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.
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.
- 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.
- Report of 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.
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.
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.
- 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.