Cardiac Output Monitoring Targeted Fluid Therapy Anaesthesia Surgery Technology Implementation

1. Oesophageal Doppler:
Enhancing Recovery from
Major Surgery
Daniel Conway
Consultant Anaesthetist
Manchester Royal Infirmary

2. Oesophageal Doppler.
A Great British Invention
Conflict of Interest: Dr Conway &
NTAC have not received funding
or financial interests in Deltex
Medical

3. Oesophageal Doppler Monitoring
a. Reduces Complications and Length of
Stay for major surgery
b. Should be available in all hospitals
that perform major surgery
c. Technology Adoption is achievable
and cost-effective

4. Implementation Failure?
• Anaesthetists, Surgeons and the
evidence-base all support its use
• Implementation across NW region is
haphazard at best
• We now have an opportunity to
implement as part of enhanced
recovery with SHA support

5. Optimisation with ODM
200ml 200ml
stroke volume
filling

6. Optimisation Studies
Conway, Mayall, Latif, Gilligan, Tackaberry Anaesthesia 2002

7. Optimisation Studies
Noblett, Snowden Br J Surg 2006
• 108 colorectal
surgical patients
• Fluid Challenge SV
optimisation
• Hospital LOS 7 v 9
days p<0.005
• Diet 2 v 4 days
• ↓ Crit Care Admits

8. Implementation Failure? Why
Scepticism: RCT
vs the real world
Changing practice
1. Needs training
2. Implies current
care may be
sub-optimal
Fail at the first ,
second etc hurdle
Alternate
Hypotheses eg
fluid restriction
Who pays – who
benefits?
Competing priorities
for resources
Leadership Failure
Capital and
Consumable Costs
Can anaesthetists
alter surgeons
outcomes !!!!

9. Implementation Project
To successfully introduce oesophageal
Doppler guided fluid Rx for major
surgical patients in 3 NHS Hospitals
Derby, Whittington & MRI
Oct 2008- Oct 2009

10. Successful Adoption
• Engage Management
• Engage Clinicians
• Control Initial Roll-out
• Demonstrate Effective Implementation
• Develop of an adoption plan to share
across the NHS
– How to Why To Guide

11. Project Team at MRI
• 12 Anaesthetic Champions
• Surgeons
• Audit Facilitator
• Project Manager at NTAC
Support of Middle Management
Support from MD and Chair of Trust

12. The Challenge
Silo Budgeting

13. Engaging Management:
The Business Case
• Overcoming Divisional silos to
recognise benefit for the organisation
• Address Fears
– What if ODM sits on shelf
– What if we use loads of probes
• Controlled Implementation
• Costs and benefits balance
• Get a manager to co-author document

14. Engaging Clinicians
• How will it improve patient care ?
– Critically appraise studies
– PROMs in the real world
• Limited Implementation
– Champion approach?
– Stick with narrow evidence base
• Survey Training Needs

15. Evidence & Guidelines

16. Centre for Evidence Based
Procurement (PASA)
in patients undergoing high risk surgery
use of ODM guided fluid administration
(sic) is likely to result in fewer deaths,
complications and a shorter LOS
costs seem likely to be compensated for
by reductions in LOS

17. Progress since 2008

18. Progress Nov 09
• 4 monitors purchased Oct 08
• 32 probes per month
• Staff training completed
• 200 Doppler patients and 200 pre-
implementation controls
– Length of Stay
– Complications

19. Before and After
Similar Patients
36
37
34
36
32
33
34
35
36
37
38
Intervention Control
Mean POSSUM score
Median POSSUM score

20. 4 Day ↓ Post-op LOS
15
24
11
15
0
5
10
15
20
25
30
Intervention Control
Mean LOS
Median LOS

21. 20% ↓ in CVC insertion rates
58%
72%
0%
10%
20%
30%
40%
50%
60%
70%
80%
Intervention Control

22. 25% ↓ in re-admission rate
12%
16%
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
Intervention Control

23. 43% ↓ in Re-operation Rate
8%
14%
0%
2%
4%
6%
8%
10%
12%
14%
16%
Intervention Control

24. ↓Critical Care Use
17%
25%
42%
53%
0%
10%
20%
30%
40%
50%
60%
Intervention Control
ITU
HDU

25. • Support Implementation ODM in 10 NW
Trusts 2009-2010
• Demonstrate LOS reductions
• Develop core metrics for major surgery
• Springboard for establishing ERS
– Colorectal --- Upper GI
– Orthopaedic --- Urology
– Vascular --- Gynaecology

26. Enhancing Peri-Operative
Pathways
• Evidence Base is starting point
• Need to Create Culture of Innovation
–Clinicians work with management
–New technology and working practice
–Improvements for patients are
demonstrated
–Experiences shared

27. Any Questions?
Step Change
We Can
Believe In