The incidence of postoperative vasopressor usage: protocol for a prospective international observational cohort study (SQUEEZE)

Background: Postoperative hypotension is common after major non-cardiac surgery, due predominantly to vasodilation. Administration of infused vasopressors postoperatively may often be considered a surrogate indicator of vasodilation. The incidence of postoperative vasopressors has never been described for non-cardiac surgery, nor have outcomes associated with their use. This paper presents a protocol for a prospective international cohort study to address these gaps in knowledge. The primary objectives are to estimate the proportion of patients who receive postoperative vasopressor infusions (PVI) and to document the variation in this proportion between hospitals and internationally. Furthermore, we will identify factors in variation of care (patient, condition, surgery, and intraoperative management) associated with receipt of PVI and investigate how PVI use is associated with patient outcomes, including organ dysfunction, length of hospital stay, and 30-day in-hospital mortality. Method: This will be a prospective, international, multicentre cohort study that includes all adult (≥ 18 years) non-cardiac surgical patients in participating centres. Patients undergoing cardiac, obstetric, or day-case surgery will be excluded. We will recruit two cohorts of patients: cohort A will include all eligible patients admitted to participating hospitals for seven consecutive days. Cohort B will include 30 sequential patients per hospital, with the single additional inclusion criterion of postoperative vasopressor usage. We expect to collect data on approximately 40,000 patients for cohort A and 12,800 patients for cohort B. Discussion: While in cardiac surgery, clinical trials have informed the choice of vasopressors used to treat postoperative vasoplegia; there remains equipoise over the best approach in non-cardiac surgery. Our study will represent the first large-scale assessment of the use of vasopressors after non-cardiac surgery. These data will inform future studies, including trials of different vasopressors and potential management options to improve outcomes and reduce resource use after surgery. Trial registration: ClinicalTrials.gov Identifier: NCT03805230, 15 January 2019

