ORCID Profile
0000-0001-7968-5716
Current Organisations
Monash University
,
Alfred Health
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Publisher: SAGE Publications
Date: 28-04-2020
Abstract: Accurately measuring the incidence of major postoperative complications is essential for funding and reimbursement of healthcare providers, for internal and external benchmarking of hospital performance and for valid and reliable public reporting of outcomes. Actual or surrogate outcomes data are typically obtained by one of three methods: clinical quality registries, clinical audit, or administrative data. In 2017 a perioperative registry was developed at the Alfred Hospital and mapped to administrative and clinical data. This study investigated the statistical agreement between administrative data (International Statistical Classification of Diseases and Related Health Problems (10th edition) Australian Modification codes) and clinical audit by anaesthetists in identifying major postoperative complications. The study population included 482 high-risk surgical patients referred to the Alfred Hospital anaesthesia postoperative service over two years. Clinical audit was conducted to determine the presence of major complications and these data were compared to administrative data. The main outcome was statistical agreement between the two methods, as defined by Cohen’s kappa statistic. Substantial agreement was observed for five major complications, moderate agreement for three, fair agreement for six and poor agreement for two. Sensitivity and positive predictive value ranged from 0 to 100%. Specificity was above 90% for all complications. There was important variation in inter-rater agreement. For four of the five complications with substantial agreement between administrative data and clinical audit, sensitivity was only moderate (61.5%–75%). Using International Statistical Classification of Diseases and Related Health Problems (10th edition) Australian Modification codes to identify postoperative complications at our hospital has high specificity but is likely to underestimate the incidence compared to clinical audit. Further, retrospective clinical audit itself is not a highly reliable method of identifying complications. We believe a perioperative clinical quality registry is necessary to validly and reliably measure major postoperative complications in Australia for benchmarking of hospital performance and before public reporting of outcomes should be considered.
Publisher: SAGE Publications
Date: 12-05-2022
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 2016
Publisher: Wiley
Date: 26-03-2018
DOI: 10.1111/ANAE.14157
Abstract: The United States Navy uses a visual feedback system for pilots, named 'the Greenie Board', to improve flight manoeuvres on aircraft carriers. Given that increased compliance with enhanced recovery after surgery protocols reduces postoperative complications, we decided to apply a similar feedback system to our institutional enhanced recovery programme. We undertook a prospective 12-month audit of 194 patients assigned to our enhanced recovery programme and evaluated adherence to the anaesthesia-related components of our protocol, before and after implementing a Greenie Board. A compliance score was calculated by summing points for adherence to: intra-operative antibiotic prophylaxis temperature management goal-directed intravenous fluid therapy postoperative nausea and vomiting prophylaxis and postoperative fluid restriction. The score for each patient was then colour-coded and anonymously displayed for each anaesthetist on a Greenie Board within the operating theatre suite. Protocol adherence improved significantly following introduction, with 'Green' scores (acceptable compliance) increasing from 33% to 72% of patients (p < 0.0001). The greatest improvement was seen with anti-emetic prophylaxis (49% to 70%, p = 0.004) with a consequent reduction in postoperative nausea and vomiting (OR 0.42, 95% CI 0.19-0.88, p = 0.021). We did not observe a decrease in other postoperative complications nor hospital length of stay. We conclude that this US Navy-inspired feedback system is an easily implemented, low-cost quality improvement tool that significantly improved adherence to intra-operative components of our enhanced recovery protocol. The system lends itself to global scaling to drive quality improvement in healthcare delivery and would be suited to institutions without electronic medical records, including low-resource countries.
Publisher: Springer Science and Business Media LLC
Date: 08-05-2017
DOI: 10.1007/S00268-017-4055-Y
Abstract: Intravenous fluid therapy is required for most surgical patients, but inappropriate regimens are commonly prescribed. The aim of this narrative review was to provide evidence-based guidance on appropriate perioperative fluid management. We did a systematic literature search of the literature to identify relevant studies and meta-analyses to develop recommendations. Of 275 retrieved articles, we identified 25 articles to inform this review. "Normal" saline (0.9% sodium chloride) is not physiological and can result in sodium overload and hyperchloremic acidosis. Starch colloid solutions are not recommended in surgical patients at-risk of sepsis or renal failure. Most surgical patients can have clear fluids and/or administration of carbohydrate-rich drinks up to 2 h before surgery. An intraoperative goal-directed fluid strategy may reduce postoperative complications and reduce hospital length of stay. Regular postoperative assessment of the patient's fluid status and requirements should include looking for physical signs of dehydration or hypovolemia, or fluid overload. Both hypovolemia and salt and water overload lead to adverse events, complications and prolonged hospital stay. Urine output can be an unreliable indicator of hydration status in the postoperative surgical patient. Excess fluid administration has been linked to acute kidney injury, gastrointestinal dysfunction, and cardiac and pulmonary complications. There is good evidence supporting the avoidance of unnecessary fasting and the value of an in idualized perioperative IV fluid regimen, with transition to oral fluids as soon as possible, to help patients recover from major surgery.
Publisher: SAGE Publications
Date: 15-12-2023
DOI: 10.1177/0310057X221119814
Abstract: Intermediate and high-risk patients undergoing surgery are often managed on a surgical ward in the absence of haemodynamic or ventilatory support requirements necessitating intensive care unit or high dependency unit admission. We describe a model of care for the multidisciplinary management of selected postoperative patients and the epidemiology of patients managed using this model at a tertiary Australian hospital. Of 25,139 patients undergoing inpatient surgery at our institution over a two-year period, 506 (2%) were referred to the Perioperative Medicine team. The median age of patients referred was 74 years 85% had an American Society of Anesthesiologists physical status ≥3, and 44% underwent emergency surgery. Major complication or death within 30 days was 44.2% (213/482). The most common complications, as defined by the American College of Surgeons National Surgical Quality Improvement Program were transfusion within 72 h (17.4%), pneumonia/aspiration pneumonitis (11.3%), and acute renal failure (10.6%) median time to Medical Emergency Team call was 146 (interquartile range 77–279) h. Sixty-six percent of referred patients (280/423) required an intervention during their time under the service. This high incidence indicates that this population of patients merits closer attention, including routine measurement and reporting of postoperative outcomes to monitor and improve quality of care at our institution as part of an integrated perioperative service. We believe that with so much current focus on perioperative medicine, it is important we translate this to clinical care by evolving traditional models of management into more innovative strategies to meet the complex demands of today’s surgical patients.
No related grants have been discovered for Jonathan Nicholson.