SNAP 3 – An Important Patient Safety Issue

Authors: Amy Donnelly & Andrea Haren SNAP 3 Leads: Prof. I Moppett, J. Partridge, C. Swarbrick & SNAP3 Study Management Group NCPA: M.Dockery, A. O’Brien, U.Quill

National audit projects are one of the mechanisms by which safety and quality of practice can be improved, and anaesthesiology has harnessed the power of such instruments of change over the past two decades. The National Audit Projects (NAPs) have, in their various iterations, informed our understanding of complications of low incidence but with potentially serious consequences for patients and anaesthesiologists alike. In Ireland, participation in NAP5 was a significant undertaking which not only ascertained incidence of awareness under general anaesthesia but also provided important information on staffing and demography of anaesthesiology departments in the Republic of Ireland. The Sprint National Anaesthesia Projects (SNAP) examine important themes in perioperative care. They are intended to provide a ‘snapshot’ evaluation of clinical activity and patient centred outcomes. For example, SNAP 1 focused on patient reported outcomes after anaesthesia including satisfaction and patient reported awareness, while SNAP 2 described the provision of critical care services postoperatively. SNAP 3, which is planned for early next year, focuses on the perioperative care of the older person. The number of older people undergoing surgery is increasing. It is estimated that by 2030 one fifth of surgical candidates will be over the age of 75.(1) In Ireland, we know that about 25% of this age cohort is frail.(2) Frailty is a distinctive syndrome related to, but not exclusively associated with, ageing in which decreased resilience across multiple systems leads to an increased vulnerability to external stressors, leading to a slower or indeed incomplete recovery following a physiological challenge. It is generally recognised that postoperative outcomes are worse in the presence of frailty, conferring an increased risk of both morbidity and mortality. For the person living with frailty, this diminished functional reserve may mean that a “stressor” such as surgery, or indeed a postoperative complication, leads to a loss of independence. Acknowledging the perioperative implications of geriatric syndromes (such as frailty, cognitive impairment, and diminished functional reserve) for both patients and hospital systems, guidelines for preoperative assessment of the older person advocate specific evaluation of frailty using a validated tool.(3) Embedding routine frailty screening into the perioperative pathway provides an opportunity to articulate risk and inform decision making, and allows us to age attune our services, designing collaborative care pathways ensuring early input by allied health professionals and medicine for the older person specialists with the aim of preventing postoperative functional decline. Importantly, frailty is a modifiable syndrome, with an evolving evidence base supporting the use of comprehensive geriatric assessment perioperatively, in both the elective(4) and emergency(5) settings. Understanding the prevalence and consequences of perioperative frailty is a patient safety issue which will help to drive service development in this critical area. The aim of SNAP 3 is to assist with decision making by clinicians and patients but also provide evidence for optimal design of perioperative services. It aims to describe the impact of frailty and delirium, and their management, on outcomes following surgery in older people. There are three parts to the study; an observational cohort study, an organisational survey of current perioperative care and a physician survey of acute referrals related to the surgical population. For the first time, Irish sites have been invited to participate in the SNAP projects, along with the United Kingdom, Australia and New Zealand. Our national healthcare policies are responding to the ageing demographic and to the role frailty plays in healthcare resource utilisation. The National Clinical and Integrated Care Programme for Older People aims to re-design the way care for the older person is organised and delivered. The National Clinical Programme for Anaesthesia (NCPA) endorses SNAP 3 as an opportunity to examine these processes specifically around the time of surgery, and so in Ireland we will participate in the organisational survey component of this project. This is a service evaluation asking for information on the preoperative and postoperative care provided for adult surgical patients. In 2014, the NCPA produced a Model of Care for development of preadmission units (PAUs) in which the aim was to focus on better patient safety and better patient care. It was intended as a ‘how to’ toolkit for hospitals without PAUs but also outlined opportunities to maximise peri-operative service delivery and improve patient experience.(6) It has been seven years since this document was produced and our lives and practices have changed in myriad ways since then. With the advancement of eHealth and phone and video-assessments which were made necessary overnight, but now are a cornerstone in many practices, we have established new norms and so have our patients. It is timely therefore that this survey will assess our current practice. We can reflect on what we do but also what we can change in order to optimise utilisation of increasingly scarce resources and ensure that our services remain patient centred, and indeed simultaneously safer.

References: 1. Fowler AJ, Abbott TEF, Prowle J, Pearse RM. Age of patients undergoing surgery. Br J Surg. 2019;106(8):1012-8. 2. O’Halloran A MC, Scarlett S, Roe L, Romero-Ortuno R, Kenny R-A,. TILDA Report on Population Estimates of Physical Frailty in Ireland to inform Demographics for over 50s in Ireland during the Covid-19 Pandemic. The Irish Longitudinal Study on Ageing (TILDA); 2020. 3. Membership of the working party RG, Beech F, Brown A, Dhesi J, Foo I, Goodall J, et al. Peri-operative care of the elderly 2014. Anaesthesia. 2014;69(s1):81-98. 4. Partridge JSL, Harari D, Martin FC, Peacock JL, Bell R, Mohammed A, et al. Randomized clinical trial of comprehensive geriatric assessment and optimization in vascular surgery. BJS. 2017;104(6):679-87. 5. Oliver CM, Bassett MG, Poulton TE, Anderson ID, Murray DM, Grocott MP, et al. Organisational factors and mortality after an emergency laparotomy: multilevel analysis of 39 903 National Emergency Laparotomy Audit patients. British Journal of Anaesthesia. 2018;121(6):1346-56. 6. National Clinical Programme for Anaesthesia. Model of Care for Pre-Admission Units. 2014. 7. SNAP 3: https://www.niaa-hsrc.org.uk/SNAP-3-Frailty-and-Delirium-Hospital-List#pt [Accessed 01/12/21]