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PERIOPERATIVE MEDICINE IN

PRIVATE PRACTICE

“A LOCAL RESPONSE TO A

LOCAL NEED”

Dr Prakash NayagamMBBS (Hons), MRCP (UK), FRACP.

Physician

Gunnamatta Beach, VictoriaGunnamatta Beach, VictoriaGunnamatta Beach, VictoriaGunnamatta Beach, Victoria

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MORNINGTON PENINSULA,

VICTORIA, AUSTRALIA

HOSPITALS ON THE

MORNINGTON

PENINSULA

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2011 census2011 census2011 census2011 census

Cardiovascular Cardiovascular Cardiovascular Cardiovascular diseasediseasediseasedisease

�AF/CCF/PPM/ICD

�CAGS

GORD, OSAGORD, OSAGORD, OSAGORD, OSA

StrokeStrokeStrokeStroke

Renal FailureRenal FailureRenal FailureRenal Failure

DiabetesDiabetesDiabetesDiabetes

DementiaDementiaDementiaDementia

PolypharmacyPolypharmacyPolypharmacyPolypharmacy

CancerCancerCancerCancer

CO MORBIDITIES WITH AGEING

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HOSPITAL DEMOGRAPHICSHospitalHospitalHospitalHospital BedsBedsBedsBeds Operating Operating Operating Operating

TheatreTheatreTheatreTheatre

Emergency Emergency Emergency Emergency

DeptDeptDeptDept

ICU BedsICU BedsICU BedsICU Beds HDU BedsHDU BedsHDU BedsHDU Beds

Public-

Frankston

454 5 34 10

Public- Rosebud 60 1 9

Private

Ramsay-

Peninsula

253 6+1 Cath Lab 14 10 4

Private

Ramsay-

Beleura

157 4 + 1 Cath Lab 6

Private –

The Bays

109 5 5

PRIVATE SECTOR PROFILE

Number of Operations Per yearNumber of Operations Per yearNumber of Operations Per yearNumber of Operations Per year

Peninsula Private 12,000

Beleura 6,000

The Bays 9,800

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GeneralGeneralGeneralGeneral

OrthopaedicsOrthopaedicsOrthopaedicsOrthopaedics

UrologyUrologyUrologyUrology

VascularVascularVascularVascular

BreastBreastBreastBreast

ENTENTENTENT

DentalDentalDentalDental

OroOroOroOro----MaxillaryMaxillaryMaxillaryMaxillary

OGD/ColonoscopyOGD/ColonoscopyOGD/ColonoscopyOGD/Colonoscopy

BronchoscopyBronchoscopyBronchoscopyBronchoscopy

PlasticsPlasticsPlasticsPlastics

TYPES OF SURGERY

PERIOPERATIVE MORBIDITY“Near Misses” due to inadequate pre“Near Misses” due to inadequate pre“Near Misses” due to inadequate pre“Near Misses” due to inadequate pre----op op op op assessment and poor postassessment and poor postassessment and poor postassessment and poor post----op op op op cocococo----ordination.ordination.ordination.ordination.

Highlighted by HDU Nursing Staff initiallyHighlighted by HDU Nursing Staff initiallyHighlighted by HDU Nursing Staff initiallyHighlighted by HDU Nursing Staff initially

Led to………………..Led to………………..Led to………………..Led to………………..

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SurgeonsSurgeonsSurgeonsSurgeons

AnaesthetistsAnaesthetistsAnaesthetistsAnaesthetists

PhysiciansPhysiciansPhysiciansPhysicians

Nursing StaffNursing StaffNursing StaffNursing Staff

Hospital AdminHospital AdminHospital AdminHospital Admin

Well attended Well attended Well attended Well attended

----weekday eveningweekday eveningweekday eveningweekday evening

hosted by one of the hosted by one of the hosted by one of the hosted by one of the

private hospitalsprivate hospitalsprivate hospitalsprivate hospitals

Attendance over 50Attendance over 50Attendance over 50Attendance over 50

From this group of 50…..From this group of 50…..From this group of 50…..From this group of 50…..

CONVENING OF A GENERAL MEETING

Chairman (Physician)Chairman (Physician)Chairman (Physician)Chairman (Physician)

SurgeonSurgeonSurgeonSurgeon�Orthopaedic (1)� Vascular (1)�General (1)�Plastic (1)�Urology (1)�Gynaecology (1)

Anaesthetist (2)Anaesthetist (2)Anaesthetist (2)Anaesthetist (2)

Cardiologist (1)Cardiologist (1)Cardiologist (1)Cardiologist (1)

Gastroenterologist (1)Gastroenterologist (1)Gastroenterologist (1)Gastroenterologist (1)

CEO (3)CEO (3)CEO (3)CEO (3)

DON (3)DON (3)DON (3)DON (3)

WORKING PARTY ESTABLISHED

3x two hour meetings

17 attendees in all

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WHERE TO NOW?

