Thread by @GongGasGirl

I’m here in Terrigal at the NSW ACE Spring meeting.

Co-convenor legends Dr Frances Page and Dr Douglas Gray poised and ready to open the meeting while everyone gets caffeinated!

I mean, the venue is pretty awful.

First up @mike_grocott who is HERE!!

His enormous CV includes being a junior Dr with Dr Page at Middlesex! (Nothing dodgy apparently! …. 😉

#NSWACE22

Shout out to perioperative work of @RossKerridge1 who is sitting next to me!

MG notes the remarkable improvement in the peri-operative journey with multi-disciplinary teams over the last 20 years - enhanced recovery a remarkable thing, decreased length of stay, improved outcomes (esp for a specialty focussed on safety).

MG notes in the UK - every over 50 talking about retirement, under 50's talking about part time work. Says everyone is knackered. They are not the happy people they were 3 years ago. Covid-19 has knocked people about.

The pandemic however, has taught us incredible lessons around how quickly we changed healthcare delivery during the pandemic.

We can change if we want to.

#NSWACE22

Solutions:

Rethinking healthcare delivery - who, what, where, how?
Re-designing pathways - patient focussed, not provider centred.

#NSWACE22

MG says in every threat comes an opportunity.

How can we harness the current issues to engage in healthcare redesign?

Perioperative death is the third highest cause of death.
It's a public health issue.

#NSWACE22

#NSWACE22

We are getting older.

When the Queen was born, her life expectancy was 62years.

During her lifetime life expectancy increased linearly by 2.5 days each week (!).

We are living older however, we are collecting morbidity.

#NSWACE22

Innovation is great, but an enormous increase in cost.

#NSWACE22

If the cost increase continues, US will spend all of their GDP on healthcare …. #NSWACE22.

Alternative pathways.. CRNA’s…. Robots delivering anaesthesia….

#NSWACE22

In Victoria this week, a $66 million proposal to improve efficiency of healthcare delivery ….

…. This proof of concept study showed cardiac anaesthesia could successfully be delivered by robots. #NSWACE22

If you have a post-op complication, you are more likely to die prematurely. Also very $$. A small number of patients, contribute a large proportion of costs. Most patients have no issues, however a few have major issues. How can we stratify to decrease suffering? #NSWACE22

Excellent point about our tendency as clinicians to blame managers when it comes to cost-effectiveness. Just because something is more expensive, doesn't mean it is better. If we spend more in one place, less money to spend elsewhere.

#NSWACE22

But what is PERI-OPERATIVE MEDICINE?

'from the moment of contemplation of surgery until fully recovered'

Patient centred.
Multidisciplinary.
Integrated care.

#NSWACE22

Notes how silo'd we are.
We need to focus on the patient pathway.

#NSWACE22

Five simple assumptions:

1. I am a partner in my own care.

therefore:

2. Right decision
3. Well prepare
4. Properly cared for
5. Fully recover (back to how I was before)

#NSWACE22

Collaborative decision making

'no decision about me without me'

However, some patients want paternalism. Need to target to their needs.

#NSWACE22

'Unwarranted variation' in procedure rates - some operation rates are linked to number of providers in the area, not need.

#NSWACE22

Notes prehabilitation is a 'teachable moment'.

Patients like getting physiologically prepared for surgery.

Complications are reduced and recovery is improved.

Perhaps, will lead to long term behavioural change (with improved healthy behaviours).

#NSWACE22

Movement to risk-adapted post-operative care.

Not necessarily go to critical care based on the procedure, based on the overall perioperative risk. Perhaps send to ward with peri-operative care team visiting and enhanced monitoring?

#NSWACE22

Pathway re-engineering is essential to improve peri-operative care.

Agree the pre-assessment visit as usually practised is pretty much useless.

This will go badly, but we won't de-list and there's nothing we are going to do to decrease risk.

#NSWACE22

What about training?

Junior drs industrial action, plenty of distress. But what should it look like?

#NSWACE22

UK anaesthesia training. #NSWACE22

Less than full time training is huge in UK.

As an example, in one area of UK not a single ICU trainee working full time.

Despite hearing heaps about this via my Twitter mates here, I’m shocked LTFT so common.

#NSWACE22

What is perioperative medicine training like in the UK?

MG says large variation across UK. Some places have very meaningful high quality training, others more a tick box exercise.

#NSWACE22

Who should do PoM?

Contentious.

Which specialists? Which teams? Do we feel threatened?

#NSWACE22

Lovely talk thank you @mike_grocott.

Loads for us to grapple with as we brace for launch of the PoM diploma.

#NSWACE22

https://twitter.com/yusuke_mazda/status/1591226094967197697?s=20&t=hIMZ1MjTOBkIrGDg8U-ivQ