Australian and New Zealand College of Anaesthetists
The Australian and New Zealand College of Anaesthetists (ANZCA) ), including the Faculty of Pain Medicine, is one of Australasia's largest specialist medical colleges and is responsible for the training, examination and specialist accreditation of anaesthetists and pain medicine specialists and for the standards of clinical practice.
5.
Avoid initiating anaesthesia for patients with significant co-morbidities without adequate, timely preoperative assessment and postoperative facilities to meet their needs.
The ability to provide adequate perioperative care for patients with significant co-morbidities including morbid obesity is a crucial factor in determining whether surgery should be performed in a particular facility. The complexity of the proposed surgery should also be considered. Adequate and timely preoperative assessment must be facilitated to ensure that scheduling of a procedure is appropriate for the facility. In particular, small private hospitals which have no on-site medical practitioners overnight and no intensive care backup must have robust pre-admission processes in which higher risk patients are screened to ensure that they are not accepted for overnight admission unless they have been assessed as suitable for that facility by an anaesthetist or medical specialist.
Intraoperative staffing, equipment and infrastructure are crucial. Postoperatively, staffing ratios and skill sets, requirements for monitoring, medical support and high dependency unit care, as well as optimal pain management, must be considered.
Patients with obstructive sleep apnoea (OSA) and obese patients who may or may not have a formal diagnosis of OSA and/or obesity hypoventilation syndrome represent a particularly high risk group when pain management includes opioid analgesics. The inherent risks of postoperative respiratory depression demand adequate post procedure monitoring by skilled staff.
In summary, the patient and the proposed surgery must be appropriate for the facility. Importantly, patients in rural and remote locations may accept higher risk to be closer to home and a discussion may be required with the patient and treating physicians about whether performing a procedure at a local facility is an acceptable risk.
Supporting evidence
- Coroner’s Court of South Australia. Finding of Inquest. Adelaide 2014. From: http://www.courts.sa.gov.au/CoronersFindings/Lists/Coroners%20Findings/Attachments/581/RYAN%20John%20William%20and%20WALTON%20Patricia%20Dawn.pdf.
- McNicol, L (ed). Safety of anaesthesia: a review of anaesthesia-related mortality reporting in Australia and New Zealand 2009-2011. Melbourne: Australian and New Zealand College of Anaesthetists, 2014 From: http://www.anzca.edu.au/documes/soa-mortality-report_p4.pdf
- Kaw R, Chung F, Pasupuleti V, et al. Meta-analysis of the association between obstructive sleep apnoea and postoperative outcome. Br J Anaesth 2012;109(6):897-906.
- ANZCA Professional Document PS07 Guidelines on Pre-Anaesthesia Consultation and Patient Preparation. From: http://www.anzca.edu.au/getattachment/resources/professional-documents/ps07bpguidelines_pre-anaesthesia_consultation_patient_preparation.pdf.
- Goodmedical practice: a code of conduct for doctors in Australia. Medical Board of Australia 2014. From: http://www.medicalboard.gov.au/Codes-Guidelines-Policies/Code-of-conduct.aspx.
- Reportof the Review of Hospital Safety and Quality Assurance in Victoria. Targeting zero. Supporting the Victorian hospital system to eliminate avoidable harm and strengthen quality of care. Victorian Government 2016. From: https://www2.health.vic.gov.au/hospitals-and-health-services/quality-safety-service/hospital-safety-and-quality-review.
How this list was made
ANZCA’s Safety and Quality Committee established a working group that developed a preliminary list of 10 anaesthetic-related practices that, based on clinical evidence, may have possible limited benefit, no benefit or may potentially cause harm to patients. Using an on-line survey tool, all ANZCA Fellows and trainees were invited to rank these recommendations and provide relevant comments. This engagement facilitated consensus and informed Fellows and trainees about ANZCA’s involvement with the Choosing Wisely campaign.
Recommendation 1-5
ANZCA’s final list of 5 Choosing Wisely recommendations deliberately supports the clinician’s judgements and emphasises the importance of considering patient and surgical factors in decision making; in particular, as regards the selection of necessary preoperative testing and appropriate facilities for all patients and the expected outcomes and goals of care for the medically frail.
Recommendation 6
The ANZCA Safety and Quality Committee proposed that the college submit a statement to Choosing Wisely Australia as part of analgesic stewardship.
The committee agreed that the existing document development group (DDG) for ANZCA and FPM professional document PS41(G) Position statement on acute pain management would be well-placed to develop the Choosing Wisely recommendation. It was also agreed that an expert group should be formed comprising members with expertise in obstetric anaesthesia, paediatric anaesthesia, and paediatric pain medicine, to provide input to the Choosing Wisely recommendation.
The draft document was circulated for consultation in February 2022 with the following stakeholders: ANZCA national/regional committees, NZ national committee, FPM committees, Australian Society of Anaesthetists (ASA), New Zealand Society of Anaesthetists (NZSA), ANZCA Special Interest Groups (SIG) including Obstetric SIG and Acute Pain SIG, and Society for Paediatric Anaesthesia in New Zealand and Australia (SPANZA). The one-month consultation period finished in March 2022. After consideration of the feedback received during this period, the DDG made further amendments to the CW recommendation. The ANZCA Safety and Quality Committee approved the post consultation version and sent to Choosing Wisely for consideration by the Representative Panel. Feedback obtained from that consultation was then collated and discussed at the Board meeting before some minor amendments were made to clarify the explanation section of the recommendation.Download ANZCA Recommendations
Related recommendations
- 1 Avoid routinely performing preoperative blood investigations, chest X-ray or spirometry prior to surgery, but instead order in response to patient factors, symptoms and signs, disease, or planned surgery.
- 2 Avoid ordering cardiac stress testing for asymptomatic patients prior to undergoing low to intermediate risk non-cardiac surgery.
- 3 Avoid administering packed red blood cells (blood transfusion) to a young healthy patient with a haemoglobin of ≥70g/L who does not have on-going blood loss, unless the patient is symptomatic or haemodynamically unstable.
- 4 Avoid initiating anaesthesia for patients with limited life expectancy, at high risk of death or severely impaired functional recovery, without discussing expected outcomes and goals of care.
- 5 Avoid initiating anaesthesia for patients with significant co-morbidities without adequate, timely preoperative assessment and postoperative facilities to meet their needs.
- 6 Avoid routine prescription of slow-release opioids in the management of acute pain unless there is a demonstrated need, close monitoring is available and a cessation plan is in place