Due to the burning issue of significant mortality and morbidity following high-risk surgery in Europe, the Improving Patient Outcomes (ImPrOve) think tank outlines the necessary measures to be implemented to ensure patient safety for European citizens.
We are all likely to be impacted by surgery in our lifetimes, but it is, fortunately, safer today than ever before. However, on closer inspection of death and injury rates, surgery is not without risks to patient safety. Data from Europe and across the world show in-hospital mortality rates after surgery are approximately 4%, with postoperative complication rates at 17%. 1,2
Most hospital deaths and complications occur in a sub-group of high-risk patients – the elderly, those with multiple comorbidities and those undergoing complex procedures.1,3 Of the patients who survive postoperative complications, many leave the hospital with worsened long-term survival and quality of life.1
This is not a small population of high-risk patients. Around 2.4 million undergo high-risk surgery in Europe every year, each at an elevated threat of harm.4 Clearly, postoperative complications are still a common and significant cause of preventable death and injury across Europe.
Tackling the issue head-on: the ImPrOve Think Tank
Throughout 2020 and 2021, a multidisciplinary, pan-European group of anaesthetists, surgeons and patient representatives, the Improving Patient Outcomes (ImPrOve) Think Tank, met with an urgent purpose. This endeavour was to highlight the specific dangers of high-risk surgery and identify solutions to reduce serious complication rates in the days and weeks following discharge.
An underappreciated yet dangerous perioperative complication
The period that patients spend in hospital, from their pre-op assessment, during their procedure and through to their recovery in the critical care unit, is known as the perioperative period. High-risk patients are at threat of various complications during this period and beyond, such as hypothermia, sepsis and blood clots. However, the ImPrOve Think Tank believe one of the most pressing and underserved complications to be haemodynamic instability, manifested as drops in blood pressure during surgery, also known as intraoperative hypotension (IOH).
Consequences of IOH during high-risk surgery
Adequate delivery and flow of blood are critical during anaesthesia to ensure that vital organs and tissue receive oxygen and nutrients and that waste products are removed.5 However, there are various mechanisms that can cause IOH whilst undergoing general anaesthesia, such as significant bleeding.6 In fact, a large systematic review found that up to 99% of patients can experience IOH during surgery under anaesthesia.7
But what does this mean for high-risk patients? There is now considerable evidence to show a strong association between periods of IOH and severe complications related to organ dysfunction after surgery.8 While IOH can damage any organ, the heart and kidneys are most affected.9 Patients who experience IOH during high-risk surgery are more likely to be re-hospitalised or have a more extended hospital stay. 10 As well as the burden this puts on individual patients, there is an additional financial and capacity impact on already strained critical care units.10
Every minute of IOH matters
IOH is a dangerous complication, and it only takes a minute of low blood pressure before a patient’s risk of serious injury increases.11 But, despite its severity, actions can be taken to lessen the risk of harm to a patient. Administering fluids and drugs in a protocolised manner, known as goal-directed haemodynamic therapy (GDHT), has been shown to reduce organ damage and death.12 Digital haemodynamic monitoring technology also plays a crucial role in GDHT by giving clinicians a visual interpretation of blood pressure. In recent years, newly developed advanced haemodynamic monitoring technology has even been able to predict IOH occurring.13
High-risk surgery patient’s outcomes are a pressing concern for European healthcare systems. Moreover, with Europe’s ageing population and a subsequent increase in the number and complexity of high-risk procedures, action is needed now to reduce the burden of IOH in the future. That is the ImPrOve Think Tank’s current goal, as is presented in their recent European report.
