Three NHS hospitals have implemented the new technique into their clinical practice with the aim of improving the quality of care for surgical patients.

Below you can access the learning gathered from the anesthetists, surgeons, nurses and managers who have worked on this technology implementation project. In addition there are support tools and resources for you to download, adapt and use.

To explore this section and view information relevant and useful to you and your organisation please click on the headings below:

• Project Background
• Project Sites
• Change Rationele
• Project Outcome Measures
• Achieving Change
• Impact Evaluation
• Measurements of Success

Project Background

Three NHS hospitals across England implemented Doppler guided intraoperative fluid management into their routine clinical practice with the aim of improving surgical outcomes and reducing hospital stay for patients undergoing major surgery.

Following a structured implementation programme, patient outcomes were measured in 1200 patients consisting of intervention and control groups of patients, the control group consisting of historical cases undertaken in the year prior to the project start date.

The benefits and barriers and impact of implementation on the use of NHS resources was assessed for each patient care episode by measuring and comparing hospital stay, the use of invasive central venous monitoring catheters (CVC), reoperation and readmission rates.

Project Sites

Central Manchester Hospitals NHS Foundation Trust (CMFT)

Clinical Implementation Lead - Dr Dan Conway, Consultant Anaesthetist

Manchester Royal Infirmary is multi-speciality, tertiary teaching hospital for Manchester University's Medical School. It is the regional centre for encapsulating peritoneal sclerosis, kidney and pancreas transplant surgery. There is a major vascular surgery programme. Recent developments in service across the Trust have resulted in an increase in upper GI, hepatic, gynaecological and urological cancer surgery. CMFT is an inner city tertiary teaching hospital and treats patients with complex co-morbidities and complex surgical procedures. On January 1st 2009, CMFT became a foundation Trust and currently employs over 8000 staff. Over 94,000 operations are performed each year and approximately 2000 of these operations are major surgical procedures.

As part of the implementation project, anaesthetic consultants volunteered to 'champion' the technology in a range of surgical specialities. Following classroom and in-theatre training provided by the supplier and peers, the champions initiated the audit with the following conditions:

1. Oesophageal Doppler monitoring will guide intra-operative fluid replacement to optimise stroke volume in appropriate cases according to strict criteria and protocol agreed by the group.
2. Data should be collected with 100% compliance by the consultant champions

Oesophageal Doppler guided intraoperative fluid management has been successfully implemented in the following surgical areas: urology, vascular, upper gastro intestinal cancer, emergency, colorectal, orthopaedics and transplantation.

Patient outcomes were measured in patients consisting of intervention and comparator groups of patients, the comparator group consisting of historical cases undertaken in the year prior to the project implementation start date of January 2009.To minimise bias, both groups were closely matched according to specialist surgical team and OPCS code.

In comparison to the other project sites, Manchester has implemented the Doppler technology in a range of emergency and scheduled surgical procedures as well as elective and planned cases. These factors have contributed to Manchester observing a higher pre-operative risk score (POSSUM) in both the intervention and comparator groups.

Derby Hospitals NHS Foundation Trust

Clinical Implementation Lead - Dr Stuart Gold, Consultant Anaesthetist

The Royal Derby Hospital is a £334 million new hospital providing a wide range of services including general medical, surgical, maternity, rehabilitation care and accident and emergency services, With a total of 1,187 beds and 35 operating theatres, the Trust serves a population of over 600,000 people in and around southern Derbyshire.

As part of the implementation project we chose to focus on implementation of oesophageal Doppler guided intraoperative fluid management in elective colorectal surgery, This service had already been moved to the new hospital site and it was possible to concentrate our project on this patient group. Elective colorectal surgery also has the greatest body of evidence supporting the use of the oesophageal Doppler monitor for fluid optimisation.

Following classroom and in-theatre training we encouraged anaesthetists to use oesophageal Doppler monitoring for all colorectal resections.

