National Public Health Service for Wales
Critical care public health tool –updated overview of evidence base
Critical care public health
tool – overview of
evidence base for surgical
outcomes
Author: Dr Nina Williams, Consultant in Public Health
Date: May 2009
Version: 1
Status: Final
Intended Audience: Public (Internet) / NHS Wales (Intranet) / NPHS (Intranet) /
Critical Care Networks
Purpose and Summary of Document:
This tool draws together updated evidence upon critical care for improving surgical
outcomes. It is formatted to assist the critical care networks in identifying current best
evidence and to provide summaries of key messages.
Publication/Distribution:

Publication in NPHS Document Database HSCQ Team

Link from NPHS e-Bulletin

Link from Stakeholder e-Newsletter

Inform networks directly
Author: Dr Nina Williams, Consultant
in Public Health
Version: 1. Published May 2009
Review Date March 2010
Date: 310509
Status: Final
Page: 1 of 11
Intended Audience: Public (Internet) /
NHS Wales (Intranet) / NPHS (Intranet)
/ Critical Care Networks
Critical care – evidence update:
Improving surgical outcomes
Critical care - overview of the evidence base for improving surgical outcomes
This is one of series of regular evidence updates, which are undertaken by LKMS as part of NPHS support to the All Wales Critical Care Advisory
Group. The aim is to “research and identify the evidence base for the best practice and new technology for the management of critically ill
patients based on a strong national and international evidence base.” 1 A systematic search methodology is followed so the results are easily
updated and reproducible. Details of full methodology, search results and literature review are available from LKMS.2
The initial searches identified very few papers of high quality evidence (systematic reviews, RCTs and meta-analyses). Most are single centre
primary research studies.
The focus is on outcomes in terms of ICU quality measures like average length of stay, ICU mortality, patient/family satisfaction, sub optimal
pain management, effectiveness and cost effectiveness, care bundle compliance e.g, prevention of ventilator associated pneumonia, rate of
infections related to instrumentation.
Intervention
Reference
Comment
Improving surgical outcomes
1. Improving Surgical Outcomes Group.
Modernising care for patients undergoing
major surgery: improving patient
outcomes and increasing clinical efficiency.
London: ISOG; 2005.
The Improving Surgical Outcomes Group
[ISOG] reports1,2 were reviewed and
selected as key documents as they
identified three key areas for improved
outcomes, which were indicated as having
the most impact on patient outcomes in
terms of numbers and effective use of
1
Designed for Life: Quality requirements for adult critical care in Wales. EH/ML/008/08
2
LKMS, National Public Health Service for Wales, NPHS, 36, Orchard St, Swansea. 01792 607331 Email : LKMS
Author: Dr Nina Williams, NPHS
2
May 2009
Review date: March 2010
Critical care – evidence update:
Improving surgical outcomes
Intervention
Reference
Type III evidence
2. Improving Surgical Outcomes Group.
Modernising care for patients undergoing
major surgery: implementation guide.
London: ISOG, 2007.
Type III evidence
Comment
critical care.
Further searches were undertaken to focus
and update the evidence on more specific
questions. These were limited to papers
published 2004-2008, updating evidence
cited in the ISOG reports. The three areas
are:



3. National Confidential Enquiry into
Perioperative Deaths. The 2002 report of
the National Confidential Enquiry into
Perioperative Deaths. London: NCEPOD;
Author: Dr Nina Williams, NPHS
3
Improved pre-operative assessment
including
lifestyle
improvement’
such as, smoking cessation
Improved peri-operative care
Improved post –operative care
Summary of the main evidence for
improving
outcomes
for
patients
undergoing major surgery
May 2009
Review date: March 2010
Critical care – evidence update:
Improving surgical outcomes
Intervention
Reference
2002.
4. National Confidential Enquiry into
Perioperative Deaths. The 2003 report of
the National Confidential Enquiry into
Perioperative Deaths. London: NCEPOD;
2003.
Type III evidence
Pre-operative
Author: Dr Nina Williams, NPHS
Comment
“Many patients die within 30 days of
surgery do so in general wards without
being admitted to critical care. Of these,
the vast majority have significant comorbidities at time of surgery like a coexisting cardiovascular or respiratory
pathology. About 42 % of patients who
died following surgery had pre-operative
assessment scores recorded as ASA
(American Society of Anaesthesiologists
Score) of 3 or less which suggests that the
severity of the illness and actual risk of
death was not fully appreciated in the preoperative assessment.3,4 Subjective
assessment underestimated the risk of
death for patients undergoing surgery
where the surgeon’s assessment was
compared to physiological and operative
severity scores5”
5. McCullogh P. Mortality and morbidity in Improved Pre-Operative Assessment,
gastro-oesophageal cancer surgery. BMJ Triage and Preparation
2003;327:1192-196.
4
May 2009
Review date: March 2010
Critical care – evidence update:
Improving surgical outcomes
Intervention
Reference
Comment
 Objective evaluation of individual
risk e.g. Cardio-pulmonary exercise
6. Lee J, Chaloner E, Hollingsworth S. The
(CPX) testing has been shown to
role of cardiopulmonary fitness and its
determine pre-operative fitness and
genetic influences on surgical outcomes:
correlates well with post-operative
review. Br J Surg 2006;93:147-57.
survival
 Use of CPX enables triage of
patients to general ward, HDU or
ICU for immediate post-operative
period
 CPX testing can identify those
patients unfit for major surgery or
should
undergo
a
less
risky
operation
In addition to above report: central to
post-operative outcome is the ability to
increase cardiovascular output in response
to increased oxygen demand associated
with major surgery. Genetic factors can
influence by increasing oxygen demand
further. Both CPX testing and identification
of such genetic predisposition may have a
role6.
Author: Dr Nina Williams, NPHS
5
May 2009
Review date: March 2010
Critical care – evidence update:
Improving surgical outcomes
Intervention
Reference
Comment
Optimisation
Haemodynamic optimisation – avoids preoperative dehydration and poor perfusion
to
major
organs
through
use
of
standardised
fluid
and
electrolyte
replacement regimes



