Preoperative Assessment Clinic Research Articles

Coerced consent in clinical research: study protocol for a randomized controlled trial

BackgroundDespite the low-risk nature of participation in most clinical anesthesia trials, subject recruitment on the same day as surgery is often restricted due to the concerns of researchers and local research ethics boards that same-day consent may not afford adequate time and opportunity for patients to weigh and make decisions, as well as perceptions of patient vulnerability immediately prior to surgery that could impact the voluntary nature and the rigor of the informed consent process. However, specialties such as anesthesiology, critical care, interventional radiology, and emergency medicine have a varied pattern of practice and patient acquaintance that does not typically afford the luxury of time or, in many cases, advance consent for participation in research. Indeed, the initial encounter between anesthesiologists and patients undergoing elective procedures routinely occurs on the day of surgery. Concerns of coercion related to same-day consent for clinical anesthesia research trials have not been borne out in the literature, and represent a significant obstacle to clinical researchers, as well as to the patients who are denied opportunities for potential benefit through participation in research studies.MethodsWe describe the protocol for a prospective randomized controlled trial examining the voluntariness of patient consent, solicited either in advance of surgery or on the same day, to participate in an anesthesia research study at Women’s College Hospital. One hundred fourteen patients scheduled to undergo ambulatory anterior cruciate ligament repair facilitated by general anesthesia with an adductor canal block will be randomized for recruitment either (a) in the pre-operative assessment clinic before the day of surgery or (b) on the day of surgery, to be approached for consent to participate in a fabricated research study of adjunct medications in adductor canal blocks. Regardless of allocation, patients in both groups will receive the same routine standard of care and will complete a post-operative questionnaire to signal perceptions of undue influence in the process of providing informed consent for the fabricated trial.DiscussionThis study will inform trial design and practice guidelines surrounding the amount of time patients ought to be afforded in order to make durable decisions to participate (or not) in clinical research studies. This is expected to impact trial recruitment in a variety of clinical settings where researchers have only brief opportunities to interface with patients.Trial registrationThe trial was registered prospectively on the Open Science Framework (OSF), registration #46twc, on 2023-Mar-17.

Preoperative Glycosylated Haemoglobin Screening to Identify Older Adult Patients with Undiagnosed Diabetes Mellitus-A Retrospective Cohort Study.

More than 25% of older adults in Europe have diabetes mellitus. It is estimated that 45% of patients with diabetes are currently undiagnosed, which is a known risk factor for perioperative morbidity. We investigated whether routine HbA1c screening in older adult patients undergoing surgery would identify patients with undiagnosed diabetes. We included patients aged ≥65 years without a diagnosis of diabetes who visited the preoperative assessment clinic at the Amsterdam University Medical Center and underwent HbA1c screening within three months before surgery. Patients undergoing cardiac surgery were excluded. We assessed the prevalence of undiagnosed diabetes (defined as HbA1c ≥ 48 mmol·mol-1) and prediabetes (HbA1c 39-47 mmol·mol-1). Using a multivariate regression model, we analysed the ability of HbA1c to predict days alive and at home within 30 days after surgery. From January to December 2019, we screened 2015 patients ≥65 years at our clinic. Of these, 697 patients without a diagnosis of diabetes underwent HbA1c screening. The prevalence of undiagnosed diabetes and prediabetes was 3.7% (95%CI 2.5-5.4%) and 42.9% (95%CI 39.2-46.7%), respectively. Preoperative HbA1c was not associated with days alive and at home within 30 days after surgery. In conclusion, we identified a small number of patients with undiagnosed diabetes and a high prevalence of prediabetes based on preoperative HbA1c screening in a cohort of older adults undergoing non-cardiac surgery. The relevance of prediabetes in the perioperative setting is unclear. Screening for HbA1c in older adult patients undergoing non-cardiac surgery does not appear to help predict postoperative outcome.

