Developing a complex preoperative intervention with primary care

Transcription

1 Developing a complex preoperative intervention with primary care Prof Gerard Danjoux Consultant in Anaesthesia/Sleep Medicine South Tees Hospitals NHSFT

2 No conflicts of interest to declare Acknowledgements Some of the work presented has been funded through: South Tees CCG Research/Innovation fund Preoperative Association Research grant

3 Workshop session Presentation The current preoperative situation: Care pathways + silos Suboptimal RF management Facilitating change - engagement: - Primary/secondary HCPs exploring knowledge and current practice - Patients - behaviour change preoperatively (exercise) Local outcomes - Patient management and research

4 Preoperative models of care

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6 Primary care silo

7 Primary care silo Fit for referral

8 Primary care silo Secondary care silo

9 Primary care silo Secondary care silo Fit for surgery

10 System inefficiencies

11 Not really FFR = downstream delay

12 Pathway delays within secondary care

13 Further assessment or optimisation

14 Large feedback loop

15 Large feedback loop Inefficient Lacks patients focus Facilitates poor communication and probably suboptimal outcomes

16 Patient risk factors and outcome

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21 Smoking Inactivity/exercise Alcohol Nutritional imbalance Perioperative Insult

22 Smoking Inactivity/exercise Alcohol Nutritional imbalance Perioperative Insult Anaemia Cognitive Frailty Comorbidities

23 Large feedback loop Inefficient Lacks patients focus Facilitates poor communication and probably suboptimal outcomes

24 Smoking Inactivity/exercise Alcohol Nutritional imbalance Perioperative Insult Sub-optimal outcome Anaemia Cognitive Frailty Comorbidities

25 Facilitating change

26 COMPELL research team : Systematic WPs Knowledge and attitudes to change amongst HCPs Patient willingness to engage Outcomes and local models of change

27 WP1: Online survey HCPs

28 Aims Establish knowledge of impact of risk factors on perioperative outcome Explore attitudes to screening and managing modifiable risk factors preoperatively collaboratively

29 Methods Structured online survey distributed to: - Primary HCPs via CCG networks and RCGP - Secondary HCPs via POA 20 questions knowledge and practices Free-text option exploring attitudes

30 Responses Primary Secondary GP GP Reg Nurse Pract Other Consultant ST SAS Preop nurse Other N = 372 N = 271

31 Which conditions predispose to perioperative complications?

32 Which conditions predispose to perioperative complications? Primary Secondary Smoking Hazardous drinking Mild anaemia Frailty Cognitive imp

33 Which conditions predispose to perioperative complications? Primary Secondary Smoking Hazardous drinking Mild anaemia Frailty Cognitive imp

34 Preoperative behaviour advice

35 Preoperative behaviour advice Primary Secondary Smoking cessation Lose weight Gain weight Reduce drinking Increase activity None of these

36 Preoperative behaviour advice Primary Secondary Smoking cessation Lose weight Gain weight Reduce drinking Increase activity None of these

37 Routine screening

38 Routine screening Primary Secondary BP Anaemia Frailty Cognitive imp OSA None

39 Routine screening Primary Secondary BP Anaemia Frailty Cognitive imp OSA None

40 Guidance recommendation

41 Guidance recommendation Primary Secondary Hazardous drinking Activity recommendation

42 Guidance recommendation Primary Secondary Hazardous drinking Activity recommendation

43 Attitudes/comments >65% Fitness for surgery: Collaborative Commence on referral Primary care: Limited time and resources Generally positive response

44 Attitudes/comments >65% Fitness for surgery: Collaborative Commence on referral Don t start chucking more work at under resourced primary care! Fascinating it will influence my behaviour... never thought to advise preop exercise. It makes sense! I don t ROUTINELY advise lifestyle change prior to referral for major surgery as I assume this is covered by preop assessment. I think there is a role for primary care to help in this at referral. Primary care: Limited time and resources Generally positive response What a long overdue and refreshing project. This is also a stimulating way of presenting the task. We should be adopting this challenge UK wide.

45 Attitudes/comments >65% Fitness for surgery: Collaborative Commence on referral Primary care: Limited time and resources Generally positive response Secondary care: More engagement primary care Generally positive response

46 Attitudes/comments This >65% is important Fitness work for surgery: any suggestions how to Collaborative liaise with primary care? Commence on referral I think this is a really important area of research and practice. Primary care: Limited time and resources on the uphill task of engaging GPs. Generally positive response Good work! If you can engage GPs to do anything other than pass the buck! Good luck Highly topical the most significant research area for our specialty at present. Secondary care: More engagement primary care Generally positive response I strongly believe that patients should be optimised at primary level and uncontrolled comorbidities should be looked at at the time of referral to avoid delays, cancellations and to avoid patient frustration.