Seaford Seaford Seaford Seaford Pier, Pier, Pier, Pier, VictoriaVictoriaVictoriaVictoria

ENHANCING PERI-OPERATIVE

CARE IN THE PRIVATE HOSPITALS ON THE

MORNINGTON PENINSULA, VICTORIA

A Working Party A Working Party A Working Party A Working Party

DocumentDocumentDocumentDocument

May 2011May 2011May 2011May 2011

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RECOMMENDATIONS OF

WORKING PARTYApproved by MAC’sApproved by MAC’sApproved by MAC’sApproved by MAC’s

& widely distributed & widely distributed & widely distributed & widely distributed

to to to to Medical, Nursing, Allied Health Medical, Nursing, Allied Health Medical, Nursing, Allied Health Medical, Nursing, Allied Health and Hospital Administrations and Hospital Administrations and Hospital Administrations and Hospital Administrations of all 3 private hospitalsof all 3 private hospitalsof all 3 private hospitalsof all 3 private hospitals

PRE-OPERATIVE RECOMMENDATIONSPreamblePreamblePreamblePreamble�Inadequate pre op assessment of elderly, multiple co-morbidities

�Early recognition ensures comprehensive assessment prior to surgery

�Optimize unstable medical condition�Decision re private vs public, ICU back up etc.

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PRE –OP CARE RECOMMENDATIONS

High risk patient cohort should be identified and High risk patient cohort should be identified and High risk patient cohort should be identified and High risk patient cohort should be identified and

assessed preop at preadmission clinics (PAC) assessed preop at preadmission clinics (PAC) assessed preop at preadmission clinics (PAC) assessed preop at preadmission clinics (PAC)

&/or physician/anaesthetic consultation&/or physician/anaesthetic consultation&/or physician/anaesthetic consultation&/or physician/anaesthetic consultation

�ASA Scale used:

�1 & 2 -No pre-op review

� 3 - Pre-op review

�4 & 5 -Pre-op review &

Surgery with ICU back up

Adequate notice for formal assessments in Adequate notice for formal assessments in Adequate notice for formal assessments in Adequate notice for formal assessments in elective cases. elective cases. elective cases. elective cases.

If semi urgent or urgent, communication If semi urgent or urgent, communication If semi urgent or urgent, communication If semi urgent or urgent, communication between surgeon & anaesthetist/physician between surgeon & anaesthetist/physician between surgeon & anaesthetist/physician between surgeon & anaesthetist/physician

for review for review for review for review to ascertain fitness for surgeryto ascertain fitness for surgeryto ascertain fitness for surgeryto ascertain fitness for surgery

PRE –OP CARE RECOMMENDATIONS

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PRE –OP CARE RECOMMENDATIONS

Avoid Sunday Admissions for review before Avoid Sunday Admissions for review before Avoid Sunday Admissions for review before Avoid Sunday Admissions for review before

Monday surgery if in ASA 3Monday surgery if in ASA 3Monday surgery if in ASA 3Monday surgery if in ASA 3----5555

PRE –OP CARE RECOMMENDATIONS

Pre Pre Pre Pre Admission Admission Admission Admission clinicsclinicsclinicsclinics

Surgeons encouraged to refer to PACs when Surgeons encouraged to refer to PACs when Surgeons encouraged to refer to PACs when Surgeons encouraged to refer to PACs when feasible; feasible; feasible; feasible;

or provide results of investigations/previous or provide results of investigations/previous or provide results of investigations/previous or provide results of investigations/previous assessments so that they are available at time of assessments so that they are available at time of assessments so that they are available at time of assessments so that they are available at time of

surgerysurgerysurgerysurgery

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PRE –OP CARE RECOMMENDATIONS

Up Up Up Up to date to date to date to date protocols;protocols;protocols;protocols;

PPM/ICD, Lap BandsPPM/ICD, Lap BandsPPM/ICD, Lap BandsPPM/ICD, Lap Bands

Details Details Details Details include preferred include preferred include preferred include preferred

clinical pathways of clinical pathways of clinical pathways of clinical pathways of

surgeons to be maintained surgeons to be maintained surgeons to be maintained surgeons to be maintained

by by by by hospitalshospitalshospitalshospitals

PRE –OP CARE RECOMMENDATIONS

Cognitive impairment & Minimising postCognitive impairment & Minimising postCognitive impairment & Minimising postCognitive impairment & Minimising post----op delirium op delirium op delirium op delirium

by formal assessment of cognitive function ( Clock by formal assessment of cognitive function ( Clock by formal assessment of cognitive function ( Clock by formal assessment of cognitive function ( Clock

drawing test) in PAC, for all patients over 75 drawing test) in PAC, for all patients over 75 drawing test) in PAC, for all patients over 75 drawing test) in PAC, for all patients over 75 years.years.years.years.

