POSSUM - preoperative risk assessment, managing treatment, level of care and length of stay Wilhelmina Ekström, MD, PhD Karolinska Institute Karolinska University Hospital, Department of Orthopedics, Stockholm, Sweden

What you want to know before starting surgery  How well is the patient prepared for the operation ?  Are there any risk for complications ?  Can we offer an adequate level of care for the patient ?  Do we have the necessary staff competence ? 2

POSSUM  =Physiological and Operative Severity Score for enUmeration of Mortality and morbidity  Graham Copeland 1996  Methodology for assessing clinical performance against the expected outcome for the case-mix  Calculating the risk for every patient as an individual 3

POSSUM instrument 4 SCORE1248 Age< >71 (yrs) Cardiac On CardiacOedemaJVP signs drugs orWarfarin Normalsteroid CXR BorderlineCardio cardiomegalymegaly Resp. signs SOB SOB rest Exertionstairs Normal Any other CXR Mild COADMod COADchange SYSTOLIC >171<89 BP (mmHg) Pulse >121 (/min) <39 Coma Score <8 Urea< >15.1 (mmol/l) Na> <125 (mmol/l) K <2.8 (mmol/l) >6 Hb <9.9 g/100ml >18.1 WCC >20.1 x1012/l <3 ECGNormal AF ( )Any other change SCORE1248 Op magnitudeMinorInterMajorMajor + Number of op1 2>2 within 30days Blood loss< >1000 per operation ContaminationNoIncisedMinorGross woundcontam or ie stabnecrotic tissue Presence ofNo1oNodeDistant malignancy metastases Timing ofElec. Emerg. operation resus possimmed <48hrs<6hrs POSSUM sheet for physiological score POSSUM sheet for operative severity score

3 month prospective pilot study  Orthopedic patients at Karolinska Solna  428 patients and 485 operations  27% emergency  Follow up after 30 days 5

Results POSSUMPredictedOutcome Mortality4.8 %1.1% Morbidity27 %26.2%

Casemix morbidity

Level of care  11% of the patients had less than 10% risk ( routine care or daily round by internist?)  24% of the patients had 10-20% risk ( High Dependency Unit after surgery?)  65% of the patients had >20% risk ( Intensive Care Unit after surgery?) 8

Complications per surgeon Odds ratio 1= expected frequency

Results length of stay The mean length of stay for patients with  <10% risk score was 7 days  10-20% risk score was 19 days  >20% risk score was 11 days 10

Conclusion POSSUM  can predict complications well and also give a good idea of casemix  can be useful to plan future level of care  can deliver constructive information of the staff competence  information regarding length of stay needs to be further evaluated

Thanks for listening Special thanks to : Carl Aulin Per Svedmark Lars Weidenhielm Lennart Adamsson and Stockholm County Council Ann Fjellner 12