Our project implementation start date was the 18th September 2008. We have collected data from all colorectal procedures carried out following the start of our project; this data has been compared to the previous years colorectal surgical cases. All data has been collected prospectively by one of 2 audit facilitators. We have subjected our data to quality assurance assessment through systematic examination of our data which verified the accuracy of our clinical data.

Whittington NHS Trust

Clinical implementation Lead - Dr Martin Kuper, Consultant Anaethetist

The Whittington is an acute general hospital in Archway, North London, which serves a diverse local population of approximately 250,000 and has 467 inpatient beds. The Whittington is one of the teaching hospitals for University College London.

At the Whittington, the Doppler project implementation went live on 1st April 2008 and project data collection completed on 30th April 2009. We aimed to collect data on at least 200 patients undergoing orthopaedic and colorectal surgery. In orthopaedic surgery we recruited patients undergoing urgent repair of neck of femur fracture and elective total hip replacement. In colorectal surgery we recruited patients undergoing emergency or elective bowel resection, excluding simple appendicectomy and small bowel perforation. Approximately equal numbers of retrospective comparators, matched for speciality and urgency, were drawn from patients who had met the same operative criteria during the preceding year i.e. 1st March 2007-31st March 2008.

Change Rationale

About 3 million operations are carried out in the UK every year, with a hospital mortality rate of 0.8-1.0 %. Over 20,000 patients die a year following surgery and there are concerns that UK may have significantly higher mortality rates compared with the health care systems in comparable countries.

Optimal management of cardiac output, fluid balance and haemodynamic status is considered to be a key factor in improving the outcomes of high risk surgery and critically ill patients.

Using cardiac output monitoring to guide fluid replacement and pharmacological treatment allows haemodynamic status to be optimised, and thus helping to maintain adequate blood supplies to the tissues. Monitoring therefore, offers the potential to reduce mortality, complication rates, length of stay in critical care facilities and overall hospital stay, all of which offer significant potential to reduce healthcare costs

In 2007 the Improving Surgical Outcomes Group , an independent medical group comprising surgeons, anaesthetists, critical care consultants and others involved in operative management and care published a report "Modernising Care for Patients Undergoing Major Surgery". This report highlighted a number of clinically proventechniques and technologies that improve outcomes for patients stating that "haemodynamic optimisation and other interventions significantly reduce both the rates of post-operative complications and mortality, as well as significantly reducing both the length of hospital stay and the overall number of ICU / HDU bed days used."

Despite a comprehensive evidence base comprising of eight randomised controlled trials demonstrating significantly improvements in surgical outcomes, uptake of this technology has been poor across the NHS. In late 2007 this technology was selected by the NHS Technology Adoption Centre as one of its first implementation projects in which it set out to understand and overcome the barriers to widespread adoption of this technique by working with clinicians and managers throughout the implementation process with 3 NHS organisations in England

Each organisation implemented Doppler guided intraoperative fluid management into routine clinical and operational practice representative of NHS practice and assessed the impact on patient outcomes and the use of resources compared to historical standards of care.

Project Outcome Measures

The impact of implementation was measured by assessing the peri-operative morbidity and mortality risk, intraoperative audit and post operative morbidity assessment

Perioperative Risk Evaluation

The POSSUM peri-operative risk evaluation scoring system was utilised to assess patient morbidity and mortality risk and to record operative severity. With the variety of surgical procedures undertaken as part of the audit, it was important to use a scoring system which would be applicable across the surgical spectrum as well as in elective and emergency settings.

POSSUM has been validated in the UK across a wide spectrum of surgical procedures for both research and clinical audit and most centres have experience with its use.

Intraoperative Audit

An electronic audit form was developed to record details of the intervention including the methods of haemodynamic monitoring used, cardiac output measurements recorded, intra-operative fluids administered and any related complications recorded during surgery.

