title: Methodology for a study of structured co-management of high-risk postoperative patients in a teaching hospital.
abstract: BACKGROUND
  Patients undergoing major surgery often suffer postoperative complications, and in many cases these are related to medical comorbidity.
  
  
  OBJECTIVE
  To develop a structured approach for referral, postoperative management and surgeon communication for high-risk surgical patients based on medical co-management using a Post-Operative Surveillance Team (POST). DESIGN, SETTINGS, PARTICIPANTS: Pilot study involving (i) a literature review to identify risk factors for postoperative complications; (ii) assessment of Medical Emergency Team (MET) call rates on surgical wards; (iii) development of a potential target surgical cohort from hospital electronic databases; (iv) formulation of checklists for assessment and intervention; (v) formulation of guidelines for referral to the POST and communication with surgeons; and (vi) guidelines for interactions with other postoperative surveillance services. The pilot study was conducted in two surgical wards of an academic teaching hospital between 1 March and 30 June 2010.
  
  
  METHODS
  Successful development of a feasible, reproducible and testable model for medical co-management of postoperative care.
  
  
  RESULTS
  Increasing age, unplanned surgical admission, low preoperative albumin level, and increasing American Society of Anesthesiologists (ASA) score were identified as preoperative risk factors for postoperative complications. Funding was obtained for two senior registrars, two intensive care nurses and a project officer. Surgeons were consulted and included at all phases of study development. Two surgical wards receiving 28% of all MET calls in the preceding 15 months were targeted for the pilot. Analysis of the hospital electronic database for 4 months of admissions in five target surgical groups admitted to the target wards during 2009 identified a cohort of patients based on eligibility criteria of (i) unplanned admission in patients aged ≥55 years; or (ii) planned admission in patients aged ≥80 years; and/or (iii) admission to the intensive care unit. An extensive education program was conducted to facilitate referrals from the Post Anaesthetic Recovery Unit, surgeons, and ward nursing staff to the POST. Checklists for assessment and intervention were developed based on five domains: (i) analgesia; (ii) surgical site management; (iii) resuscitation of deranged physiology; (iv) rehabilitation; and (v) management of medical comorbidities in the postoperative period. Based on expected caseload, a 5-day postoperative review period was recommended by the management committee. After this period, patients with ongoing problems were to be referred to a medical unit.
  
  
  CONCLUSIONS
  We successfully developed a feasible, reproducible and testable model to study the effects of a POST in selected wards at our hospital. The acceptance of this model by surgical ward staff and surgeons, as well as its effect on patient outcomes, remain to be determined.
mesh_terms: D003422:Critical Care / Q000458:organization & administration*; D006784:Hospitals, Teaching; D006801:Humans; D011182:Postoperative Care; D011183:Postoperative Complications; D012307:Risk Factors