2. 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 wilhelmina.ekstrom@karolinska.se

3. 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

4. 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

5. POSSUM instrument 4 SCORE1248 Age<6061 - 70>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 SYSTOLIC110 - 130131 - 170>171<89 BP 100 - 10990 - 99 (mmHg) Pulse50 - 8081 - 100101 - 120>121 (/min) 40 - 49 <39 Coma Score1512 - 149 - 11<8 Urea<7.57.6 - 1010.1 - 15>15.1 (mmol/l) Na>136131 - 135126 - 130<125 (mmol/l) K3.5 - 53.2 - 3.42.9 - 3.1<2.8 (mmol/l) 5.1 - 5.35.4 - 5.9>6 Hb13 - 1611.5 - 12.910 - 11.4<9.9 g/100ml 16.1 - 1717.1 - 18>18.1 WCC4 - 1010.1 - 20>20.1 x1012/l 3.1 - 3.9<3 ECGNormal AF (60 - 90)Any other change SCORE1248 Op magnitudeMinorInterMajorMajor + Number of op1 2>2 within 30days Blood loss<100101 - 500501 - 999>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

6. 3 month prospective pilot study  Orthopedic patients at Karolinska Solna  428 patients and 485 operations  27% emergency  Follow up after 30 days 5

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

8. Casemix morbidity

9. 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

10. Complications per surgeon Odds ratio 1= expected frequency

11. 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

12. 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

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