1871 Encouraging Mental Capacity Act assessments in cognitively impaired or delirious patients over 65 at an orthopaedic hospital

Abstract Introduction The Mental Capacity Act (MCA) is designed to protect patients who may lack capacity to make decisions about their proposed treatment. At the Nuffield Orthopedic Centre (NOC), Oxford, nurses obtain a baseline abbreviated mental test score (AMTS) during the pre-operative assessment clinic. Post-operatively, the AMTS should be repeated with the 4AT to screen for delirium. If the AMTS is less than 8, or the patient is clinically believed to be delirious, then an MCA assessment should be undertaken and documented for the decision to accept treatment. The aim of this QI project was to widen this practice to all the junior doctors at the NOC. Method Baseline AMTS and MCA data were collected from one month of inpatients >64 years old at the NOC. Patients with post-op AMTS of <8 or those with delirium were identified and checked for documented MCA assessments. The results, teaching and training on capacity and consent were presented to the junior doctor team and a repeat audit cycle was performed to assess if the practice was being implemented. Results Data collected from 10/01/23 – 10/02/23 (n=125) showed that out of 10 patients meeting the AMTS criteria, only 4 had MCA assessments completed. Once the QI project was presented on 25/05/23, data collected from 12/06/23 – 15/07/23 showed that out of 5 eligible patients, 4 of them had MCA assessments documented. Conclusion Prior to this QI project, only 40% of patients with suspected cognitive impairment were undergoing an MCA assessment. Following the teaching and training to the junior doctors, the data collected shows that this figure had increased to 80%. In conclusion, this QI project has shown an improvement in appropriate application of the MCA. It should be repeated every 4 months to account for each new rotation of junior doctors.

564 Tackling tobacco dependency in surgical patients

Abstract Aims Smoking is associated with an increased risk of developing post-operative complications and is a risk factor for abscess development. We aimed to audit our performance in delivering very brief advice (VBA) to surgical patients, and establish a smoking cessation pathway to promote smoking cessation particularly within elective and ambulatory care patients. Methods A retrospective audit was undertaken to identify whether smoking status was documented for all surgical inpatients on admission over a 24 hour period, and those attending the surgical ambulatory care unit with an abscess over a 3 week period. Data was collected on whether very brief advice and referral to smoking cessation service or nicotine replacement therapy was offered. Results In total, 36 inpatients were identified. 4 reported smoking (11.1%), 26 (72.2%) reported no smoking and 6 had no documentation (16.7%). Of those identified as smokers, 50% had documented VBA and 75% were offered NRT. Of the 51 ambulatory patients attending with abscesses, 13 (25.4%) reported smoking, 10 (19.6%) reported no smoking and 28 had no documented smoking status (54.5%). Only 1/13 had VBA documented (7.7%) Conclusions Smoking status is poorly documented in surgical patients presenting to ambulatory care in particular, and there is a high rate of smoking in patients presenting with abscesses. Ambulatory care represents a good opportunity to deliver VBA and direct patients to smoking cessation services. A combined effort between the surgical department and the tobacco dependency service that is present in many hospitals represents a good opportunity to advocate for smoking cessation, primarily in pre operative assessment clinic or surgical ambulatory care.

Effectiveness of a digital vs face-to-face preoperative assessment: A randomized, noninferiority clinical trial

Study objectiveDigitalizing the preoperative assessment clinic can be a solution to keep up with the growing demand for surgery. It remains unclear if a digital preoperative assessment clinic is as safe, and effective in terms of patient health outcomes and experience compared to face-to-face consultations. This study aimed to compare quality of recovery and mental state in patients undergoing a digital preoperative assessment versus regular face-to-face consultations. DesignThis was a single centre, randomized (1:1), parallel, open-label, noninferiority trial. SettingThe preoperative clinic and preoperative unit of an urban secondary care hospital. PatientsAll adult, Dutch speaking, ASA I-IV patients with access to an online computer who required surgery. InterventionsDigital preoperative screening, consisting of an electronic screening questionnaire and web-based platform with personalized information and recommendations related to the procedure, or face-to-face screening, consisting of two 20-min in-hospital consultations. MeasurementsThe primary endpoint was quality of recovery, measured 48 h after surgery. The analysis followed a per-protocol principle, and only patients who underwent the intended screening were included in the analysis. The noninferiority margin was set at −6. The trial was registered at ClinicalTrials.gov, NCT05535205, during the study on 09/08/2022, before analysing results. Main resultsBetween March 1, 2021 and 30 august 2021, 480 patients were assessed for eligibility. 400 patients were randomly assigned to the digital group (n = 200) or face-to-face group (n = 201), of which respectively 117 and 124 patients were eventually included in the primary analysis. The mean quality of recovery score of patients undergoing digital screening (158) was non-inferior to that of patients undergoing face-to-face screening (155), with a mean difference of 3·2 points and a 97.5% lower confidence limit of −2.1 points. There were no adverse events. ConclusionsA digital preoperative screening is not inferior to face-to-face consultations in patients undergoing predominantly low to moderate risk surgery. Given its potential to reduce physician workload, reallocate healthcare resources, and lower healthcare costs, a digital preoperative screening may be a better choice for preoperative assessments.

