Is the pursuit of DREAM ing (drinking, eating and mobilising) the ultimate goal of anaesthesia? (2016)

Defining good anaesthetic care has been subject of much debate, but there is still no consensus. Differences in anaesthetic care have been shown not to affect surgical mortality, even in patients undergoing cardiac surgery 1, and death under general anaesthesia is now such a rare event that alternative measures of the quality of anaesthetic care provision have been explored. These include: measuring patient satisfaction; patient-reported outcome measures (PROMS); measuring quality indicators, including postoperative pain scores, incidence of postoperative nausea and vomiting, postoperative temperature, postoperative functional and cognitive performance; and assessing the patient's perception of the anaesthetist's communication skills 2-6. The analysis of quality of recovery has changed and has progressed from the immediate assessment of physiological parameters at a single postoperative time-point to the assessment of broader postoperative ability 2, 3. It is now known that communication skills and discussing information influences patients’ satisfaction with anaesthetic care. Flierler et al. demonstrated that more than 90% of patients want to be involved in decision-making about their anaesthetic care, and they concluded that shared decision-making and the patient/physician relationship were vital for providing high levels of patient satisfaction 4. Furthermore, it is also appreciated that patients who view their doctors as unfriendly, unhelpful, or uncommunicative are more likely to complain. It has been argued that if doctors with poor communication skills improved their interpersonal skills, as well as improving patient satisfaction, it could make patients happier and less likely to complain and, therefore, make doctors happier 7. Myles et al. in their prospective study of nearly 11, 000 patients demonstrated that most patients were highly satisfied (97%) with their anaesthetic care 8. However, they identified the following as risk factors for dissatisfaction: intra-operative awareness; moderate or severe postoperative pain; and severe postoperative nausea and vomiting. They concluded that several factors associated with patient dissatisfaction may be preventable or better treated. Subsequently, they were able to develop and validate a 40-item questionnaire as a measure of quality of recovery (QoR-40) 9. In 2013, the QoR-40 rating scale was subjected to a quantitative systematic review. Data were combined in meta-analyses using random effects models. This resulted in a total sample of 3459 patients from 17 studies originating in nine countries, and it was concluded that the QoR-40 was a suitable measure of postoperative quality of recovery in a range of clinical and research situations 10. Myles et al. have also developed and validated a simpler nine-point quality of recovery (QoR) score 11. A further study involving 700 patients demonstrated a similarly high rate of satisfaction with anaesthetic care (> 90%) 12. The questionnaire used in this study was subsequently adapted for the first Sprint National Anaesthesia Project (SNAP-1) 13. This UK-based project was designed to be a snapshot of clinical activity and patient-centred outcomes that were believed to be important and relevant to both patients and anaesthetists. Every adult patient that had an anaesthetic over a two-day period in May 2015 was given a questionnaire to complete and entered into the study. Patients answered 23 questions within 24 h of surgery and after discharge from recovery. Being a patient-focused study, the questions included asking the patient if at any point they had experienced drowsiness, pain at the site of surgery, thirst, sore throat, nausea or vomiting, feeling cold, confusion, shivering, and accidental awareness under anaesthesia, as well as their perception of the anaesthetist and the pre-operative assessment. Within this population, drowsiness, pain at the surgical site and thirst were cited as the most frequent causes of post-anaesthesia discomfort. Whilst many of these complaints can be attributed to the conduct of anaesthesia, many are multifactorial. Hocking et al. performed a radical two-part study in order to assess the impact of communication skills on patient satisfaction with anaesthesia 14. In the first part, they developed and validated a short psychometric instrument, the Perception of Quality in Anaesthesia questionnaire. This part of the study identified communication with the anaesthetist, avoidance of postoperative nausea and vomiting, and postoperative pain management as the three most important factors affecting a patient's perception of the quality of anaesthesia. The specific aspects of communication that were identified as being most valued were: gentleness and