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      Enhanced peri-operative care to improve outcomes for high-risk surgical patients in Brazil: a single-centre before-and-after cohort study.

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          Abstract

          Mortality and morbidity for high-risk surgical patients are often high, especially in low-resource settings. Enhanced peri-operative care has the potential to reduce preventable deaths but must be designed to meet local needs. This before-and-after cohort study aimed to assess the effectiveness of a postoperative 48-hour enhanced care pathway for high-risk surgical patients ('high-risk surgical bundle') who did not meet the criteria for elective admission to intensive care. The pathway comprised of six elements: risk identification and communication; adoption of a high-risk post-anaesthesia care unit discharge checklist; prompt nursing admission to ward; intensification of vital signs monitoring; troponin measurement; and prompt access to medical support if required. The primary outcome was in-hospital mortality. Data describing 1189 patients from two groups, before and after implementation of the pathway, were compared. The usual care group comprised a retrospective cohort of high-risk surgical patients between September 2015 and December 2016. The intervention group prospectively included high-risk surgical patients from February 2019 to March 2020. Unadjusted mortality rate was 10.5% (78/746) for the usual care and 6.3% (28/443) for the intervention group. After adjustment, the intervention effect remained significant (RR 0.46 (95%CI 0.30-0.72). The high-risk surgical bundle group received more rapid response team calls (24% vs. 12.6%; RR 0.63 [95%CI 0.49-0.80]) and surgical re-interventions (18.9 vs. 7.5%; RR 0.41 [95%CI 0.30-0.59]). These data suggest that a clinical pathway based on enhanced surveillance for high-risk surgical patients in a resource-constrained setting could reduce in-hospital mortality.

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          Author and article information

          Journal
          Anaesthesia
          Anaesthesia
          Wiley
          1365-2044
          0003-2409
          April 2022
          : 77
          : 4
          Affiliations
          [1 ] Graduate Program in Medical Sciences, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.
          [2 ] School of Medicine, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Brazil.
          [3 ] School of Medicine, Department of Surgery, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.
          [4 ] Department of Surgery, Anaesthesia and Peri-operative Medicine Service, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil.
          [5 ] Department of Statistics, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.
          [6 ] Pain and Palliative Care Service, Laboratory of Pain and Neuromodulation, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil.
          [7 ] William Harvey Research Institute, Queen Mary University of London, London, UK.
          [8 ] Department of Surgery, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.
          Article
          10.1111/anae.15671
          35167136
          215a418a-2a9f-4215-8bc2-9af73736ceb2
          History

          high-risk surgical patient,failure-to-rescue,outcome assessment,patient care team,postoperative care

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