To TRACE or not to TRACE

To TRACE or not to TRACE

  • Issue 71

Christa Boer
c.boer@vumc.nl

Prevention of postoperative complications

Although mortality rates associated with anaesthesia and surgery are relatively low in Western society, a substantial number of patients still face complications and delayed recovery in the postoperative phase. In particular, the literature reports postoperative complication rates up to 50%, which are associated with extended length of hospital stay and an increased mortality risk. A presumed cause of these high complications rates is the absence of a structured organisation of the postoperative period. Consequently, apparently irrelevant alterations in vital parameters may develop into severe complications.

In a pilot study at the surgical ward, we recently showed that early deteriorations of postoperative vital signs as measured by remote monitoring are associated with an increased risk of postoperative pulmonary complications. Although the literature on this topic is limited, there is increasing evidence that improving the diagnostic and therapeutic structure work-up in the postoperative period might decrease the number of postoperative complications, and may lead to a reduction in failure-to-rescue rates following surgery. It is, however, still unknown whether interventions targeting these trivial health changes will contribute to improved postoperative outcome. In the Routine posTsuRgical Anesthesia visit to improve patient outcome (TRACE) study we therefore aim to investigate whether a standardised visit of an anaesthetist in the postoperative period may lead to early recognition and treatment of health condition abnormalities, and whether early interventions contribute to a reduction in complications and failure-to-rescue rates.

The TRACE study design

The TRACE study, a Dutch collaborative initiative led by Prof Dr Wolfgang Buhre, Prof Dr Christa Boer, and Prof Dr Dr Markus Hollmann, is financially supported by the Netherlands Organisation for Health Research and Development, the ESA Air Liquide Healthcare Grant on Patient Safety, and Zorgverzekeraars Nederland. The study is performed in eight Dutch university and top-referent peripheral hospitals and aims to include 5600 patients. Eligible patients have an indication for a postoperative hospital stay and are 65 years or older, or younger than 65 years with an indication for follow-up by an acute pain service and/or with cardiovascular comorbidities and/or a low surgical APGAR. Based on a stepped-wedge design, the study starts with a control period, followed by an intervention period. During the control period, a local investigator visits patients on the first and third postoperative days in order to measure the modified early warning score (MEWS). Patients are subsequently followed for one year in order to assess complication and mortality rates, the budget impact of complications, and failure-to-rescue, and the cost-effectiveness of the intervention.

During the intervention period, an anaesthetist additionally visits the patient on the first and third postoperative days. The anaesthetist initiates interventions in collaboration with the ward physician and nurses when health deterioration is diagnosed. Among others, these interventions include changes in postoperative pain treatment strategies, adjustment of the fluid status, changes in the medication regimen, or the initiation of a diagnostic work-up for complications such as pneumonia.

Study in progress

The TRACE study started 1 November 2016, and in February 2017 we included our 2000th patient. The VU University Medical Centre in Amsterdam was the first of the eight participating centres that started the intervention period. For a smooth implementation of the anaesthesia visit we established a close collaboration with the ward physicians, as they will most likely implement and monitor the advice of the anaesthetist.

A routine postoperative visit by an anaesthetist is associated with an increased workload, and some of our colleagues believe that the postoperative follow-up of patients should be a task and responsibility of the surgeon and ward physician. However, it is our perception that the TRACE intervention fulfils an unmet need. The TRACE intervention particularly aims at the grey area between an uncomplicated postoperative course and a progressive complicated course that requires the involvement of an emergency response team. From the TRACE intervention period we have now experienced that this grey area indeed exists, and patients in this area are at risk to ‘fall between two stools’. Overall, we believe that the TRACE intervention will support a focus shift from intraoperative care towards perioperative medicine and will lead to better training of attending ward physicians. Moreover, the complimentary knowledge and skills of an anaesthetist will improve the quality of postoperative care and patient recovery, and hopefully result in a reduction in the complication rates following surgical procedures.