Subsequent management by Subsequent management by Subsequent management by Subsequent management by Physician Physician Physician Physician

accordinglyaccordinglyaccordinglyaccordingly

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PRE –OP CARE RECOMMENDATIONS

PrePrePrePre----operative weight loss operative weight loss operative weight loss operative weight loss

programmes for selected cases programmes for selected cases programmes for selected cases programmes for selected cases

E.g. E.g. E.g. E.g. Radical Prostatectomy,Radical Prostatectomy,Radical Prostatectomy,Radical Prostatectomy,

CholecystectomyCholecystectomyCholecystectomyCholecystectomy

PRE –OP CARE RECOMMENDATIONS

Current Current Current Current Medication lists and/or medications Medication lists and/or medications Medication lists and/or medications Medication lists and/or medications

brought by patient when admitted for surgery brought by patient when admitted for surgery brought by patient when admitted for surgery brought by patient when admitted for surgery ––––

part of hospital admission protocol part of hospital admission protocol part of hospital admission protocol part of hospital admission protocol packagepackagepackagepackage

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Rye Ocean Rye Ocean Rye Ocean Rye Ocean Beach, Beach, Beach, Beach, Victoria Victoria Victoria Victoria (“A birds eye(“A birds eye(“A birds eye(“A birds eye----view”)view”)view”)view”)

POST–OPERATIVE CARE RECOMMENDATIONS

Poor lines of communication when multiple doctors are Poor lines of communication when multiple doctors are Poor lines of communication when multiple doctors are Poor lines of communication when multiple doctors are involvedinvolvedinvolvedinvolved---- “No one takes ultimate responsibility”“No one takes ultimate responsibility”“No one takes ultimate responsibility”“No one takes ultimate responsibility”

Confusion as to WHO Confusion as to WHO Confusion as to WHO Confusion as to WHO is responsible especially is responsible especially is responsible especially is responsible especially first 24 hoursfirst 24 hoursfirst 24 hoursfirst 24 hours

Medication and fluid orders Medication and fluid orders Medication and fluid orders Medication and fluid orders not written up or verbal ordersnot written up or verbal ordersnot written up or verbal ordersnot written up or verbal ordersnot signed leading to nurses not signed leading to nurses not signed leading to nurses not signed leading to nurses doing this “de facto”……= illegal! doing this “de facto”……= illegal! doing this “de facto”……= illegal! doing this “de facto”……= illegal!

Preamble

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When condition deteriorates, nurses asked to “contact a physician”, who has no knowledge of the patient

Medical documentationvaries from comprehensiveto None! Medico –Legal implications

POST–OPERATIVE CARE RECOMMENDATIONS

PreamblePreamblePreamblePreamble

(a) Surgeon (a) Surgeon (a) Surgeon (a) Surgeon �Unexplained hypotension

�Haemorrhage

�Fluid Balance

� Ileus

Treating Surgeon ultimately ResponsibleTreating Surgeon ultimately ResponsibleTreating Surgeon ultimately ResponsibleTreating Surgeon ultimately Responsible

POST OP CARE RECOMMENDATIONS

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POST OP CARE RECOMMENDATIONS

(b) Anaesthetist(b) Anaesthetist(b) Anaesthetist(b) Anaesthetist�Post op Nausea and Vomiting

�Post Op Respiratory Complications

�Analgesic regimes e.g. Ketamine, Epidurals

�Airways/Pressure care & positioning issues

� (ANZCA guidelines re 24 hr post op cover)

Treating Surgeon ultimately ResponsibleTreating Surgeon ultimately ResponsibleTreating Surgeon ultimately ResponsibleTreating Surgeon ultimately Responsible

Treating Surgeon ultimately ResponsibleTreating Surgeon ultimately ResponsibleTreating Surgeon ultimately ResponsibleTreating Surgeon ultimately Responsible

POST OP CARE RECOMMENDATIONS

(c) Physician(c) Physician(c) Physician(c) Physician�Cardiac arrhythmias/APO

�Suspected AMI/PE

�Acute Renal Impairment

�Sepsis/Pneumonia

�Stroke/TIA

�TPN

�Unstable Diabetes

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Medication & Fluid orders written up in theatreMedication & Fluid orders written up in theatreMedication & Fluid orders written up in theatreMedication & Fluid orders written up in theatre

Nursing staff to use the ISBAR tool to communicateNursing staff to use the ISBAR tool to communicateNursing staff to use the ISBAR tool to communicateNursing staff to use the ISBAR tool to communicate

with medical staffwith medical staffwith medical staffwith medical staff

Paper documentation in notes by all Medical/Nursing Paper documentation in notes by all Medical/Nursing Paper documentation in notes by all Medical/Nursing Paper documentation in notes by all Medical/Nursing

staff involved in care. staff involved in care. staff involved in care. staff involved in care.