Arthroscopic Meniscal Repair: University Hospital Southampton Experience.

Introduction The meniscus plays an integral role in the proper functioning of the knee joint. Located between the articular surfaces of the tibia and femur, the meniscus functions to provide stability to the knee joint, even out axial load, absorb shock, and provide some lubrication to the knee joint. Accordingly, treatment of meniscal injuries aims to preserve as much meniscal tissue as possibleto avoid the myriad complications that arise from its removal. This study of the all-inside technique for meniscal repair evaluates the University Hospital Southampton experience by comparing our outcomes with the available literature. Patients and methods This is a retrospective study from January 2016 to December 2020. Records of patients were obtained through the preoperative assessment clinics network and electronic notes. The endpoints of the study were defined as patients who either were discharged, experienced failure of repair, i.e., symptomatic or magnetic resonance imaging (MRI) changes, or were offered re-surgery. Results Eighty-one patients, comprising 51 males and 30 females, were included in the study, and 85 repairs were performed. A steady increase in the number of procedures was observed year on year until the outbreak of COVID-19. The mean age of patients was 24.7 years, with a range of 39 years. The medial meniscus was found to be injured more often than the lateral meniscus. The most commonly observed injury pattern was the bucket handle (BH) type. Anterior cruciate ligament (ACL) injury was found to be associated with meniscal injuries in around half of patients. The reason for this occurrence can be attributed to the ligamentous connection between the medial meniscus and the anterior cruciate ligament in the phenomenon described in the "unhappy triad." On average, three FasT-Fix sutures were required per procedure. Discussion and conclusion After a follow-up of 11 months, 11 (13.6%)treated patients were noted to have failed repair, as defined by the endpoint criteria. Age and acuity were noted to not affect outcomes, and the results suggest that males are at higher risk of failed repair than females (p<0.05).

Diagnostic and prognostic value of cardiac stress testing before major noncardiac surgery—A cohort study

ObjectiveTo assess the incremental contribution of preoperative stress test results toward a diagnosis of obstructive coronary artery disease (CAD), prediction of mortality, or prediction of perioperative myocardial infarction in patients considering noncardiac, nonophthalmologic surgery. Design, setting, participantsA retrospective cohort study of visits to a preoperative risk assessment and optimization clinic in a large health system between 2008 and 2018. MeasurementsTo assess diagnostic information of preoperative stress testing, we used the Begg and Greenes method to calculate test characteristics adjusted for referral bias, with a gold standard of angiography. To assess prognostic information, we first created multiply-imputed logistic regression models to predict 90-day mortality and perioperative myocardial infarction (MI), starting with two tools commonly used to assess perioperative cardiac risk, Revised Cardiac Risk Index (RCRI) and Myocardial Infarction or Cardiac Arrest (MICA). We then added stress test results and compared the discrimination for models with and without stress test results. Main resultsAmong 136,935 visits by patients without an existing diagnosis of CAD, the decision to obtain preoperative stress testing identified around 4.0% of likely new diagnoses. Stress testing increased the likelihood of CAD (likelihood ratio: 1.31), but for over 99% of patients, stress testing should not change a decision on whether to proceed to angiography. In 117,445 visits with subsequent noncardiac surgery, stress test results failed to improve predictions of either perioperative MI or 90-day mortality. Reweighting the models and adding hemoglobin improved the prediction of both outcomes. ConclusionsCardiac stress testing before noncardiac, nonophthalmologic surgery does not improve predictions of either perioperative mortality or myocardial infarction. Very few patients considering noncardiac, nonophthalmologic surgery have a pretest probability of CAD in a range where stress testing could usefully select patients for angiography. Better use of existing patient data could improve predictions of perioperative adverse events without additional patient testing.

