BULLETIN

Recommendations

Info

Page 46 | Bulletin 93 | September 2015 In order to establish anaesthetists’ existing knowledge of legislation relating Figure 1 Example of a poster used to highlight the dangers of drug driving (iii) The surgery itself does not prevent driving e.g. inguinal to drug-driving, we distributed a short hernia repair. online questionnaire to anaesthetists of all grades in the East of England School of Anaesthesia in January 2015. A total of 116 anaesthetists completed the survey, including 61 Consultants, and 59% of the respondents stated that they frequently discharged patients from day-surgery units or pain clinics on opioid or benzodiazepine medications. 44% of those responding were aware of impending legislation relating to driving whilst taking medications such as opioids or benzodiazepines. Despite this awareness, and despite a large number of patients being discharged with such medications, only 36% of respondents reported routinely advising patients of the dangers of driving whilst taking opioids or benzodiazepines. Furthermore, only 25% were aware that their patients received any written information regarding postoperative analgesia (including opioids). Provision of written information regarding postoperative analgesia is a standard of the guide for provision of anaesthetic services (GPAS) published by the College. 9 It is also one of the standards that departments need to meet if they wish to achieve accreditation with the coveted Anaesthesia Clinical Services Accreditation (ACSA) scheme. 10 Whilst it is legally the responsibility of the patient not to drug-drive, the medical community must take some responsibility to ensure that patients know the legal and sedative consequences of taking these drugs. We therefore advocate a six-pronged approach to help ensure that our patients are made aware of the new legislation: ■■ Publication of articles (such as this) in the anaesthetic literature to help ensure that all anaesthetists are aware of the new legislation, so patients can be appropriately advised. ■■ Anaesthetic departments should ensure that the literature relating to postoperative analgesia is ■■ ■■ distributed to every patient pre-operatively (under GPAS recommendations) and that information about the new drug driving law is contained within it. The Royal College of Anaesthetists, in collaboration with the Association of Anaesthetists of Great Britain and Ireland (AAGBI), should consider creating a specific patient information leaflet about drug-driving. This would ensure widespread consistency, and prevent replication of work by all anaesthetic departments. The College needs to update its frequently asked questions web page 1 , which states that patients should refrain from driving for 24 hours following general anaesthesia. The modification should include: (i) The patient should ideally only recommence driving once they are no longer taking opioid containing medication. (ii) If the patient wishes to drive before stopping the opioid or benzodiazepin-based medications, the patient must be confident that their driving skills are not impaired by that medication. ■■ As it is more difficult to wean off compound opioid preparations, hospitals and day surgery units should consider discharging patients on individual analgesics, e.g. paracetamol and codeine, or paracetamol and oramorph, rather than compound preparations such as co-codamol or co-dydramol. This is because it is possible for the patient to stop the opioid earlier, and continue to take the paracetamol. They can therefore resume driving more safely (provided there is no ongoing surgical issue). ■■ Strategically positioning posters (such as Figure 1) in the hospital, to reinforce to patients the dangers and legal consequences of drug-driving. References 1 Common Concerns and FAQs. RCoA (www.rcoa.ac.uk/node/2229) (accessed 25 April 2015). 2 FAQs. Direct Line. (http://bit.ly/1KRrG3t) (accessed 25 April 2015). 3 Convalescence After Major Surgery. Aviva. http://bit.ly/1LUaeue (accessed 25 April 2015). 4 M Herbert et al, Profile of recovery after general anaesthesia. BMJ 1983;286:1539. 5 Drug Driving. UK Government. 2013 (http://bit.ly/1kszpc8 (accessed 25 April 2015). 6 Gourlay GK, Willis RJ and Lamberty J. A double-blind comparison of the efficacy of methadone and morphine in postoperative pain control. Anesthesiology 1986;64(3):322-327. 7 Driving Under the influence of drugs - Report from the expert panel on Drug Driving. March 2013 http://bit.ly/1KXOixN (accessed 25 April 2015). 8 Brake, the road safety charity. Response to ‘Driving Under the influence of drugs - Report from the expert panel on Drug Driving’. http://bit.ly/1HQtNlx (accessed 25 April 2015). 9 Guidelines for the provision of anaesthesia services for pre-operative assessment and preparation 2014. RCoA www.rcoa.ac.uk/ node/14666/ (accessed 25 April 2015). 10 Anaesthesia Clinical Services Accreditation standards 2015. RCoA http://www.rcoa.ac.uk/acsa (accessed 25 April 2015).