Improving patient safety: why perioperative care and effective monitoring matters
As part of the ImPrOve Think Tank’s commitment to improving patient safety, they authored a comprehensive report that underlined the issue of IOH and highlighted the barriers to its prevention and treatment. These barriers include:
- Changes in risk during the perioperative period
- Similar perioperative pathways for most patients, regardless of their risk profile
- Access and cost issues regarding the latest haemodynamic monitoring technology
- A lack of haemodynamic ‘champion’ clinicians to advocate and implement the latest innovation
- Low awareness of haemodynamic instability standards and little recognition of the dangers in European guidelines
- Patients being unaware of IOH and not pushing for the latest haemodynamic monitoring technology
Based on these hurdles and the need to enhance patient safety, the Think Tank provided six ‘ImPrOve points’ for already occurring practices to ensure that IOH is better understood, monitored and managed:
- Research and funding to better understand the cause and consequences of IOH
- Education on and awareness of IOH and its strong association with poor patient outcomes
- Communicating the risk of surgery to patients and informing them of any complications observed during their procedure
- Evaluating novel technologies and therapies to monitor, manage and mitigate IOH effectively
- Availability of appropriately staffed and equipped postoperative beds and long-term monitoring
- High-risk patient safety and outcomes in line with other established patient safety organisations and movements
The impact of IOH on a patient and societal level is clear. But, with effective management and monitoring, IOH-related complications can be averted, and patient safety and outcomes are significantly boosted. Therefore, the Think Tank defined clear calls-to-action for the three stakeholders who can make meaningful change to patient safety and outcomes – clinicians, policymakers and patients:
- Train – Ensure adherence to and implementation of new European guidelines on blood pressure during surgery by improving training for clinicians. (For clinicians)
- Invest – Secure new sources of funding for hospitals to invest in innovative digital monitoring technologies, such as advanced haemodynamic monitoring, to maintain stable blood pressure during surgery. (For policymakers)
- Support – Recognise in health data policies the value of patient safety data generated by innovative digital monitoring technologies. (For policymakers)
- Involve – Involve patients in a dialogue about the risks of IOH, so they are invested in the actions taken to ensure the best outcomes and safety before, during and after surgery. (For clinicians and patients)
The fundamental aim of these calls to action is to reduce the risk of IOH and improve patient safety and outcomes after high-risk surgery.
Bringing meaningful change to Europe
While it is vital that the IOH issue and solutions to address it are detailed in the report, this important topic must be brought directly to key healthcare stakeholders and policymakers to enable change across Europe.
On 28 September 2021, the ImPrOve Think Tank hosted a European webinar to launch the Improving Patient Safety report, with 80 multidisciplinary attendees from 23-countries. ImPrOve Chair, Professor Olivier Huet, Professor of Anaesthesia and Intensive Care Medicine, opened proceedings by highlighting the Think Tank’s aims of “improving perioperative outcomes of our patients, decreasing the number of complications, shortening hospital stays, avoiding rehospitalisation and optimising healthcare costs.”
The webinar was supported by two MEPs from Ireland, Ciarán Cuffe and Sean Kelly. Ciarán Cuffe, MEP, said: “At a time of major modernisation in healthcare, patient safety must remain at the centre of the discussion, and we as policymakers can ensure that changes move in the right direction.”
In addition to highlighting the need for healthcare innovation, the webinar also provided an opportunity to give more detail on IOH from the perspective of clinicians and patient advocates who face it daily. Professor Monty Mythen, Smiths Medical Professor of Anaesthesia and Critical Care, highlighted the reality of IOH in clinical practice today. Professor Mythen commented: “This issue of IOH should be right at the top of our agenda as we face the enormous backlog of elective surgeries due to the COVID-19 pandemic.”
Professor Michael Sander, Professor of Anaesthesia and Intensive Care Medicine, discussed the need for a better-designed patient pathway for high-risk patients; from the moment they first meet with their treating clinicians to discharge. He explained: “When selecting therapeutic support for high-risk patients, such as advanced haemodynamic monitoring, we should be holding discussions with our patients about the procedure, the possible risks, like IOH, and what actions we will take to mitigate these risks.”