Consequences of preoperative cardiac stress testing—A cohort study

ObjectiveTo understand the consequences of functional cardiac stress testing among patients considering noncardiac nonophthalmologic surgery. DesignA retrospective cohort study of 118,552 patients who made 159,795 visits to a dedicated preoperative risk assessment and optimization clinic between 2008 and 2018. SettingA large integrated health system. PatientsPatients who visited a dedicated preoperative risk assessment and optimization clinic before noncardiac nonophthalmologic surgery. MeasurementsTo assess changes to care delivered, we measured the probability of completing additional cardiac testing, cardiac surgery, or noncardiac surgery. To assess outcomes, we measured time-to-mortality and total one-year mortality. Main resultsIn causal inference models, preoperative stress testing was associated with increased likelihood of coronary angiography (relative risk: 8.6, 95% CI 6.1–12.1), increased likelihood of percutaneous coronary intervention (RR: 4.1, 95% CI: 1.8–9.2), increased likelihood of cardiac surgery (RR: 6.8, 95% CI 4.9–9.4), decreased likelihood of noncardiac surgery (RR: 0.77, 95% CI 0.75–0.79), and delayed noncardiac surgery for patients completing noncardiac surgery (mean 28.3 days, 95% CI: 23.1–33.6). The base rate of downstream cardiac testing was low, and absolute risk increases were small. Stress testing was associated with higher mortality in unadjusted analysis but was not associated with mortality in causal inference analyses. ConclusionsPreoperative cardiac stress testing likely induces coronary angiography and cardiac interventions while decreasing use of noncardiac surgery and delaying surgery for patients who ultimately proceed to noncardiac surgery. Despite changes to processes of care, our results do not support a causal relationship between stress testing and postoperative mortality. Analyses of care cascades should consider care that is avoided or substituted in addition to care that is induced.

Letter: Two Practices to Improve Informed Consent for Intraoperative Brain Research.

To the Editor: We read with great enthusiasm the paper by Peabody et al1 discussing the challenges of the informed consent for clinical research in the context of intraoperative brain research. This is a crucial ethical challenge requiring deep reflexion in the current environment within the neurosurgical practice. The authors highlight the heterogeneous impact and retention of the information provided during the consent process as well the unique place occupied by the relational dimension between the surgeon and the patient during this process. They suggest the involvement of a patient's advocate and reconsent during awake craniotomy (if applied) to overcome some of the abovementioned limitations. At our center, we have established a dedicated neuro-oncology preoperative assessment clinic for discussing the diagnosis and the treatment plan with both patients and their relatives.2 We strongly agree that patient's relatives should be involved in the decision-making process from very early stages to support the patient to take the best informed decisions for himself. The introduction to potential research programs is performed by the responsible neurosurgeon although the research consent process is independent and performed by the research team. Nevertheless, the responsible neurosurgeon is at the center of the consent process given the personalized relational dimension outlined by Peabody et al1 and unique relationship between the surgeon and the patient, particularly in the setting of the awake craniotomy. A point that is worthwhile mentioning is how the research-derived information can help the clinical consent process. At our institution, we performed extensive preoperative mapping that is explained to the patients as part of their consent process.3,4 This significantly improves their understanding about the procedure, particularly the benefits and risks involved.5 Therefore, there is an active interaction between the clinical and research consent processes. Although they are independent in their nature, the information provided by one can facilitate the understanding of the other and promote a more informed decision and potential involvement in both treatment and research processes. Patient information for patients with cancer is a vital part to personalized informed consent6 and forms a national measure to hold UK oncology centers accountable. According to the National Cancer Patient Experience Survey in the United Kingdom,7 89.4% of patients, who underwent surgery for cancer, said that before their treatment started, they had the information they needed in a way they could understand. It demonstrated that although the experience was good, we still had more room for improvement and innovation in the way we educate patients and make them understand regarding their disease process. Different strategies have been used to improve the consent form process, such as personalized 2-dimensional and 3-dimensional imaging available during consent process8 which is aligned with the General Medical Council in UK recommendations in their principles of decision making and consent.9 Thus, pushing the boundaries with innovative technology that is patient friendly promoting positive patient experience would act as an important process in the armamentarium for the current and future neurosurgeons. The increase utilization10 and recent advances in intraoperative neuromonitoring and mapping paved the way to a better understanding of the mechanisms underlying the brain function. Despite being independent processes, clinical treatment and research have a dynamic interaction where the neurosurgical team has a pivotal role in integrating the information provided. We could not agree more that the patient is at the center of all the decisions made even at the time of surgery during awake procedures.1 The challenge to the surgical teams is to provide constantly updated information to allow the best decision-making process to the patients and their advocates before surgery and to the patient himself during the awake procedure.

