The hidden pandemic of postoperative complications

While surgery is essential to treat a high proportion of health conditions, hospital waiting lists alone show us the increasing challenges in accessing that care in a timely manner.

The Australian Government Intergenerational Report 2023 tells us much about why: increasing demand for care and budgetary challenges. In addition, analysis of quality databases such as the American College of Surgeons’ NSQIP tells us that many patients in the future will have more complications and postoperative requirements.

What we increasingly understand from recent and ongoing work into peri-operative care, however, is that there is a lot which can be done to address these complications. In particular, data are emerging on interventions that improve patient outcomes and, usually by virtue of creating better health for patients, generate positive outcomes for the system in terms of efficient use of resources and costs. Having all stakeholders sit together and consider how we can drive this value-generating work has been the theme behind ‘The Hidden Pandemic’ Summit I in 2020, Summit II in 2023, and perhaps an international summit in 2024.

Summit I

On 6 March 2023, Summit I was held in Adelaide to start this process. Attendees represented professional Colleges and organisations, quality and safety organisations, public and private healthcare insurers and providers, academic institutions, and consumer groups. Principles to underpin change and improvement were generated, as were priority areas of unmet need. The output was summarised in the peer-reviewed literature

Summit II

COVID prevented a face-to-face follow up meeting until July 2023, when stakeholder groups again met in Adelaide with the broad objectives of reviewing the draft principles and identifying priority action items. Assistance in developing this summit this was gratefully provided in particular by Professor Tarik Sammour of the University of Adelaide and CALHN, and Professor David Watters of Safer Care Victoria.

We are most grateful for funding support from Edwards Lifesciences and CALHN/University of Adelaide’s PARC Clinical Research, for the facilitation provided by Dr Norman Swan, and for the organisational skills of Francesca Zappia, and Vicky Troptsidis from Eventful Projects.

A workshop on Advanced Recovery Room Care (ARRC) was held at RAH the afternoon before the fully body of the summit. This allowed delegates to hear first-hand about the unit from those on the ground, and to understand the theory and results being achieved. It was pleasing to see the enthusiasm for this concept flow into the full body of the summit, with calls for ARRC to be priority initiative nationally.

Health Minister Chris Picton kindly opened the summit, and we were privileged to have Jack Buckskin provide a moving and entertaining Welcome to Country.

Speakers provided views on what they saw as the ‘ideal state’, the gaps, and what might be needed to close these gaps. Then the task of developing action plans was handed over to a series of focus groups. This included a ‘disruptors group’ of young students and doctors who challenged to find solutions to inevitable personnel shortages (not just in healthcare) by our international dinner speaker, Mr Tim Cook from nGAGE Talent – UK’s 2022 winner of the Queen's Award for Enterprise.

Key messages

A wealth of information was provided from a large range of perspectives, collected from presentations, focus group feedback, and very extensive notes of discussions.

A formal comprehensive report is being generated from Summit II and will be distributed widely in due course. However, a number of key messages and suggestions are already evident.

• The situation is urgent.

» Concern was universally expressed about the size and scope of the challenge facing the provision of surgical and peri-operative care. There were calls for the rapid formation of a national taskforce(s) to address the issue.

• System approaches underpin the solutions. These include:

» An explicit framework (or journey) to guide activity from the start to the end of peri-operative care is needed to provide a roadmap for all planning; the framework of ANZCA is one example (see figure).

» Formal assessment of patients’ risk and needs from when surgery is considered to guide decision-making, triage and streaming. Review and risk re-assessment when and as needed.

» Consistent evidence-based care pathways for patients with a range of needs – formal defined national suite of pathways is feasible and, if effectively delivered, will induce improved outcomes and value. Defined health pathways are not an unfamiliar concept, with Health Pathways being an example.

» Access to culturally appropriate pathways and care. Involvement of key stakeholder groups to ensure these are both available and delivered.

» Appropriate acknowledgement of performance. Mechanisms to support implementation of best practice (process) as well as endpoints (modifiable outcomes) are needed.

• Data and information is the foundation.

» Accurate information on process and outcomes relevant to key stakeholders (and including consumer- relevant outcomes) is essential to guide performance and value. What is already collected, and what we now better understand should be collected, are not necessarily the same.

» Data will guide future directions – hypothesis generation.

» A platform to collect, analyse and share these data is essential. The concept of registries is not alien but existing databases are either insufficiently comprehensive, or poorly linked, or both. In an era of electronic medical records this is now highly feasible.

» The R&D division. An essential element of any business. Quarantined resources, and allowance and capacity for executives to explore change from the status quorapid testing (examine, iterate and fail or adopt fast). Don’t assume anything is working optimally.

» Standardised handover/communication. A priority is a national standardised discharge summary (possibly automatically generated), comprehensible to clinicians and consumers, provided at the time of discharge, and clearly identifying roles and responsibilities of clinician and consumers.

• Information technology

» Two messages from Tim Cook (nGAGE Talent):

○ Workforce challenges face all industries, and new roles and tools such as IT will be essential.

○ Today’s consumers wish to have control of, and choice in, their business.

» Our young ‘disruptors group’ imagined an end-to-end app that provides functions relevant also to nonhealthcare businesses:

○ Spans the peri-operative journey

○ Is a visible dashboard

○ Provides a comprehensive summary of health data- from clinicians, wearables

○ Integrates with a national EMR

○ Analyses and curates data on eg risk (AI)

○ Assists/automates referrals, appoints and schedules

○ Creates and distributes data summaries

○ Functions as a passport for patients

• Standards

» A comprehensive national set of perioperative standards, evidence-based, is seen as a priority.

• Specific activities

» Preparation for surgery – risk assessment; care pathways, ‘preparation lists’ rather than waiting lists; re-evaluation of need over time; comms and activities shared across in- and out-of-hospital-sectors. Role for a national working group/network on this area.

» Early postoperative care – Advanced Recovery Room Care (ARRC) as a priority. Role for a national network/ registry

» Identify and support ‘best care’. Provision of clear evidence-based guidelines for decision makers on care which optimises value

The summit format has allowed a large group of stakeholders with an interest and passion for improved surgical and perioperative care to meet and share information and ideas. The summit report will, we believe, provide a clear summary of a range of options available to decision-makers.

There was a strong call for a national taskforce to deliver options for change. Regardless, we see value in continuing this Summit series as an independent ‘collation of the willing’ prepared to give time to proceed in this area critical to Australians’ health and wellbeing.

Professor Guy Ludbrook leads the PARC research group based at the University of Adelaide.