Smoking cessation
7. Moller A, Tonnensen H. Risk reduction:
perioperative smoking intervention. Best
practice and research. Clinical
Anaesthesiology 2006; 20:237-48.
8. Theadom A, Cropley M. Effects of
preoperative smoking intervention on
incidence and risk of intraoperative and
post operative complications in adult
smokers: a systematic review. Tob Control
Author: Dr Nina Williams, NPHS
6
Nutritional supplementation
Short period on ICU for very high
risk patients to obtain pre-operative
cardiovascular optimisation
Exercise
In addition

Smoking Cessation - longer periods
of smoking cessation e.g. 6-8 weeks
before surgery can reduce post–
operative
complications
and
improves wound healing7,8
May 2009
Review date: March 2010
Critical care – evidence update:
Improving surgical outcomes
Intervention
Reference
2008; 10:407-12.
Comment
Type I evidence

Furlong C. Preoperative smoking
cessation.A model to estimate potential
short term health gain and reductions in
length of stay. London: LHO; 2005
Peri-operative care
Improved Peri–Operative Care


Author: Dr Nina Williams, NPHS
This report builds on the literature
review published in early 2005 on
the impact of preoperative smoking
cessation on the outcomes of
surgery. It models the effects of a
systematic preoperative smoking
cessation intervention for elective
surgical patients for all London PCTs
and for all London acute hospital
trusts.
7
Haemodynamic
optimisation
(accurate fluid intervention) guided
by a cardiac output algorithm can
significantly reduce both rates of
complications,
mortality
and
significantly reduces length of
hospital stay
Patient warming during surgery,
May 2009
Review date: March 2010
Critical care – evidence update:
Improving surgical outcomes
Intervention
Reference
Comment
beta blockade, higher supplemental
inspired oxygen and optimised
administration of blood products
also show benefit
Post-operative care
Improved Post–Operative Care



Author: Dr Nina Williams, NPHS
8
Level
of
post-operative
care
appropriate to patient’s assessment
and current condition e.g. overnight
intensive recovery unit (OIRU),
separate post—operative critical
care facility 2
Improvements in intra-operative
care and increasing planned critical
care
admission
for
those
at
increased risk of complications
reduces ICU and HDU bed days
Outreach critical care focused on
monitoring and providing care for
surgical patients and HDU where it
does not already exist
May 2009
Review date: March 2010
Critical care – evidence update:
Improving surgical outcomes
Intervention
Work in progress
Reference
9. Intensive Care Society. Perioperative
critical
care
criteria
in
adults.
(Unpublished, work in progress)
Comment
Progress on guidance for appropriate
elective surgical admissions to level 2
and level 3 critical care
Further work in this area is being taken
forward by the Intensive Care Society in
“Perioperative Critical Care Criteria in
Adults”9 which is still draft and not ready
for publication. The document has been
commissioned
by
the
Standards
Committee of the Intensive Care Society.
The aim is to produce a set of objectives,
easily applied, clinical criteria to provide
guidance for clinicians and to increase
standardisation of provision.
Example of local practice guideline
Author: Dr Nina Williams, NPHS
Hope D. Suggested current elective These guidelines are intended to cover
admissions to critical care units – a local most planned admissions. Individual cases
view.
may need to be discussed with the Critical
Care Consultant if admission is thought to
be of benefit.
9
May 2009
Review date: March 2010
Critical care – evidence update:
Improving surgical outcomes
Intervention
Reference
Comment
Appropriate elective surgical admissions to
critical care: evidence briefing for AWCCG.
Swansea: NPHS; 2009.
Surgical Factors
o
o
o
o
o
Major vascular surgery e.g.
Abdominal Aortic Aneurysm Repair,
major vessel grafting
Major head and neck surgery e.g.
neck dissection, laryngectomy,
glossectomy, mandibulectomy
Major Gastrointestinal surgery e.g.
gastrectomy, pancreatectomy,
obesity surgery
Major neurosurgery e.g.
craniotomy, aneurysm clipping,
evacuation intracerebral
haematoma
Major thoracic surgery e.g.
thoracotomy.
Medical Factors
Patients with severe co-morbidities at high
risk of deterioration in the peri-operative
Author: Dr Nina Williams, NPHS
10
May 2009
Review date: March 2010
Critical care – evidence update:
Improving surgical outcomes
Intervention
Reference
Comment
period e.g. acute or chronic
respiratory or renal disease.
heart,
Pain Control
Patients who are likely to benefit from
epidural/spinal analgesia and who cannot
be cared for safely on general wards.
CONCLUSION
There is still ongoing work in this area but
there is evidence behind assessing the risk
to patients and improving outcomes for
patients undergoing surgery that requires
a combined multi-disciplinary approach
between surgical and anaesthetic teams
which is more than just saying which types
of surgery require what level of care. The
development of guidance for appropriate
surgical admission to level 2 and level 3
critical care should take this evidence into
account.
Author: Dr Nina Williams, NPHS
11
May 2009
Review date: March 2010