M.D. Gupta R. Koepke E.J. et al.Perioperative Quality Initiative consensus statement on postoperative blood pressure, risk and outcomes for elective surgery.Br J Anaesth. 2019; 122: 575-586Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar, 9Sanders R.D. Hughes F. Shaw A. et al.Perioperative Quality Initiative consensus statement on preoperative blood pressure, risk and outcomes for elective surgery.Br J Anaesth. 2019; 122: 552-562Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar, 10Sessler D.I. Bloomstone J.A. Aronson S. et al.Perioperative Quality Initiative consensus statement on intraoperative blood pressure, risk and outcomes for elective surgery.Br J Anaesth. 2019; 122: 563-574Abstract Full Text Full Text PDF PubMed Scopus (186) Google Scholar suggesting some of these undetected adverse events may have consequences for patient recovery and outcomes. Data from the UK revealing that loss of higher acuity care was associated with higher complication rates and longer lengths of stay suggest that there are also cost consequences for institutions.3Swart M. Carlisle J.B. Goddard J. Using predicted 30 day mortality to plan postoperative colorectal surgery care: a cohort study.Br J Anaesth. 2017; 118: 100-104Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar The impact of ARRC on short- and long-term patient outcomes and costs will be available on completion of this multicentre trial, although, based on these data, quality improvement activities to address this issue at the Royal Adelaide Hospital have already commenced. The ARRC trial is a feasibility trial and not powered for outcomes, although the data from this single site suggest that adverse events are much more common than anticipated, and it is possible there is reversal in the incidence of MET-level events after discharge from the ARRC based on the 24–48 h data presented here. Alternate approaches to postoperative ward care may be indicated. The authors declare that they have no conflicts of interest.