Competence assessment in anaesthesia nursing care

In order to provide high-quality anaesthesia nursing care, competence assessment of nurses is essential. However, in anaesthesia nursing care there has been a lack of psychometrically tested competence assessment scales. Therefore, the purpose of this study was i) to develop an Anaesthesia Nursing Competence Scale (AnestComp) and ii) to assess the anaesthesia nursing competence of nurses using the scale, with the goal of promoting anaesthesia nursing competence of nurses and providing high-quality anaesthesia care. The study was carried out in two phases: Phase I focused on describing the concept of anaesthesia nursing competence based on a literature review and experts’ descriptions which then became the foundation for the AnestComp; this was followed by testing the psychometric properties of the scale. In Phase II, the anaesthesia nursing competence of anaesthesia nurses (n=222) was self-assessed by using the AnestComp. The psychometric properties of the AnestComp were tested: reliability (Cronbach’s α), face validity, content validity, and construct validity. In this study, the data of nursing students (n=205) were also collected and analysed for the purpose of the construct validity testing of the AnestComp. Anaesthesia nursing competence is a multi-dimensional conception comprising of seven competence areas: (1) ethics of anaesthesia care, (2) patient risk care, (3) patient engagement with technology, (4) collaboration within anaesthesia care, (5) anaesthesia patient care with medication, (6) anaesthesia nursing intervention, and (7) knowledge of anaesthesia care. The AnestComp developed based on these competence areas consists of 39 items and uses a Visual Analogue Scale (0-100mm). The AnestComp is considered a promising scale for assessing the anaesthesia nursing competence of nurses based on the testing of psychometric properties. Nurses’ self-assessed competence (VAS 88) exceeded the expected level; in this study, the expected level was set as a mean of VAS 80. Collaboration within anaesthesia care was the highest competence area, whereas patient risk care and knowledge of anaesthesia care were the lowest, and thus identified as fields requiring educational needs. Work experience and specialised anaesthesia nursing education were significant factors related to the higher anaesthesia nursing competence of nurses. The competence of nurses (particularly novices) in patient risk care and knowledge of anaesthesia care should be ensured through regular competence assessments. More opportunity for specialised anaesthesia nursing education might be one way to improve the anaesthesia nursing competence of nurses.Ammattipätevyyden arviointi anestesiahoitotyössä Ammattipätevyyden arviointi on välttämätöntä korkealaatuisen anestesiahoitotyön toteuttamiseksi. Anestesiahoitotyössä ei ole aikaisemmin ollut validia psykometrisesti testattua ammattipätevyyden arviointimittaria. Tämän tutkimuksen tarkoituksena oli i) kehittää validi ammattipätevyyden arviointimittari anestesiahoitotyötä varten (AnestComp) ja ii) arvioida anestesiahoitajien anestesiahoitotyön ammattipätevyyttä hyödyntämällä kehitettyä arviointimittaria. Tavoitteena oli anestesiahoitotyön pätevyyden ja korkealaatuisen anestesiahoidon edistäminen. Tutkimus toteutettiin kahdessa vaiheessa. Vaihe I painottui anestesiahoitotyön ammattipätevyyden käsitteen kuvaamiseen kirjallisuuskatsauksen ja asiantuntijoiden kuvausten perusteella. Sen jälkeen kehitettiin anestesiahoitotyön ammattipätevyysmittari (AnestComp) ja testattiin sen psykometriset ominaisuudet. Vaiheessa II anestesiahoitajat (n=222) itsearvioivat ammattipätevyyttään AnestComp mittarilla. Tilastollisten aineistojen analyysissä AnestComp-mittarin luotettavuus (Cronbachin α) ja rakennevaliditeetti testattiin sairaanhoitajien aineistolla. Tässä tutkimuksessa myös sairaanhoitajaopiskelijoiden (n = 205) aineistot kerättiin ja analysoitiin AnestComp-mittarin rakennevaliditeettitestausta varten. Anestesiahoitotyön pätevyyttä kuvataan moniulotteisena käsitteenä, joka käsittää seitsemän pätevyysaluetta: (1) anestesiahoidon etiikka, (2) anestesiapotilaan riskien hoito, (3) teknologiavälitteinen potilashoito, (4) yhteistyö anestesiahoidossa, (5) anestesiapotilaan lääkehoito, (6) anestesiahoitotyön interventio sekä (7) tietämys anestesiahoidosta. Näiden ammattipätevyysalueiden pohjalta kehitettiin AnestComp-mittari (39 väittämää, VAS 0-100). Sitä pidettiin psykometristen ominaisuuksien testauksen perusteella lupaavana mittarina anestesiahoitotyön ammattipätevyyden arvioimiseksi. Sairaanhoitajien itsearvioitu pätevyys (VAS 88) ylitti odotetun tason, joka tässä tutkimuksessa oli asetettu VAS 80:ksi. Korkein pätevyysalue oli yhteistyö anestesiahoidossa, mutta anestesiapotilaan riskien hoito ja tietämys anestesiahoidosta tunnistettiin matalimmiksi ammattipätevyysalueiksi. Työkokemus ja erikoistunut anestesiahoitajakoulutus olivat merkittäviä tekijöitä, jotka liittyivät sairaanhoitajien ammattiosaamisen korkeampaan pätevyyteen. Sairaanhoitajien osaaminen (erityisesti uusien hoitajien) kahdella heikoimmalla ammattipätevyyden osa-alueilla tulisi varmistaa säännöllisten ammattipätevyysarviointien avulla. Mahdollisuus erikoistua anestesiahoitotyöhön voisi olla keino edistää anestesiahoitotyön ammattipätevyyttä

Postoperative pain management in children: Guidance from the pain committee of the European Society for Paediatric Anaesthesiology (ESPA Pain Management Ladder Initiative)

The main remit of the European Society for Paediatric Anaesthesiology (ESPA) Pain Committee is to improve the quality of pain management in children. The ESPA Pain Management Ladder is a clinical practice advisory based upon expert consensus to help to ensure a basic standard of perioperative pain management for all children. Further steps are suggested to improve pain management once a basic standard has been achieved. The guidance is grouped by the type of surgical procedure and layered to suggest basic, intermediate, and advanced pain management methods. The committee members are aware that there are marked differences in financial and personal resources in different institutions and countries and also considerable variations in the availability of analgesic drugs across Europe. We recommend that the guidance should be used as a framework to guide best practice

The relationship between preoperative hypertension and intraoperative haemodynamic changes known to be associated with postoperative morbidity

Hypertension is not consistently associated with postoperative cardiovascular morbidity and therefore not considered a major peri-operative risk factor. However, hypertension may predispose to peri-operative haemodynamic changes known to be associated with perioperative morbidity and mortality, such as intra-operative hypotension and tachycardia. The objective of this study was to determine whether pre-operative hypertension was independently associated with haemodynamic changes known to be associated with adverse peri-operative outcomes. We performed a five-day multicentre, prospective, observational cohort study which included all adult inpatients undergoing elective, noncardiac, non-obstetric surgery. We recruited 343 patients of whom 164 (47.8%) were hypertensive. An intra-operative mean arterial pressure of 100 beats per minute) occurred in 126 (38.9%) patients, of which 61 (48.4%) were hypertensive. Multivariable logistic regression did not show an independent association between the stage of hypertension and either clinically significant hypotension or tachycardia, when controlled for ASA physical status, functional status, major surgery, the duration of surgery or blood transfusion. There was no association between pre-operative hypertension and peri-operative haemodynamic changes known to be associated with major morbidity and mortality. These data therefore support the recommendation of the Joint Guidelines of the Association of Anaesthetists of Great Britain and Ireland (AAGBI) and the British Hypertension Society to proceed with elective surgery if a patient’s blood pressure is < 180/110 mmHg