47 General outcomes General willingness to collaborate Encouraging standards of practice certain areas Degree of mud-slinging between healthcare sectors! Areas of concern Education Screening practices

48 WP2: Patient willingness to engage

49 Preoperative exercise: an evaluation of patient attitudes

50 Aims General activity levels and perceptions of personal fitness Time spent engaged in regular physical activity Barriers to performing regular physical activity Receptiveness to receiving preoperative exercise advice

51 Methods Prospective patient survey: 04 06/14 Patients attending PAC prior to scheduled intermediate to high-risk surgery (NICE grade 3+4) Short structured questionnaire

52 Results 103 responses Mean age 63.4 years M:F 62:41 Surgery grade 3:4 31:72 Demographics: Low socio-economic catchment High comorbid disease

53 Patient perceptions of personal fitness 60 Number of patients Unfit Slightly fit Moderately fit Very fit Extremely fit

54 Patient perceptions of personal fitness 60 Number of patients Unfit Slightly fit Moderately fit Very fit Extremely fit Mean reported activity level 5.6 METs 55% patients spent <1 hour per WEEK engaged engaged physical activity/exercise 39% patients regular structured physical activity

55 Patient attitudes Main barriers to exercise: Personal health concerns Time and motivation Other barriers: Cost Travel Availability of facilities

56 Patient attitudes Main barriers to exercise: Personal health concerns Time and motivation Other barriers: Cost Travel Availability of facilities 90% receptive to preoperative exercise if improved perioperative outcome

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58 In-hospital 3x per week (4 weeks) 83% patients attended 9/12 sessions

59 WP3: Models of change + research

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61 Suggestions of exercises and daily activities to include Exercises Daily activities Swimming Running Fast cycling Moving furniture or carrying heavy objects HARD LEVEL OF ACTIVITY Scale of exertion Walking uphill Moderate cycling Walking on the flat Dancing Golf Slow cycling Walking dog on the flat Slow walking Darts Bowling Washing car Heavy gardening (weeding or mowing lawn) Heavy housework (vacuuming/mopping floor) Carrying shopping Light housework (dusting/ironing/ma king beds) Bathing Dressing Brushing hair/teeth MODERATE LEVEL OF ACTIVITY LIGHT LEVEL OF ACTIVITY Adapted from A Helping Hand to heart recovery Patient Information, South Tees Cardiac Rehabilitation Team

62 PIL distributed through PAC and surgical clinics

63 PIL distributed through PAC and surgical clinics Agreement with local GPs to distribute at time of referral

64 PIL distributed through PAC and surgical clinics Agreement with local GPs to distribute at time of referral Smoking cessation training through regional PH services (PAC + surgical clinics)

65 PIL distributed through PAC and surgical clinics Agreement with local GPs to distribute at time of referral Smoking cessation training through regional PH services (PAC + surgical clinics) Preop Exercise on referral scheme (GP + PAC)

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67 Research exploring more multimodal behaviour change Psychologists Newcastle University Informed development of further research and implementation of new models of care

68 The Future

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70 Silo s abolished integrated primary secondary care model

71 Embedded within model: More efficient + integrated (streamlined) pathway More primary care + patient engagement Improved Fitness for referral reduced downstream problems Economic benefits Hopefully improved outcomes

72 References 1. Turan A et al. Smoking and Perioperative Outcomes. Anesthesiology 2011; 114(4): Tønnesen H et al. Alcohol abuse and postoperative morbidity. Danish Medical Bulletin 2003,50(2): Snowden CP et al. Cardiorespiratory fitness predicts mortality and hospital length of stay after major elective surgery in older people. Annals Surgery 2013;257(6): Davenport DL et al. The influence of body mass index status on vascular surgery 30-day morbidity and mortality. Journal of Vascular Surgery 2009;49(1): Baron DM et al. Preoperative anaemia is associated with poor clinical outcome in noncardiac surgery patients. British Journal Anaesthesia 2014; 113(3): Patridge JSL et al. The impact of pre-operative comprehensive geriatric assessment on postoperative outcomes in older patients undergoing scheduled surgery: a systematic review. Anaesthesia 2014;69 (Suppl. 1): Partridge J et al. The prevalence and impact of undiagnosed cognitive impairment in older vascular surgical patients. Journal of Vascular Surgery 2014; 60(4): Buck D. Clustering of unhealthy behaviours over time. Implications for policy and practice. Kings Fund 2012

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