An important quality of the ImPrOve Think Tank is its patient advocate membership. Luciana Valente, International Relations Manager at SIHA and member of the Think Tank, was clear that patients also play a key role in reducing the risk of IOH and improving their own safety and outcomes. She said: “Many patients assume safety during their procedure and are unaware of the risks of IOH. Making high-risk patients aware of this key concern means they can push for the best haemodynamic monitoring and perioperative management.”
Following an account of the report’s ImPrOve points and calls to action, Sean Kelly, MEP, concluded: “We must appreciate that EU member states are showing a great commitment towards healthcare investment, and we, as policymakers, can support clinicians and patients to secure funding opportunities to invest in new technologies which improve patient safety during surgery.’
The future of patient safety in Europe
The ImPrOve Think Tank’s mission does not end here. Real action is needed before patient safety improves across Europe. Much confidence can be taken from the current European engagement with the Think Tank’s report and webinar. However, it is vital that the concerning complications of surgery, like IOH, remain on the agenda in Europe, with appropriate investment and action taken to reduce their burden.
To download the full European report and find more details on the ImPrOve initiative, please visit https://improvethinktank.org/
This article is sponsored by Edwards Lifesciences, who also provided financial support to the ImPrOve Think Tank. The ImPrOve Think Tank’s discussions in the European Report and calls to action were undertaken independently of industry and the group is currently looking for additional sponsors to enable them to continue their vital work long-term.
- Pearse RM et al. Mortality after surgery in Europe: a 7-day cohort study. Lancet. 2021; Sep 22;380(9847):1059- 65.
- International Surgical Outcomes Study group. Global patient outcomes after elective surgery: prospective cohort study in 27 low-, middle- and high-income countries. Br J Anaesth. 2016; Oct 31;117(5):601-609.
- Norderud K et al. Validation of the European Society of Cardiology and European Society of Anaesthesiology non-cardiac surgery risk score in patients treated with coronary drug-eluting stent implantation. Eur Heart J Qual Care Clin Outcomes. 2019. Jan 1;5(1):22-27
- Preoperative Score to Predict Postoperative Mortality – POSPOM Edward’s Presentation
- BHF. How your heart works. 2021.
- Kouz K et al. Intraoperative hypotension: Pathophysiology, clinical relevance, and therapeutic approaches. Indian J Anaesth. 2020 Feb; 64(2): 90–96.
- Bijker JB et al. Incidence of Intraoperative Hypotension as a Function of the Chosen Definition. Anesthesiology. 2007; Aug;107(2):213-20.
- Wesselink EM et al. Intraoperative hypotension and the risk of postoperative adverse outcomes: a systematic review. Br J Anaesth. 2018 Oct;121(4):706-721.
- Walsh, M et al. Relationship between intraoperative mean arterial pressure and clinical outcomes after noncardiac surgery: toward an empirical definition of hypotension.
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- Michard F et al. Potential return on investment for implementation of perioperative goal-directed fluid therapy in major surgery: a nationwide database study. Perioper Med. 2015 Oct 19;4:11.
- Salmasi V et al. Relationship between Intraoperative Hypotension, Defined by Either Reduction from Baseline or Absolute Thresholds, and Acute Kidney and Myocardial Injury after Noncardiac Surgery: A Retrospective Cohort Analysis. Anesthesiology. 2017 Jan;126(1):47-65.
- Osawa EA, et al. Effect of Perioperative Goal-Directed Hemodynamic Resuscitation Therapy on Outcomes Following Cardiac Surgery: A Randomized Clinical Trial and Systematic Review. Crit Care Med. 2016 Apr;44(4):724-33.
- Schneck E, et al. Hypotension Prediction Index based protocolized haemodynamic management reduces the incidence and duration of intraoperative hypotension in primary total hip arthroplasty: a single centre feasibility randomised blinded prospective interventional trial. J Clin Monit Comput. 2020 Dec;34(6):1149-1158.