Multidisciplinary Perioperative Anaesthetic Clinic

Aim

To characterise the current patient population seen in clinic, assess the current clinic workload, and investigate outcomes and trends that suggest patient and hospital benefits from the introduction of this program.

Outcomes

• Clinic is servicing ~ six patients a week, with room for further referrals
• DOS cancellations have halved if compared to previously comparable population groups (2.1%)
• ~9% patients have had their goals of care changed (exclude surgery or less invasive procedure), reflecting multi-disciplinary informed shared decision-making
• Significant involvement of cardiology and respiratory physicians
• Early signs of reduced hospital/ICU LOS, and reduced representation rates in select patient populations
• Median hospital savings up to $5,500/patient/stay, but could be >$100,000 for some patients that decided to opt for conservative management who otherwise may have had their high risk procedure (cased matched cohort who are highly co-morbid undergoing high risk surgery with long HLOS + ICU LOS)

Background

Patients presenting for surgery may be classified as high risk based on both surgical factors, and patient factors. A combination of the requires a nuanced approach to management that is best achieved in a multidisciplinary fashion, whereby a patient can be maximally informed of their options and risks. Unfortunately, this multidisciplinary approach has often been lacking in the pre-operative space, and is left to the post-operative phase where healthcare becomes more reactionary rather than preventative, resulting in more patient harm and hospital expense.

International guidelines suggest the optimal management for high risk patients in the perioperative space is a multidisciplinary approach [1]. This often consists of an anaesthetist, intensivist, physician, and may involve other specialties based on the individual's needs, highlighting the more tailored approach to perioperative care in this cohort.
A multidisciplinary approach has been shown to provide many benefits, including; reduced unnecessary procedures; identifying patient values and preferences; reduced ICU admissions; reduced hospital length of stay; reduced 30-day mortality; reduced 30-day readmission [1, 2].

Discussions in forums of the 'final 1000 days of life' has focused on patient values when they are fully informed of likely trajectories, and risks of available treatments. This area of medicine has been largely overlooked due to the increased time required to have these conversations, as well as the difficulties surrounding these conversations. Even in patients who may not be in their final 1000 days, it is important to have similar discussions of goals of therapy, expected outcomes, risks of surgery, and risks of conservative management. Only by fully informing a patient, which is best achieved in a multi-disciplinary fashion, is the patient able to be supported in a decision relating to their ongoing care. And in this multidisciplinary approach, management can be tailored to reduce the chance of complications of therapy.

Given this identified gap, Dr Christopher Slattery (FANZCA) developed a trial program; Multidisciplinary Perioperative Anaesthetic Clinic (MPAC). This program allows referral of patients considering high risk surgical procedures that are also medically morbid. Goals of the clinic are to reduce day of surgery cancellations (which have a detrimental effect on hospital resources, flow, and patient psychology), reduce unnecessary procedures that do not align with patient goals, identify high risk patients and implement plans to support them through the perioperative phase, and reduce perioperative complications.

Given the pilot nature of this program, an audit was conducted of the first six months of the clinic to produce a snapshot of the patient cohort, and assess any outcomes in relation to clinic goals. Given the relatively short investigative period, meaningful comparisons to pre-clinic cohorts were difficult, however some important trends were evident that identify the clinic as a vital aspect of patient access to the health service which directly benefits both the consumer, and the health service, with a very minimal cost.

Discussion

Local support of the MPAC clinic allowed staffing allocations every Friday to ensure consistent patient access. A clinic area was available for use during this time, as were experienced perioperative nursing staff for assistance in the clinic. A critical care principle house officer on their anaesthetic rotation was tasked with weekly preparation of the clinic list to identify issues and collate available history and investigations. Data was collected throughout the process which allowed the auditing process to proceed smoothly to assess the pilot programme's effectiveness.

Results revealed trends that suggest multiple benefits that strongly justify the continuation of this clinic. Patient benefits were identified with cancellation rates, reflecting a deeper and holistic patient understanding of the perioperative journey and associated risks. Day-of-surgery cancellation rate reduction also reflects an increase in the patient experience, as well as reducing the opportunity cost where other procedures could take place during this scheduled time. Metrics such as hospital LOS, ICU LOS, and representation rates revealed important preliminary data suggesting potential large-scale savings in hospital spending, whilst also benefiting the patient cohort by reducing their time spent away from their home environment.

The primary limitation identified is the small numbers that under-power the audit. This was accepted prior to initiating the audit process, but was a necessary limitation to provide an early snapshot of data on a pilot program. Given the positive trends in a number of surgical populations, further investigation should be conducted at a later date to allow for more meaningful population comparisons.

Given many Queensland facilities offer high risk surgeries to high risk patients, this clinic model has the potential to become the mainstay of high risk perioperative care. Tailoring of the clinic to the hospital's resources would be the primary variance between providers. For example, a hospital with fewer high dependency unit capabilities may require increased involvement from intensive care colleagues to determine a patient's suitability for surgery at that hospital.

Our aim is to move the clinic from a pilot program to a permanent program given the known benefits of a multidisciplinary approach, and to continue to audit clinic data to ensure positive outcomes are continuing to be achieved. This allows patient access to the gold standard of perioperative care.

References

1. Kuiper BI, Janssen LMJ, Versteeg KS, ten L, van, Lubbers WD, et al. Does preoperative multidisciplinary team assessment of high-risk patients improve the safety and outcomes of patients undergoing surgery? BMC Anesthesiology. 2024 Jan 2;24(1).
2. Fullbrook AI, Redman EP, Michaels K, Woods LR, Moorthy A, Thorne K, et al. A multidisciplinary perioperative medicine clinic to improve high-risk patient outcomes: A service evaluation audit. Anaesthesia and Intensive Care. 2021 Dec 6;50(3):227-33.
3. High Risk Anaesthetic Assessment (Condition) - Refer Your Patient [Internet].
   Qld.gov.au. 2025 [cited 2026 Feb 17]. Available from: https://www.goldcoast.health.qld.gov.au/referrals/conditions/high-riskanaesthetic-assessment-