Abigail Whiteman
Abigail is a consultant in anaesthesia at University College Hospital, London and an honorary associate professor at UCL. Her main specialist interests are perioperative medicine and medical education
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Abigail Whiteman replied to John Orton
Fantastic summary @JohnOrton
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Thank you Daiva: I agree a protocol often wouldn't fit this patient group. But what about a pathway ensuring that there was a more holistic view of these patients: assessing for multimorbidity, frailty and POCD and providing MDT care? We will look at just this in a few steps time.
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There is no clear or single intervention proven to modify the syndrome of frailty or to impact on postoperative outcomes in frail individuals. However, improving outcome in high-risk patients is likely to depend on earlier recognition of the high-risk frail individual, followed by risk stratification and optimisation, with the aim of modifying the degree of...
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Sounds like a review of process is definitely needed! I agree that POM is all about care co-ordination and attention to detail. Can make sure a difference to a patient's outcome.
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Abigail Whiteman replied to William Thompson
I agree @WilliamThompson. Close liaison with the GP or family doctor is so important so that chronic conditions identified at PAC can continue to be monitored and optimised. What makes you fitter for surgery makes you fitter overall!
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Thank you @EwanRoss. I agree it is not widely known about or discussed with patients pre-operatively. Raising awareness amongst the whole MDT is key as it's prevention and management requires an MDT approach.
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Abigail Whiteman made a comment
So pleased to see so many learners staying with us through to the last week. This week is my favourite: the unique perioperative problems of the elderly, POCD, frailty and a brief look at how COVID has changed perioperative care. Do let us know your thoughts on these.
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Frailty is indeed an independent risk factor for a poorer outcome. We will be covering this in much more detail next week- stay with us for that.
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Thank you Elizabeth. The concept that the operation is only the start of the journey is one we don't yet teach well pre-operatively. I agree that psychological support in recovery would be immensely valuable.
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Abigail Whiteman replied to Guy Titley
But it's one that's easy to remember and patients can engage with- teaching them to dream!
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Abigail Whiteman made a comment
Thank you for all your positive comments about the app. Finding easy ways of data collection is so important if we are to prove benefit and implement positive change.
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Abigail Whiteman replied to Charlotte C
@CharlotteC - that's an interesting outcome. Is that still the case? Is the ER programme still running? Has benefit been proven?
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Abigail Whiteman made a comment
The common themes in this thread and the poll results show that most of you are very positive about protocols:
-they aid juniors in making decision
-they ensure a basic standard of care for all patients
-they assist in quality assurance and education for the whole MDT.
I agree with all these points. Reducing variation improves care. However, I also...
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I agree @GrahamHastie- any systems change needs strong leadership to implement and sustain.
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The PREVENTT trial did prove that IV iron was very safe: we will learn more about that in the next few steps. The risk of anaphylaxis/severe hypersensitivity reaction is thought to be less than 1 in 250 000.
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I agree Guy. I think the benefit (both patient and cost) probably needs to proven incontrovertibly before it could happen on a national level. In the meantime we need to give teams the resources to do this. CPOC have also recently updated their guidance and is a helpful...
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Delighted to have orthopods on the course! Hopefully you will find the learning in week 3 about protocolising the management of patients with hip fractures of particular interest.
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Abigail Whiteman replied to Charlotte C
I agree: it is something we as clinicians need to learn to do well. We often haven't been taught the skills to properly involve patients in their own decisions. You might find the shared decision aids in the next step useful!
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Omar- I completely agree about health literacy and empowering those with lower health literacy. Alongside that, we as clinicians need to learn to tailor the information we give to make it appropriate for each individual patient and their families.
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Abigail Whiteman replied to Abigail Whiteman
Hello Helen,
I am sure if you got in touch with the POPS team administrator she would pass on your message to the appropriate person. There are contact details on their website: https://www.guysandstthomas.nhs.uk/our-services/ageing-and-health/specialties/pops/overview.aspx
Good luck with it all- a fantastic thing to undertake! -
Thank you very much for sharing how the three delays are very real.
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I completely agree Christopher: we go onto discuss the role of risk assessment tools next week and this is a very important function of them.
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Abigail Whiteman replied to Siaelda Green
Thank you @SiaeldaGreen. I completely agree that a holisic patient view and an MDT approach is the way forward.
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@Christopherparnell I agree- I think it is a really important practice. We will cover this more next week.
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Agree, a much more costly reactive approach.
A proactive patient centred approach with elective admission to a PACU, and subsequently avoiding complications, would improve outcomes and be considerably more cost effective! -
Great to see more surgeons on the course: please do spread the word to your collagues! @AmiraShamsiddinova I completely agree that a joint model of care would be the best way forward. The POPs model (https://www.futurelearn.com/courses/perioperative-medicine/9/steps/1072925) is an example of where this works extremely well.
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Thank you @ChristianaTamakloe. Really interesting to hear about the surgical pathway in Ghana. Do you feel this set up works well for complex patients?
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Abigail Whiteman made a comment
I have been reading through these comments with great interest: already on only the second day of the course Mary's case has generated a lot of discussion and debate.
I agree with you all: there were many ways in which Mary's perioperative care could have and should have been better.
As we will explore in the next couple of steps, avoidable...
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This is a lovely definition Jessica.
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Abigail Whiteman made a comment
Really delighted to see so much discussion already. I know this is self selecting group but it is great that so many participants are already so positive about the benefits of POM for patients. We hope to persuade you over the next few weeks that it is not only beneficial for patients but also the most cost effective way to provide health care.
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Abigail Whiteman made a comment
Thank you all for your very kind comments: we are delighted that you have found the course useful and hope it will inspire some change in clinical practice. Please do spread the word about the course as, COVID allowing, we hope to run it again in early 2021.
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Thank you @FionaHansell - a really great post.
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@TanyaJones I completely agree. In my trust, anaesthetist presence in the MDT is gradually increasing. This must be of benefit to the patient.
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That's great to hear @VictoriaWhite. If overall, it reduces post operative morbidity, it would be a worthy investment!
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However, the poll results are not as skewed as I would have expected!
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Abigail Whiteman replied to C Soo
@CSoo Yes, there were fewer readmissions in the IV iron group. BUT this was a secondary outcome and the study wasn't powered for this. It's a positive signal but has to be treated with caution.
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Thank you- well spotted! I'll change it now.
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Thank you @ThomasGeorgiou. That may change if your hospital chases the best practice tariff. At UCH we attend for all laparotomies with a predicted mortality >5% and this is rigidly adhered to.
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@EmmaPickavance I completely agree.
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Abigail Whiteman replied to Eva Watson
Thank you @EvaWatson. Sounds like you have a very good set up at your hospital.
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I certainly hope that is not the answer! Maybe we need to tailor our pre-op management a bit more: large doses of IV iron, epo, folate...
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Indeed, intra or post op infusions would mean a significabnt reduction in infrastructure and cost.
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Abigail Whiteman made a comment
Delighted to see so much discussion about the results of the PREVENTT trial. I think the positive results of the trial (46% reduction in readmission to hospital) do have to be treated with caution: this was a secondary outcome and trial was not powered to detect a difference here. However it is a signal that it might have benefit: more work in this area...
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Thank you! I will take this back to Danny and allow him to answer.
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Thank you @SM. Can I just check what you meant by your first comment? Have we made an error with the editing? Many thanks.
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Thank you @ShambhuAcharya. I think it is so important that this vital step of diagnosing the cause of perioperative anaemia is not missed even if we are able to effectively treat and manage the anaemia pre-operatively.