Page 47 | Bulletin 93 | September 2015 Development of the NHS preoperative testchecher app How do you decide which blood tests your patient should have before an operation? How often are these tests abnormal? And if the results are abnormal, what do you do differently? Matthew Taylor ST4 in Anaesthetics and Intensive Care Medicine Wessex Deanery Helen Bingham Library and E-Learning Resources Manager, Health Education Wessex Christian Schopflin ST5 Anaesthetics, Wessex Deanery Asymptomatic patients presenting for elective surgery do not usually have abnormal blood tests. Anaemia is present in 5%, although usually mild. Thrombocytopaenia, electrolyte abnormalities and creatinine elevation are all rare. Coagulation screen anomalies are more common but only change management in 0.8%, cases whilst ECG abnormalities change management in 0-2.2% cases. 1 There is a common theme: asymptomatic patients occasionally have abnormal tests which rarely change management. In 2003, NICE attempted to rationalise the tests we request pre-operatively in asymptomatic elective surgical patients. 2 Now, a little over a decade after the publication of this guidance we have evaluated whether it is followed in our region, how many patients receive ‘unnecessary’ tests, and how much this costs. In the light of the results, we have developed an app and website decision support tool based on the NICE guidelines to help our local hospitals and those further afield to better select preoperative tests. This article details the results of this evaluation and the process of developing a computerised decision support tool. Evaluation of practice A one week ‘snap shot’ of patients (n=1310) presenting for elective surgery under general anaesthetic across seven local hospitals in our region were included in the evaluation. Those undergoing cardiothoracic surgery, neurosurgery, obstetric procedures, and those under 16 years of age were excluded. Notes were assessed retrospectively for ASA grade, operation performed and comorbidity. Blood tests performed specifically for the purpose of pre-operative assessment were recorded. Tests were only considered unnecessary if they were not indicated by NICE guidance (green or amber colour codes) and additionally there was no clinical indication apparent from the history, examination and operation planned. Thirty seven percent of their blood tests performed preoperatively were considered unnecessary by NICE guidance (colour coded red) and had no other clinical indication (0.63 unnecessary tests per patient). Using the ‘mid’ cost from the guidance supplemented by cost estimates from our local health authority (FBC £2.35, U+E £3.40, Coag £3.65, LFT £3.20, Bone profile £4.10, ESR £2.30, CRP £2.30) we estimate the cost of this unnecessary testing to be approximately £136,000 per annum across just these seven hospitals (£2.07 per case). The reasons for this departure from the clinical guidance are not always clear, but common themes were acuity within the pre-assessment areas making it difficult to spend time going through the NICE guidance, and a perception that doing more rather than less was a safer option when it came to preoperative testing. Knowledge surrounding the subject was generally good. Development of a computerised decision support tool Our initial solution focused on raising awareness of the issue using posters and small group sessions. These interventions were attractive for their low expense and relative simplicity, however they were largely ineffective. The teaching quickly appeared to become diluted within the busy preassessment clinic such that within a month there was barely any demonstrable effect. We then took a step back and actually thought through the process that staff go through when organising tests. This was a key moment in the development of a robust solution to this problem as it quickly became clear that the issue was not awareness of the problem, but rather that the process of reading and following the NICE recommendations was complicated and time consuming. The solution needed to make the process simpler, more efficient and more accurate. This was
Page 1 and 2: ROYAL COLLEGE OF ANAESTHETISTS ACCR
Page 3 and 4: Page 3 | Bulletin 93 | September 20
Page 19 and 20: ROYAL COLLEGE OF ANAESTHETISTS Page
Page 45: Page 45 | Bulletin 93 | September 2

BULLETIN

Create successful ePaper yourself

Delete template?

Save as template?