A pharmacist-led penicillin allergy de-labelling project within a preoperative assessment clinic: the low-hanging fruit is within reach

Having a false penicillin-allergy label is linked to longer hospital stays and to an increased risk of Clostridioides difficile and meticillin-resistant Staphylococcus aureus infection. To assess a penicillin-allergy de-labelling tool designed for use by the non-allergist. Patients attending the surgical preoperative assessment clinic (POAC) at a large UK teaching hospital, who reported a penicillin allergy, were directly de-labelled by nursing or pharmacy staff, where appropriate. A penicillin-allergy de-labelling tool designed for use by the non-allergist was adapted and applied; nursing staff were provided with supporting information and education to enable removal of spurious labels. Antimicrobial pharmacists (AMPs) provided follow-up, cross-checked prophylactic antibiotics administered, interrogated clinical notes, and telephoned patients following their surgery, for details of any adverse reactions suffered. A total of 163 patients reporting a penicillin allergy were identified for intervention. Twenty-nine (17.8%) patients reported a penicillin-allergy history appropriate for direct de-labelling, of whom eight (27.6%) declined to consent. The remaining 21 patients (12.8%) were directly de-labelled, with 12 (7.4%) patients consenting during their POAC appointment; the remaining nine (5.5%) patients were consented and de-labelled after their surgery by an AMP. The POAC was identified as an appropriate location and time-point in the patient pathway to enable the direct removal of spurious penicillin-allergy labels prior to surgery. Results suggest that this could be undertaken by nursing staff, although support from AMPs enabled a greater number of patients to be de-labelled.

Digital innovation in the surgical pathway: building a digital pre-operative triage and risk assessment tool using a population health platform

Background: We present the use of a Digital Population Health Platform to automate risk stratification and triage of patients awaiting preoperative assessment (POA). Our at-a-glance ‘surgical dashboard’ integrates the surgical waiting list (Patient Treatment List, PTL) operational data with the patient-level primary care data on their Integrated Care Record (ICR). The aim was to develop the dashboard to allow groups of patients to be identified and triaged according to their comorbidities. For surgical patients on the admitted pathways this enables high- and low-risk patients waiting for surgery, to be instantly identified. We present the results of pre-implementation dashboard testing to assess functionality and safety. Methods: Comorbidities were allocated to colour coded triage categories. These categories are used by POA nurses to streamline patients into appropriate POA clinics. The coding rules were then applied digitally to all 38 000 patients on the PTL, including the >5000 patients awaiting surgery. During development, iterative testing of the dashboard coding was ongoing. Testing involved comparison between the dashboard-allocated triage category and a manually defined triage after review of electronic medical records and the completed POA assessment. Our final patient cohort of low-risk ‘Gold Colour’ patients was tested, and each patient was declared either true low risk (ASA 1 equivalent) or a triage ‘failure’. Results: Of the final 100 patients sampled, the triage tool correctly identified 85% as ASA 1 equivalent. These patients are treated as ‘low risk’ and eligible for healthcare assistant (HCA) clinic only.Tabled 1Table 1 Incorrect triage ‘failures’—reasons for triage failure and Summary Care Record data available for each patientTriage failure (>ASA 1) reasonInformation from GP data/Summary Care Record interrogationBMI<18 (BMI=16.3)Incomplete height/weight data since 2021BMI>35 (BMI=36.1)No height, weight, or BMI visible on SCRBMI>35 (BMI=38.6)Last height/weight data entered 2016 when BMI=32.1BMI>35 (BMI=44.0)Last height/weight data entered 2020 when BMI=39.4BMI>35 (BMI=46.3)Last height/weight data entered 2017 when BMI=32.7BMI>35 (BMI=37.0) and OSA on CPAPNo data available on SCROSA on CPAPRecorded as ‘sleep apnoea’—possibly missed on comorbidity codingAsthma and type 2 diabetes mellitusAsthma last recorded 1969. Diabetes recorded as ‘non-diabetic hyperglycaemia’AsthmaDiagnosis not recorded on SCRAlcohol consumption 63 units/weekNot recorded on SCRIron deficiency anaemiaDiagnosis not recorded on SCRHypothyroidismNo SCR available for patientThyroiditis under investigationDiagnosis not recorded on SCR (new clinical issues since triage)Ulcerative colitisRecorded as ‘proctitis’ on SCRHIVDiagnosis not recorded on SCRHIV, human immunodeficiency virus; SCR, Summary Care Record Open table in a new tab HIV, human immunodeficiency virus; SCR, Summary Care Record Conclusion: Our surgical dashboard is accurate at triaging surgical patients according to their comorbidities and surgical risk determinants including smoking status and BMI. Triaging errors (Table 1) were either as a result of incomplete and inaccurate patient data held on the ICR or in the event of changes in a patient’s circumstances (e.g. BMI, new diagnoses) between the recording of data in primary care and POA. Using the dashboard, further collaborative work is ongoing with Primary Care and Public Health in Buckinghamshire, to identify patients awaiting surgery with medical conditions amenable to optimisation. We believe our PTL Surgical Dashboard Tool will be transformative in how elective surgical patients are managed at both a clinical and administrative level in Buckinghamshire Healthcare NHS Trust.