Postoperative outcomes associated with procedural sedation conducted by physician and non-physician anaesthesia providers: findings from the prospective, Observational African Surgical Outcomes Study (ASOS)

Background There is an unmet need for essential surgical services in Africa. Limited anesthesia services are a contributing factor. Non-physician anesthesia providers are utilized to assist with providing anesthesia and procedural sedation in order to make essential surgeries available. There is a paucity of data on outcomes following procedural sedation for surgery in Africa. We investigated the postoperative outcomes following procedural sedation by non-physicians and physicians in Africa. We hypothesized that the level of training of the sedation provider may be associated with the incidence of severe postoperative complications and death. Methods A secondary analysis of a prospective cohort of in-hospital adult surgical patients, representing 25 African countries was performed. An inverse probability of treatment weighting model was developed to assess the association between receiving procedural sedation conducted by a non-physician (vs physician) and in-hospital outcomes. All patients who only received procedural sedation for surgery were included. The primary outcome was the incidence of the composite of severe complications and death. Results 336 patients met the inclusion criteria, of which 98 (29.2%) received sedation from a non-physician provider. The incidence of severe postoperative complications and death was 10/98 (10.2%) in the non-physician group, and 5/238 (2.1%) in the physician group. The association between procedural sedation conducted by a nonphysician provider and in-hospital outcomes showed an eight-fold increase in the odds of severe complications and death (odds ratio 7.7; 95% CI 2.5 to 23.7). Conclusions The modest number of observations in this secondary data analysis, suggests that shifting the task of procedural sedation from physicians to non-physicians in order to increase access to care may be associated with severe postoperative complications and death in Africa. Research focusing on identifying factors contributing to adverse outcomes associated with procedural sedation is necessary to make this practice safer

A Descriptive Survey to Explore Non-Medical Practitioner Roles in Acute Healthcare Settings within the United Kingdom (UK)

Background Healthcare in the United Kingdom (UK) has undergone significant change which has led to workforce redesign, the extending and advancement of existing health professional boundaries and development of new roles. Of particular note has been the emergence of Non-Medical Practitioner (NMP) roles, designed to enable clinical responsibilities traditionally undertaken by doctors, to be completed by others. Aim The study aimed to explore the development and integration of NMP roles in acute healthcare settings within the UK from an organisational and NMP perspective. Literature Review A systematic approach to the literature search resulted in the critical appraisal and synthesis of 10 relevant studies which examined NMP roles in the UK. Methodology A descriptive survey was undertaken to explore the development, integration, recruitment, education and clinical governance of NMP roles in the UK. Method Study A purposively explored NHS (n=156) and Private/Independent (n=90) organisations in England. Study B investigated NMPs in the UK through convenience and snowballing approaches. Self-completed semi-structured online questionnaires were used to collect the data from the respondents. Ethical approval was obtained from Coventry University. Results A total of 23/246 useable questionnaires were returned from healthcare organisations (Study A) and 96 successfully completed questionnaires were returned by NMPs (Study B). After descriptive analysis using SPSS and thematic analysis seven NMP roles were identified, distributed throughout the UK. NMPs positively contribute to improving services and patient care. Inconsistencies were found in regulation, grading, education and understanding of NMP roles. Recommendation Further, qualitative research is recommended to explore health professionals, patients and NMPs experiences and attributes of the NMP role. Further quantitative research is recommended to capture NMPs clinical activities and responsibilities. Conclusion This study fully met the objectives and contributes further to the evidence identifying the value of NMPs as part of the healthcare workforce within the UK. NMPs are perceived to positively improve services and patient outcomes. It has highlighted that NMP roles are commonly undertaken by experienced practitioners. Development is affected by service delivery and national policies. However, several areas of concern were raised which affect integration including clinical governance, regulation, education and understanding of the NMP role

Ethical issues associated with in-hospital emergency from the medical emergency team's perspective: a national survey

Medical Emergency Teams (METs) are frequently involved in ethical issues associated to in-hospital emergencies, like decisions about end-of-life care and intensive care unit (ICU) admission. MET involvement offers both advantages and disadvantages, especially when an immediate decision must be made. We performed a survey among Italian intensivists/anesthesiologists evaluating MET's perspective on the most relevant ethical aspects faced in daily practice

