Choosing Wisely

Emily Farrow's picture

In a recent campaign to improve communication between clinicians and patients in order to avoid unnecessary tests, treatments and procedures the Royal College of Anaesthetists and the Royal College of Surgeons’ recommended that:

  1. Day surgery should be considered the default for most surgical procedures (except complex procedures). Variation in the use of day surgery for specific operations should be measured and this information should be available to patients.
  2. Patients do not need to come into hospital the day before surgery if they have had the appropriate preoperative assessment and preparation.
  3. Most patients do not need routine preoperative tests before minor or intermediate surgery. There are national guidelines to determine who needs preoperative tests.
  4. All patients considering an operation should have shared decision making consultations to discuss their individual chance of benefit or harm and to identify their personal preference. Patients choosing surgery who are at a high risk of dying (predicted 30 day mortality >1%) should be identified by their age, type of surgery and additional medical conditions.
  5. For many patients the chance of harm after an operation may be reduced if they improve fitness, stop smoking, reduce alcohol intake and in some cases reduce weight in the weeks or months before their surgery.

The Choosing Wisely Report is part of a world-wide initiative and was produced by the Academy of Medical Royal Colleges on 24th October 2016 having been put together following consultations with patient groups and experts. Medical colleges and faculties were asked to identify five treatments or procedures that were considered to be of questionable benefit to patients taking particular concern that they provided suggestions that were evidence based and relevant to NICE guidance.

I’m not from an anaesthetics background, does anyone who is have any other suggestions or recommendations?

Emily Farrow (CSH Clinical Programme Deputy Director)

Comments

Choosing Wisely in Anaesthetics

Frank Swinton's picture

Hi Emily, I'm an anaesthetist and I would suggest the following should be standard practice for all:

  • Paracetamol and NSAIDS (where not contra-indicated) to be given orally as pre-meds rather than IV
  • Benzodiazepines have no role in modern anaesthetic practice
  • There is no clinical indication for desflurane
  • If Ondansetron has been given intra-op then a second dose, as rescue therapy in recovery, is as effective as placebo
  • Almost all patients having surgery of less than 45 minutes duration do not need IV fluid.

I expect some will find these challenging but let's talk about it...

Frank

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Barriers and Facilitators to Choosing Wisely

Mark Scarfe's picture

I think Frank's suggestions are all valid, but it's his final comment that is the most telling. Barriers to change in organisations within the NHS are legion but not insurrmountable if motivated and supported.

Interestingly, the size of change and the resistance to that change never seem proportional. The removal of a desflurane vaporiser can often see as much outrage as implementing an external management consultant's theatre efficiency strategies.

Given this, it is my view that one should reserve effort for the highest value waste reduction interventions. Sadly, no one really produces a ranked list (a la NICE with its health economic assessments), but intuitively (for me) the savings are found in cultural, behavioural and organisational attitudes to delivering safe, effective and efficient anaesthetics.

So where does one start? I would argue that one should tag sustainability onto the principles of the Anaesthesia Clinical Service Assessment (https://www.rcoa.ac.uk/acsa). Based on NHSLA standards and assessment, when an anaesthetics department undertakes to acheive the standards as laid out by the RCOA, it has the opportunity to discuss and implement these wider changes that will see most benefit.

A good department that works to the standards/principles of ACSA, should find the changes that Frank suggests easier to achieve. 

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