attention; information and confidence; and addressing of patient concerns. In the second part of the study, individualised feedback was provided to anaesthetists in five different areas: attention/gentleness; pain management; information/confidence; post operative nausea and vomiting; and concerns addressed. This feedback of patient satisfaction performance scores to individual anaesthetists led to a change of practice and improvements in both patient experience and quality indicators. The practice of measuring the quality of recovery and providing feedback to anaesthetists is an exciting concept, and has been shown to lead to improvements in both district general 15 and teaching hospitals 16. In the study performed in the district general hospital setting, recovery staff entered quality indicator data into a bespoke module within the electronic theatre management system. These data were then collated with patients’ theatre data including: operation type; names of surgeons and anaesthetists; key theatre time-points; and type of anaesthetic. Quality outcome reports were then produced for individual anaesthetists, alongside departmental results for comparison. The chosen quality indicators included: temperature on arrival in recovery; pain scores; incidence of nausea; incidence of vomiting; rates of ward admission after day surgery; and unexpected critical care admission. Subsequent audit demonstrated an overall improvement in the chosen quality indicators. Within the teaching hospital environment, the implementation of enhanced feedback to anaesthetic staff was found to have a positive impact on postoperative pain measures, nurse-recorded freedom from nausea, mean patient temperature on arrival in recovery and QoR-9 score 16. For patients undergoing day-case surgery, there is no specific validated research tool to assess anaesthetic quality, and so any of the above tools can be used 17. However, it is generally agreed that, in the day surgery unit, the patient needs to able to drink and eat without nausea or vomiting and be able to mobilise to the toilet and urinate before discharge. This has recently been given the acronym of ‘DREAMing’ (DRinking, EAting and Mobilising). In the last 20 years, the complexity of the surgical procedures and the number/severity of comorbidities have increased in the day surgery environment, but throughout this period, the goal of the patient DREAMing has remained the same. The Association of Anaesthetists of Great Britain and Ireland (AAGBI) have published guidance on the minimum criteria for discharge from recovery 18. As well as ensuring cardiovascular, respiratory and neurological stability, the patient should have “pain and post-operative nausea and vomiting adequately controlled… and that temperature should be within acceptable limits”. Avoidance of inadvertent hypothermia promotes both faster return of normal bowel function and mobilisation 19, 20 and reduces the incidence of postoperative shivering, cardiac events including arrhythmias and patient dissatisfaction with the surgical experience. Thus, the pursuit of the goal of DREAMing necessitates the avoidance of inadvertent peri-operative hypothermia. It is recognised that postoperative gastrointestinal dysfunction is a major cause of morbidity and mortality, and causes are varied 19. From an anaesthetic perspective, risk factors include: under- or over-hydration; electrolyte and glucose imbalance; hypothermia; uncontrolled pain; and postoperative use of intravenous opioid analgesia. Therefore, it follows that in order to prevent postoperative gastrointestinal dysfunction and to promote early drinking and eating, the anaesthetist should avoid the risk factors outlined above, and in addition, use appropriate scoring to guide prophylaxis and prevention of postoperative nausea and vomiting 21. Achieving the goal of eating and drinking in the immediate postoperative period reduces the reliance on intravenous fluids. It is now becoming increasingly recognised that fluid and electrolyte mismanagement is a major cause of morbidity and mortality, and the National Institute for Health and Care Excellence (NICE) recently issued guidance in this area. One of the major recommendations was to “provide intravenous fluid therapy only for patients whose needs cannot be met by oral or enteral routes, and stop as soon as possible” 22. It is increasingly recognised that about 25% of surgical patients have a comorbid condition and are often on complex drug regimens to manage chronic illnesses 23. For these patients, early resumption of normal diet is critical. Firstly, it enables them to recommence their usual medication earlier in the postoperative period; this is obviously vital for patients who may require oral medication for diseases such as Parkinson's and epilepsy, where omission may cause a deterioration