How nursing care is expressed among nurse anaesthetists in the perioperative context: A meta-ethnographic synthesis

Aim To develop a conceptual framework describing nursing care from the anaesthesia nurse's perspective in the perioperative context. Background Surgical patients find themselves in a vulnerable situation in need of advanced treatment and care. Nurse anaesthetists have a central role in reducing harm and enhance patient safety, in which person-centred care has been identified as a key component. However, they are challenged by productivity and efficiency demands leading to a potential risk to patient safety. Design Noblit and Hare's interpretative meta-ethnography, directed by the eMERGe reporting guidance. Methods A comprehensive systematic search of nine databases without year limitation. Fifteen studies published between 2002 and 2021 were found eligible for inclusion. Quality appraisal was performed using the Joanna Briggs Institute Qualitative Assessment and Review Instrument. Results Four themes were identified: being vigilant to keep safe from harm, strengthening patients' confidence, expressing courage to act and speak up, and endorsing team collaboration to achieve best practice. The themes were synthesised into the metaphor, ‘Continuously assessing and acting according to the patients' needs in a holistic perspective’. A conceptual framework was developed, illustrating the interconnection between the different nursing expressions, as the nurse anaesthetists seek to care for the patient as a whole person. Conclusions Nurse anaesthetists aim to deliver holistic nursing care. Nursing care is expressed at two levels, foregrounding and backgrounding anaesthetic nursing, in line with the philosophy of person-centred care. Nursing care in anaesthesia is a matter of how and why it is performed, expressed in attitudes toward the recipients of care. Relevance to clinical practice The framework may be used to inform educational programs and clinical practice in nurse anaesthesia and to promote person-centred care as a shared value across all levels involved in perioperative patient care. No patient or public contribution Data were retrieved from already published literature.publishedVersio

Developing and validating subjective and objective risk-assessment measures for predicting mortality after major surgery: An international prospective cohort study

Background: Preoperative risk prediction is important for guiding clinical decision-making and resource allocation. Clinicians frequently rely solely on their own clinical judgement for risk prediction rather than objective measures. We aimed to compare the accuracy of freely available objective surgical risk tools with subjective clinical assessment in predicting 30-day mortality. Methods and findings: We conducted a prospective observational study in 274 hospitals in the United Kingdom (UK), Australia, and New Zealand. For 1 week in 2017, prospective risk, surgical, and outcome data were collected on all adults aged 18 years and over undergoing surgery requiring at least a 1-night stay in hospital. Recruitment bias was avoided through an ethical waiver to patient consent; a mixture of rural, urban, district, and university hospitals participated. We compared subjective assessment with 3 previously published, open-access objective risk tools for predicting 30-day mortality: the Portsmouth-Physiology and Operative Severity Score for the enUmeration of Mortality (P-POSSUM), Surgical Risk Scale (SRS), and Surgical Outcome Risk Tool (SORT). We then developed a logistic regression model combining subjective assessment and the best objective tool and compared its performance to each constituent method alone. We included 22,631 patients in the study: 52.8% were female, median age was 62 years (interquartile range [IQR] 46 to 73 years), median postoperative length of stay was 3 days (IQR 1 to 6), and inpatient 30-day mortality was 1.4%. Clinicians used subjective assessment alone in 88.7% of cases. All methods overpredicted risk, but visual inspection of plots showed the SORT to have the best calibration. The SORT demonstrated the best discrimination of the objective tools (SORT Area Under Receiver Operating Characteristic curve [AUROC] = 0.90, 95% confidence interval [CI]: 0.88–0.92; P-POSSUM = 0.89, 95% CI 0.88–0.91; SRS = 0.85, 95% CI 0.82–0.87). Subjective assessment demonstrated good discrimination (AUROC = 0.89, 95% CI: 0.86–0.91) that was not different from the SORT (p = 0.309). Combining subjective assessment and the SORT improved discrimination (bootstrap optimism-corrected AUROC = 0.92, 95% CI: 0.90–0.94) and demonstrated continuous Net Reclassification Improvement (NRI = 0.13, 95% CI: 0.06–0.20, p < 0.001) compared with subjective assessment alone. Decision-curve analysis (DCA) confirmed the superiority of the SORT over other previously published models, and the SORT–clinical judgement model again performed best overall. Our study is limited by the low mortality rate, by the lack of blinding in the ‘subjective’ risk assessments, and because we only compared the performance of clinical risk scores as opposed to other prediction tools such as exercise testing or frailty assessment. Conclusions: In this study, we observed that the combination of subjective assessment with a parsimonious risk model improved perioperative risk estimation. This may be of value in helping clinicians allocate finite resources such as critical care and to support patient involvement in clinical decision-making