Scheduling pre-operative assessment clinic with answer set programming

AbstractThe problem of scheduling pre-operative assessment clinic (PAC) consists of assigning patients to a day for the exams needed before a surgical procedure, taking into account patients with different priority levels, due dates and operators availability. Realizing a satisfying schedule is of upmost importance for a hospital, since delay in PAC can cause delay in the subsequent phases, thus lowering patients’ satisfaction. In this paper, we propose a two-phase solution to the PAC problem: in the first phase, patients are assigned to a day taking into account a default list of exams; then, in the second phase, having the actual list of exams needed by each patient, we use the results of the first phase to assign a starting time to each exam. We first present a mathematical formulation for both problems. Further, we present a solution where modeling and solving are done via answer set programming. We then introduce a rescheduling solution that may come into play when the scheduling solution cannot be applied fully. Experiments employing synthetic benchmarks on both scheduling and rescheduling show that both solutions provide satisfying results in short time. We finally show the implementation and usage of a web application that allows to run our scheduling solution and analyze the results graphically in a transparent way.

Management of common surgical complications

<h2>Abstract</h2> No surgery is ever free of the risk of a complication. As the number of surgeries increase annually, the incidence of complications is expected to rise proportionally. Surgical complications are associated with significant physiological and psychological morbidity and mortality. While there are generic complications that affect all types of surgery, each specific type of surgery in addition carries its own speciality-specific complications. General complications like pain, bleeding, atelectasis, infection and venous thromboembolism are just a few that can complicate the postoperative recovery phase. It cannot be overemphasized that the key to managing surgical complications is preventing them from manifesting in the first place. Preoperative assessment clinics and the implementation of the WHO checklist have allowed the identification and optimization of risk factors. This article explores the prevention and management of common surgical complications which a junior surgical trainee is likely to face.

Tobacco and Anaesthesia

Smoking increases the risk of perioperative morbidity and mortality in a dose-dependent manner. Cigarette smoke has more than 4500 chemicals that have detrimental effects on various organ systems. The hazard of smoking is not only limited to the general health risks but also makes smokers more vulnerable to various perioperative complications ranging from pulmonary complications to wound healing to cardiovascular events. Smoking, whether active or passive, is always a general health problem, and when such patients are posted for surgery poses additional challenges to the anaesthesiologist. The preoperative assessment clinic provides an opportunity to discuss and encourage smoking cessation, and anesthesiologists can play a vital role in encouraging smoking cessation.