Can be brief but should Can be brief but should Can be brief but should Can be brief but should

occuroccuroccuroccur

POST OP CARE RECOMMENDATIONS

Communication between surgeons, physicians and anaesthetists must be done person to person, rather than through nursing staff

POST OP CARE RECOMMENDATIONS

Communication issues

Surgeon plays the liaison role (not the nurse) in

cases with post op uncertainty

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IF Inability to Contact a treating IF Inability to Contact a treating IF Inability to Contact a treating IF Inability to Contact a treating specialist this specialist this specialist this specialist this is communicated to is communicated to is communicated to is communicated to

the surgeon who is ultimately responsiblethe surgeon who is ultimately responsiblethe surgeon who is ultimately responsiblethe surgeon who is ultimately responsible

IF Surgeon is uncontactable, then a surgical peer is called.IF Surgeon is uncontactable, then a surgical peer is called.IF Surgeon is uncontactable, then a surgical peer is called.IF Surgeon is uncontactable, then a surgical peer is called.

IF NEITHER are IF NEITHER are IF NEITHER are IF NEITHER are contactable: contactable: contactable: contactable: the hospital the hospital the hospital the hospital

supervisor notified and patient is transferred supervisor notified and patient is transferred supervisor notified and patient is transferred supervisor notified and patient is transferred outoutoutout

Incident Report sent to relevant Incident Report sent to relevant Incident Report sent to relevant Incident Report sent to relevant committee/scommittee/scommittee/scommittee/s

POST OP CARE RECOMMENDATIONS

Communication issues

Admitting Doctor should never besurprised to receive a call at any hour of the day or night,regarding their patients

Inappropriate comments to nursing staff triggers an incident report

If necessary Chair of the MAC has a “quiet word” with doctor concerned

POST OP CARE RECOMMENDATIONS Communication issues

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Blairgowrie Back Blairgowrie Back Blairgowrie Back Blairgowrie Back BachBachBachBachVictoriaVictoriaVictoriaVictoria

BENEFITS OF PROJECT

TO CURRENT SITUATION• New Specialists seeking accreditation are sent a copy of the

working party document, to raise awareness of standards

expected

• Resident cover in private hospitals enhanced by CMOs

• Triggered incident reports in periop care discussed at

Internal medicine and MACs

• More general physicians attracted to area & periop medicine

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PLANS FOR THE FUTURECentralised repository of all pathology & imaging in conjunction with local providers, private rooms, which is easily accessible by all stake holders (avoids duplication)

GP involvement in PAC’sGP involvement in PAC’sGP involvement in PAC’sGP involvement in PAC’s

KPIs to be formulatedKPIs to be formulatedKPIs to be formulatedKPIs to be formulated� -e.g. booked patients cancelled on day of surgery� -% patients cancelled due to medical conditions� -Unexpected transfers out of post surgical patients� -Undiagnosed dementia identified at PACs

PERI-OPERATIVE PARAMETERS USED

AT PHYSICIAN ASSESSMENT

• NSQIP Index (NSQIP Index (NSQIP Index (NSQIP Index (Gupta)Gupta)Gupta)Gupta)• Estimated risk probability for Periop MI

or Cardiac arrest (iphone app)

• ASA ClassASA ClassASA ClassASA Class

• Predictors of Pulmonary complicationsPredictors of Pulmonary complicationsPredictors of Pulmonary complicationsPredictors of Pulmonary complications

• PONVPONVPONVPONV

Appendix

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PERI-OPERATIVE PARAMETERS USED

AT PHYSICIAN ASSESSMENT

Appendix

• OSA ScreeningOSA ScreeningOSA ScreeningOSA Screening

• Obesity/Waist Obesity/Waist Obesity/Waist Obesity/Waist Circumference /BMICircumference /BMICircumference /BMICircumference /BMI

• Aortic StenosisAortic StenosisAortic StenosisAortic Stenosis

• NYHA Class for Heart NYHA Class for Heart NYHA Class for Heart NYHA Class for Heart FailureFailureFailureFailure

• Clock Drawing (>75 Clock Drawing (>75 Clock Drawing (>75 Clock Drawing (>75 ysysysys old)old)old)old)

• Stent management Stent management Stent management Stent management

/Warfarin//Warfarin//Warfarin//Warfarin/AntiplateletsAntiplateletsAntiplateletsAntiplatelets

/PPM/ICD’s/NOAC’s/PPM/ICD’s/NOAC’s/PPM/ICD’s/NOAC’s/PPM/ICD’s/NOAC’s

• Respiratory Failure Respiratory Failure Respiratory Failure Respiratory Failure

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