New research from the Royal College of Anaesthetists and University College London shows that while some progress is being made in improving perioperative care for patients undergoing major surgery, more focus is needed on ensuring all patients receive an individualised risk assessment, effective postoperative pain management and support with DRinking, EAting and Mobilising (also known as DREAMING) within 24 hours of surgery.
The fourth report of the Perioperative Quality Improvement Programme (PQIP) analyses data from a cohort of 11,926 patients from 135 hospitals who had surgery between July 2021 and March 2023, as well as data from three previous cohorts dating back to December 2016. In total, data from 44,114 patients across 168 hospitals is included in the PQIP research. The cohort in the new report is the first to include data from patients in Scotland, as well as England and Wales.
PQIP is designed to help improve patient outcomes from major non-cardiac surgery by supporting clinicians to use local data to enhance perioperative care. This is important for better outcomes for individual patients and for the recovery of the NHS after the pandemic. The PQIP report identifies five priorities for reducing complications and length of stay after surgery, simplifying enhanced recovery and promoting teamwork, including with patients.
The report identifies individualised risk assessment as the foundation of later high-quality patient care, facilitating shared decision making and open communication, which may help to improve patients’ adherence to treatment. Approximately 1 in 3 patients having major high-risk non-cardiac surgery did not have an individualised risk assessment, despite this being recommended by case law (Montgomery, 2015) and subject to a recent Prevention of Future Deaths review.
Drinking, Eating and Mobilising (DrEaMing) within 24-hours of surgery is associated with reduced length of stay in hospital and fewer inpatient complications. Analysis of 22,218 patients in the PQIP cohort between December 2016 and November 2020 found that only 17% of patients who ‘DrEaM’ experienced a major complication, compared to 37% who did not DrEaM.
While DrEaMing compliance has increased year on year since PQIP began, from 54% in cohort 1 (2016-2018) to 67% in the current cohort (2021-2023), progress has slowed.
Increasing rates of DrEaMing can also have financial benefits for NHS trusts due to its status as an NHS England Commissioning for Quality and Innovation Indicator (CQUIN) for a second year. The report makes a number of recommendations for how teams can improve, including through collaboration with patients.
Further improvements in clinical outcomes can be achieved through better individualised pain management and addressing perioperative anaemia. Unfortunately, a significant proportion of patients continue to report severe pain within 24 hours of surgery (12-18% of patients). The report recommends having a multi-modal analgesic plan in place, postoperative acute pain team follow-up for at risk patients, and processes to ensure the transition of this plan to the postoperative care destination.
Addressing perioperative anaemia requires both preoperative detection and management of anaemia and measures to reduce blood loss during surgery, such as administration of the cheap, safe and effective drug tranexamic acid. This is particularly pertinent given recent NHS shortages in blood products.
70% of anaemic patients having surgery in this PQIP cohort did not receive treatment for their anaemia in the months before surgery, including 31% of patients with severe anaemia. Additionally, tranexamic was administered to only 54% of patients where intraoperative blood loss was 500 – 1000ml and only 61% of patients where blood loss was >1000ml. The report highlights perioperative blood management guidance published by the Centre for Perioperative Care.
The PQIP team continue to innovate in the methods used to help hospitals embed quality improvement practices into their multi-disciplinary team working. This includes near real-time reporting of risk-adjusted outcome data, and other new online dashboards. The study is still recruiting new hospitals and more information is available at www.pqip.org.uk
Dr Fiona Donald, President of the Royal College of Anaesthetists said: “The report highlights the opportunities for improving perioperative care, which start with a high-quality preoperative assessment process. Despite the hard work of clinicians involved in perioperative care, significant numbers of patients are going into major, elective high-risk surgery without an individualised risk assessment or optimisation of their long-term conditions such as anaemia or diabetes. Changes to preoperative pathways which will be implemented by the NHS in England this year may help to address these challenges, and resources should be made available to local clinical and managerial teams to support implementation.
“Wider implementation of surgery schools and better information for patients such as through the RCoA’s 'Fitter, Better, Sooner' initiative should encourage better patient engagement with DrEaMing early after surgery, also supported by financial incentives from the NHS."