Implementation of shared decision-making conversations in the preoperative evaluation clinic: Developing an educational curriculum and improving quality

BackgroundThe American College of Surgeons created the Geriatric Surgical Verification program to improve the quality of perioperative care for geriatric patients. The standards include the incorporation of shared decision-making with goals of care discussions as well as frailty and cognitive impairment assessments. As perioperative physicians, anesthesiologists can provide many of these discussions in the preoperative assessment clinic. Our project developed an educational curriculum for anesthesiology residents to train them to effectively conduct these conversations, eventually expanding these assessments to all providers in our perioperative clinic. We describe our team's implementation of shared decision-making conversations and frailty assessments into preoperative evaluation clinic workflow for patients greater than 65 years old MethodsUsing the six-step approach to curriculum development, we provided resources to improve anesthesiology residents’ communication skills and ability to use shared decision-making conversations to guide perioperative management.1 We also used Plan-Do-Study-Act cycles to streamline the assessments and expand its utilization for all providers seeing geriatric patients in the perioperative assessment clinic. We measured added time to clinic visit and volume of patients. We provided templates and literature with faculty support for residents. The documentation was further integrated with the preoperative assessment note. ResultsDuring the initial implementation period, 110 patients participated in shared decision-making conversation with residents, increasing visit time by an average of 7.29 minutes. This was a small enough increase that the template was expanded to all providers in the preoperative assessment clinic. Residents had only 1-5 prior goals of care discussions, and believed the curriculum provided greater opportunity and structure to improve their skills in this domain. ConclusionWe found this implementation to be successful with increased value in the preoperative evaluation clinic while also bolstering our shared decision-making educational curriculum for our anesthesiology residents. Since this study is a pilot, the impact and finalized intervention and curriculum are still being refined.

Racial inequities in opioid use disorder management: can the anesthesiologist improve outcomes?

Racial inequities in opioid use disorder management: can the anesthesiologist improve outcomes?

Hospital based prevalence of smoking among surgical patients in tertiary care hospitals of Karachi Pakistan.

To determine the prevalence of smoking and to evaluate the knowledge about preoperative smoking cessation in patients coming for elective surgery. The cross-sectional study was conducted from July 30, 2019, to March 17, 2020, in the preoperative anaesthesia assessment clinic and surgical wards of Aga Khan University Hospital, Civil Hospital Karachi, and Abbasi Shaheed Hospital, Karachi, and comprised all patients of either gender aged >12 years scheduled for elective surgery having American Society of Anaesthesiologists physical status I-IV. Data was analysed using Stata 13. Of the 811 patients, 478(59%) were male and 333(41%) were female. The overall mean age was 43.4±16.4 years and mean BMI was 25.0±5.8kg/m2. There were 164(20.2%) smokers in the sample. The overall knowledge about preoperative smoking cessation was significantly associated with the level of education and gender (p<0.05). Smoking in surgical patients was about one-fifth of the overall sample, and knowledge related to preoperative smoking abstinence was significantly associated with educational status and gender.

Psoas muscle mass index as a predictor of long-term mortality and severity of complications after major intra-abdominal colorectal surgery – A retrospective analysis

Study objectiveDetermine if psoas muscle area measured in routine preoperative computed tomography scans (CT) can be used to identify patients at increased risk of adverse postoperative outcomes after major elective abdominal surgery. DesignRetrospective analysis of data from a single-centre cohort study conducted in York Hospital between the 1st August of 2015 and the 31st of august of 2020. SettingPreoperative clinic. Patients639 patients who attended the preoperative assessment clinic prior to major elective colorectal surgery and had an abdominal CT scan done up to 120 days before surgery. InterventionsNone. MeasurementsPsoas muscle area at the L3 level was measured in preoperative CT scans and normalised to patient height (psoas muscle index). The lowest sex-stratified tertile of psoas muscle index (PMI) was classed as sarcopenic.The primary outcome was 2-year mortality. Secondary outcomes included postoperative complications assessed using Clavien-Dindo graded major and minor complications, comprehensive complication index (CCI), and length of stay. Main resultsMultivariable regression analysis showed that sarcopenia was associated with 2-year mortality (aOR 1.79, 95% CI 1.03–3.10; p = 0.037) and survival at 2-years was significantly reduced in sarcopenic patients (log-rank test, p = 0.012). Sarcopenia was the only statistically significant predictor of major complications in multivariable logistic regression analysis (aOR 1.69, 95% CI 1.04–2.74, p = 0.034) and associated with an estimated increase of 16.6% in the comprehensive complication index (CCI) score of patients that had complications in multivariable linear regression analysis. Sarcopenia was not associated with length of stay. ConclusionsSarcopenia defined by psoas muscle mass is an independent predictor of 2-year mortality, major complications and severity of complications after major colorectal surgery and may be used for preoperative risk assessment.

