Enhanced peri‐operative care to improve outcomes for high‐risk surgical patients in Brazil: a single‐centre before‐and‐after cohort study

Abstract

Summary Mortality and morbidity for high‐risk surgical patients are often high, especially in low‐resource settings. Enhanced peri‐operative care has the potential to reduce preventable deaths but must be designed to meet local needs. This before‐and‐after cohort study aimed to assess the effectiveness of a postoperative 48‐hour enhanced care pathway for high‐risk surgical patients (‘high‐risk surgical bundle’) who did not meet the criteria for elective admission to intensive care. The pathway comprised of six elements: risk identification and communication; adoption of a high‐risk post‐anaesthesia care unit discharge checklist; prompt nursing admission to ward; intensification of vital signs monitoring; troponin measurement; and prompt access to medical support if required. The primary outcome was in‐hospital mortality. Data describing 1189 patients from two groups, before and after implementation of the pathway, were compared. The usual care group comprised a retrospective cohort of high‐risk surgical patients between September 2015 and December 2016. The intervention group prospectively included high‐risk surgical patients from February 2019 to March 2020. Unadjusted mortality rate was 10.5% (78/746) for the usual care and 6.3% (28/443) for the intervention group. After adjustment, the intervention effect remained significant (RR 0.46 (95%CI 0.30–0.72). The high‐risk surgical bundle group received more rapid response team calls (24% vs. 12.6%; RR 0.63 [95%CI 0.49–0.80]) and surgical re‐interventions (18.9 vs. 7.5%; RR 0.41 [95%CI 0.30–0.59]). These data suggest that a clinical pathway based on enhanced surveillance for high‐risk surgical patients in a resource‐constrained setting could reduce in‐hospital mortality.

Postoperative intensive care allocation and mortality in high-risk surgical patients: evidence from a low- and middle-income country cohort

“…We have already shown that adequate surgical ward teams improve patient safety and can reduce the incidence of postoperative complications and mortality. 11 Therefore, in hospitals that provide excellent ward-based care, the incremental benefit of ICU admissions for stable patients will be reduced. 27…”

“…In response to these challenges, we developed the Ex-Care risk model to identify high-risk surgical patients, 8 categorizing them as high-risk (5–10% likelihood of death) or very high-risk (>10% probability of death). A care bundle for these patients was successfully implemented in surgical wards, 11 with a particular interest in the outcomes of high-risk patients electively admitted to ICU.…”

How to design and publish quality science studies

“…To be considered complete, a quality improvement project must involve two phases of outcome assessmentone before and one after an interventionevaluating the same metrics, using the same instruments (which should be designed and thoroughly piloted before the first attempt at assessment is made) and should be as rigorous as a before-and-after clinical trial. Authors should also consult already published exemplars of quality science to inform their own research, keeping in mind the difference between quality assurance and audit, and quality improvement projects [4,[13][14][15].…”

How to identify a high-risk surgical patient?

“…This postoperative enhanced care pathway for high-risk surgical patients, or in other words, a “high-risk surgical bundle” with a patient-centered decision-making, may significantly improve the patient's experience and outcomes through the surgical process for patients at higher risk of adverse events. 24 In this context, a recent before-and-after cohort study with a clinical pathway based on enhanced surveillance for high-risk surgical patients has demonstrated a significant reduction of in-hospital mortality. 24 Particularly in this study, the “high-risk surgical bundle” has included six main elements, such as risk identification and communication, adoption of a high-risk post anesthesia care unit discharge checklist, prompt nursing admission to ward, intensification of vital signs monitoring, perioperative troponin measurement, and prompt access to medical support if required.…”

“… 24 In this context, a recent before-and-after cohort study with a clinical pathway based on enhanced surveillance for high-risk surgical patients has demonstrated a significant reduction of in-hospital mortality. 24 Particularly in this study, the “high-risk surgical bundle” has included six main elements, such as risk identification and communication, adoption of a high-risk post anesthesia care unit discharge checklist, prompt nursing admission to ward, intensification of vital signs monitoring, perioperative troponin measurement, and prompt access to medical support if required. 24 New research is still warranted to further evaluate which strategies designed to enhance perioperative care can actually reduce morbidity and mortality in high-risk surgical subpopulations.…”