in symptom control. A convulsion in a patient with controlled epilepsy leading to loss of a driving licence is a catastrophic event for that individual. Similarly, in diabetes, early resumption of normal diet means that the patient can recommence their usual medication sooner, and have a reduced reliance on the variable rate intravenous insulin infusion, with all its intrinsic complications 24. Additionally, earlier resumption of eating provides a greater feeling of well-being, and promotes a more rapid transition to an anabolic state 25. For many years, epidural analgesia and patient-controlled intravenous opioid analgesia (PCA) were regarded as the optimal form of analgesia after major surgery 26-28. It is only now being appreciated that these techniques may paradoxically hinder postoperative recovery. Both techniques require the co-administration of intravenous fluids and oxygen, which may delay or obstruct mobilisation. Epidurals are also associated with relative hypotension which may compromise mesenteric blood flow 26. Patient-controlled analgesia is also associated with rebound pain after falling asleep and excess post operative nausea and vomiting 28. There is now evidence that other analgesic techniques, for example, intrathecal administration of opioids and postoperative oral opioids after laparoscopic major colorectal surgery, may be superior and allow faster mobilisation and earlier discharge 29. In joint arthroplasty surgery, peripheral nerve blocks, epidurals, and PCAs, which all hinder postoperative mobilisation, are being replaced by infiltration with local anaesthetic agents and the use of oral multimodal analgesia including the use of non-steroidal anti-inflammatory agents when and where possible 30-32. Optimal analgesic techniques are both procedure- and patient-specific and can only be instigated after a comprehensive pre-operative assessment and ensuing discussion with the patient. Thus the pursuit of DREAMing promotes excellent communication as part of shared decision-making with the patient 4, 5. Promoting mobilisation is more than just optimising dynamic pain control. Mobilisation is also promoted by removal of physical obstacles, such as intravenous fluids, drip stands, drains, intravenous pumps, epidural and PCA pumps and oxygen therapy. It also encompasses the promotion of a physiological state that is capable of mobilisation. Only a patient that has sufficient oxygen delivery to their muscles will mobilise effectively. This involves optimising the cardiorespiratory system and preventing critical anaemia, alongside careful peri-operative fluid balance and avoiding fluid overload 33. Avoidance of fluid overload has been shown to be beneficial in terms of outcome, but it also means that the recovering patient has a smaller fluid burden to carry. The targeting of DREAMing also facilitates earlier hospital discharge. It is now becoming appreciated that as well as hospitalisation predisposing patients to conditions including hospital-acquired infections and venous thrombo-embolic disease, inpatients are at risk of a range of adverse health events, and they remain at risk for a period of time after. This has been named as ‘Post-Hospital Syndrome’ and appropriate earlier discharge allows less time for this to develop 34. The international initiative ‘The CHEERS-DREAM’ campaign expands on the goals of DREAMing and the acronym stands for: Carbohydrate loading; Hydration; Euvolaemia; Eunatraemia; and then Ready to Start to DRink, EAt and Mobilise. The premise of the campaign is that detailed attention to the nutritional and fluid status of the surgical patient will reduce the iatrogenic harm of injudicious intravenous fluids and simultaneously promote eating and drinking and mobilisation followed by timely discharge of the surgical patient from hospital (see http://cheers-dream.com/ accessed 28/01/2016). In summary, DREAMing may not meet all the currently accepted criteria for assessing a good anaesthetic, but drinking, eating and mobilising are patient-centred outcomes that are consistent with restoration of a normal physiological state and are integral to the road to full recovery. Good anaesthesia enables DREAMing and consequently less good anaesthesia may delay DREAMing. DREAMing is easy to measure and can be audited quickly and relatively inexpensively. International sharing of the frequency of patients DREAMing after surgery would allow benchmarking and may drive quality improvement and sharing of best-practice. Whether or not patients that are DREAMing within a few hours of major surgery have a better short-and long-term outcome is yet to be determined, but it is an attractive hypothesis, and, if validated, would serve as a surrogate measure of good anaesthesia. MM is involved in the Cheers Dream initiative. No other conflicts of interest declared.