164 OLDER PATIENTS AT THE PREOPERATIVE ASSESSMENT CLINIC: CHANGING THE FOCUS FROM FIT FOR SURGERY TO OPTIMISATION FOR SURGERY

Abstract Background The Pre-operative Assessment Clinic (PAC) is run by the Anaesthetic Department and assesses older patients undergoing elective orthopaedic surgery. The aim of this study was to examine how PAC currently assesses older patients and how effective it is in assessing for likelihood of postoperative complications and requirement for rehabilitation. Methods A single-centre, retrospective study that received approval from the local ethics committee. Data were collected on all patients post elective orthopaedic surgery admitted to the on-site specialist rehabilitation unit for older persons, between 1st May 2020 and 31st December 2021. Data were collected from hospital Information Technology platform, Bluespiers. Results Seventy-six patients (58 female; median age: 80 years) were included. Median time from PAC to surgery was 95 days. Functional assessment was completed in 63.16% of cases, formal cognitive assessment was done in 13% of cases. Number of falls in the preceding year was recorded in 31% of patients. Baseline mobility was recorded in 93% of cases. Whilst smoking and alcohol history was recorded in 96% of cases, number of units was not calculated. 45% (n=34) of patients were correctly identified as likely to require post-operative inpatient rehabilitation. PAC did not record sarcopaenia, polypharmacy or delirium risk factors. From our dataset, at least 13% had sarcopaenia, 80% had polypharmacy and 23% required opiate medications. Post-operatively, 16% of patients developed a delirium and 12% had an acute kidney injury. Conclusion In its current format, PAC fails to optimally risk stratify frail, older patients. Attention concentrates on fitness for surgery rather than optimisation of patients. Failure to record frailty, sarcopenia, cognitive impairment and risk factors for delirium is leading to missed opportunities in terms of delirium prevention, and peri-operative optimisation of older patients as well as discharge planning before surgery. Collaboration with specialist geriatric services at PAC should improve patient outcomes.

248 BENEFITS OF POST-OPERATIVE SPECIALIST GERIATRIC CARE FOR OLDER PATIENTS UNDERGOING ELECTIVE ORTHOPAEDIC SURGERY

Abstract Background The Covid-19 pandemic changed work practices across many different healthcare institutions. The difficulties with cross-site transfers created an opportunity in our institution to provide on-site post-operative rehabilitation for older patients undergoing elective orthopaedic surgery. The aim of this study is to assess the impact of post-operative specialist geriatric care on older patients. Methods This is a single-centre, retrospective study that received approval from the local hospital ethics committee. Data were collected on all patients admitted to the on-site specialist rehabilitation unit post-elective orthopaedic surgery between 1st May 2020 and 31st December 2021. Two patients in this group were excluded as they had not attended a pre-operative assessment clinic. Data were collected from hospital Information Technology platform, Bluespiers. Results 76 patients, 18 males and 58 females, were included in this study. The median age was 80 years. In the specialist rehabilitation unit, evidence of cognitive impairment was established in 40.79% of cases, there were 3 cases of newly diagnosed dementia, a history of falls was identified in 32.89% of patients and 13.16% of patients were found to have sarcopaenia. The median length of stay in the rehabilitation unit was 25 days. 51.32% of patients were discharged home independently, 23.68% of patients went home with a new Home-Care Package (HCP), 15.79% of patients were discharged home with an existing HCP, 6.58% of patients were transferred for further treatment and 2.63% patients were discharged to residential care units. Conclusion This data demonstrates a clear role for specialist geriatric care in elective rehabilitation, with a significant proportion of patients being discharged home independently. The benefits of a comprehensive geriatric assessment in the peri-operative setting include increased identification of cognitive impairment allowing appropriate implementation of brain health as well as identification of a history of falls, enabling falls risk assessment and management including bone health assessment.