Postoperative Evaluation of Morbidity

POMS is the only published prospective method for describing short term morbidity after surgery and was designed to identify morbidity of a type and severity that would delay discharge from hospital . Measurement focuses on easily collectable indications of clinically important dysfunction in key organ systems. Indicators were available from routinely available sources and did not require special or additional investigations.

In addition mortality rates were recorded for the intervention and comparator groups

Use of NHS Resources

The impact of implementation on resources was evaluated by measuring:

• Admissions and length of stay in critical care
• Overall length of hospital stay
• Rates of readmission and reoperation
• The use of invasive monitoring techniques (central venous catheters)

Achieving Change

Controlled implementation was undertaken at 3 hospital sites in England representing a broad spectrum of clinical practice Intervention with Doppler guided fluid management was continuously audited throughout the project period. Data was collected via a secure web based database. Performance reports were generated monthly for each of the participating sites.

Project teams were established at each of the implementation sites consisting of:

Clinical Implementation Project Lead - Consultant Anesthetist with responsibility for clinical leadership, directing education and in-theatre training programmes, guideline and protocol development for intra-operative fluid management (IOFM), clinical liaison with local clinical champions including troubleshooting , identifying and overcoming barriers and promoting the implementation pathway.

Clinical Audit Facilitator. Responsibility for the development and implementation of audit tools, data collection and the management of the online database. Liaison with local trust clinical and administration staff teams, education, troubleshooting and quality assurance, compliance with data collection requirements, monthly reporting to Trust management team.

General Manager: Responsibility for the local management of the overall project including the development of project plans, terms of reference, schedules of work, Responsible for ensuring a systematic approach to implementation is taken including the development of a robust business case, informatics support and the provision of adequate resources for sustainable implementation.

Clinical Champion: Responsible for leading clinical implementation, a number of core activities, including education, advocacy, relationship building and boundary spanning. The clinical champion role is a concept that has been widely promoted yet empirically underdeveloped in the NHS. In this project the Clinical Champion was central to the success of implementation.

For further information on the role of clinical champions Click Here

Impact Evaluation

Methods and procedures of quantitative, qualitative and periodical measurement and evaluation of Doppler guided intraoperative fluid management were developed by the project teams from the three implementation sites. These were used in the determination of the impact of the intervention on patient outcomes and hospital productivity.

The metrics were applied across a range of specified surgical specialties that were subject to assessment and audit and where training had been undertaken and competency assessed. This was to ensure that data integrity was always assured, thereby reducing the risk that the metrics may be tampered or modified when used for a different process.

The metrics themselves were developed by multidisciplinary teams from all 3 project sites who identified appropriate evidence based measurement and evaluation techniques.

These metrics formed the basis for the development of a secure online database consisting of 3 data collection forms in order to collect all the necessary data for comprehensive metrics analysis:

• Pre-operative morbidity assessment
• Intra-operative procedural audit
• Post operative morbidity assessment

These metrics were then organised and classified into specialty categories and the following performance aspects were measured during the project.

• Urgency of surgery
• Length of hospital stay
• Rates of readmission and reoperation
• Use of invasive monitoring techniques
• Post -operative morbidity and mortality
• Admissions and length of stay in critical care

These evaluation measures and values were subjected to independent statistical analysis undertaken by York Health Economics Consortium at York University.

Click here to access the project summary data

Measurements of Success

The primary task of this project is to improve patient outcomes following major surgery.

A fundamental goal within this was to measure the impact of this technique and identify the potential benefits, costs and practical issues associated with the routine implementation of Doppler guided intraoperative fluid management.

We undertook the following measurements to assess patient outcomes and impact on productivity and the use of resources so that we could provide relevant information to help providers and commissioners make informed choices about how the adoption of this technique could make a positive difference to NHS performance and the well being of patients.

• Post operative morbidity and mortality
• Admission rates to critical care
• Length of critical care and overall hospital stay
• Readmission and reoperation rates
• The use of central venous monitoring catheters (CVC)
• Critical Care length of stay

Click here to access the implementation project summary data

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