Case Studies: After Surgery
Appropriate prescribing after surgery
At the West Suffolk Hospital the acute pain team appreciates the medical and social harm from prolonged use of post-operative analgesics. We are also aware of the dangers of drug driving. Furthermore, we recognise that compound preparations of analgesics hinder weaning off the analgesic medication. In addition, it is recognised that the paracetamol containing compound preparations have the intrinsic risk of inadvertent paracetamol overdose. In an effort to mitigate these risks and promote deprescribing the anaesthetic team has instigated the following strategies:
- Compound analgesics have been removed from Day Surgery.
- All surgical patients are given verbal and written instructions to aid post –operative deprescribing and are warned of the dangers of drug driving.
- All surgical patients are informed that it is expected that all new analgesics should be stopped within 2 weeks of surgery
- All patients newly prescribed oxycodone are warned about the addictiveness of the agent, and the need to consciously wean themselves off it.
- Minimal use of compound analgesic both in hospital and on discharge.
- The use of new in patient prescriptions of modified release oxycodone is heavily scrutinised by the surgical ward pharmacists, as it so difficult to wean off. Patients are given written guidance on weaning and the need to see their GP if further assistance is required
- Communication is on-going with the local Clinical Commissioning Group to promote deprescribing of chronic pain patients, who have had corrective surgery.
Step Down Unit (SDU)
The Royal Derby Hospital is a large University/District General Hospital with approximately 1200 beds.
This unit provides for patients with significant co-morbidities undergoing major surgery or any patient undergoing very complex surgical procedures, and who do not require the highest level of critical care post operatively. The provision of an extended period of perioperative critical care, more frequent nursing observations, timely delivery of analgesia, accurate fluid management and access to medical staff, particularly out of hours, is likely to lead to a reduction in complications. This complements the highest level critical care delivered by the intensive care/high dependency unit which often has demand that exceeds availability.
The 16 bed Royal Derby Hospital SDU admits surgical patients requiring perioperative level 1 and certain aspects of level 2 care, with the facility to de-escalate patients to 4 ICS level 0 beds co-located within the same ward space.
The SDU is also used as a transitional step when patients are discharged from the Intensive Care Unit (ICU/HDU) but have complex care needs, allowing for a further transitional step in care before transfer to general surgical ward. It has close proximity to ICU and theatre suites allowing for easy availability of more senior critical care advice and referral to senior clinicians, particularly out of hours.
In summary the Step Down Unit complements the availability of ICU/HDU beds, allowing ready access to an intermediate level of critical care with an extended period of closer observation and medical management than may be offered on a general surgical ward.
Multidisciplinary rapid access pain clinics involving members of the perioperative medicine team are a developing area of care. They may significantly reduce the number of patients with poor outcomes and chronic pain after surgery. Once such clinic can be found at the James Cook University Hospital, South Tees Hospitals NHS Foundation Trust.
The acute pain team, comprised of a group of advanced nurse practitioners working with a pain consultant lead, have developed a robust pathway following up and troubleshooting epidural or spinal analgesia patients post-operatively to improve efficacy of analgesia, safety and support surgical nurses in patients’ care.
Acute Kidney Injury (AKI) Follow-up Clinic
From early 2015, patients with acute kidney injury will be screened over the months after surgery for chronic kidney disease, in a follow-up clinic led by the departments of critical care, nephrology and biochemistry. Existing management strategies will be employed to reduce its progression in affected patients.
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