Skuteczne rozpoznawanie wysokiego ryzyka okołozabiegowego przez pielęgniarkę przy użyciu skali Helios

Introduction

Detection of patients with increased risk of periprocedural conditions is a prerequisite for effective optimisation of treatment [1]. On the other hand, ordering unnecessary specialist consultations does not improve results but generates costs [2–4]. Finding the most balanced method of optimising treatment before surgery is still a challenge. The clinician’s experience of validated scales, which is used to assess the risk of treatment, is commonly postulated.

Aim of the research

The aim of the study was to compare the adequacy of periprocedural risk assessment performed by an anaesthesiologist during premedication with the same assessment made by a nurse using the Helios Score, in successive patients in the Department of Vascular Surgery.

Material and methods

A retrospective analysis of clinical data of patients treated in the Vascular Surgery Department of Pomeranian Medical University from 1.01.2018 to 30.03.2018 was performed. The group consisted of 185 patients qualified for vascular treatment using a hybrid or “open” technique. Patients qualified for intravascular treatment were excluded (because they were not subject to the expert’s assessment, i.e. they were not subjected to anaesthesiological premedication).
Two methods of screening of patients used in the search for patients with an increased risk of surgical treatment were compared. The first method was direct evaluation by the anaesthetist during premedication (expert assessment). The anaesthesiologist assessed the risk according to their own informal criteria and recommended additional consultations or optimisation of the treatment before the surgery.
The second method was risk assessment by a nurse based on risk classification according to the Helios Score [2].
The Helios Score includes clinical data as in Figure 1.
The score summary qualifies patients for low-risk groups ≤ 6 points, intermediate-risk group = 7, and high-risk group ≥ 8. According to the standard of this scale, patients with high or medium perioperative risk should be treated as potential candidates for specialist consultations because they may require optimisation of treatment before surgery [1, 2].

Statistical analysis

A comparison of countable variables was made using the exact Fisher test. Differences were considered statistically significant at p < 0.05. The statistical analysis was carried out using the Statistica program (version 13, StatSoft, Dell, Round Rock, Texas, USA).

Results

The following surgical procedures were performed in the study group: open artery surgery/stent-graft implantation – 3/21, aorto-bifemoral implant surgery – 5, hip joint/hybrid iliac artery – 18/4, acute ischaemia treatment – 6, amputation or necrosis – 22, patency of the carotid arteries / other treatments on the arteries of the aortic arch of the aorta – 55/3, femoropopliteal bypass – 33, profundoplasty – 13, and implantation of stent-graft into the thoracic aorta – 2. The remaining patients underwent conservative treatment.
One hundred and fifty-two cases were treated without complications. In the given period there were seven deaths and 26 cases of general deterioration due to complications.

Opinion of an expert (anaesthetist)

During premedication, anaesthesiologists identified 20 patients with increased operative risk and ordered 20 specialist consultations (including two internists, one dental, one ENT, one nephrological, one neurological, and 14 cardiac).
Seven patients required additional optimisation of pre-operative treatment. Despite this, 2 patients died in this group, and four had complications. According to an expert (anaesthetist), no consultation or optimisation of treatment was needed in 165 cases. Nurse’s rating according to the Helios Score.
According to the assessment made by the nurse, on the basis of the Helios Score, 54 patients had a high risk in the procedure. On the other hand, average risk was evaluated in one patient and low in 131 patients (Table 1).
The percentage of deaths envisaged by the anaesthetist was in total 43% (three out of seven found) and 27% (seven out of 26).
The rate provided by the Helios Score equal up to 43% (three out of seven) and 19% (five out of twenty sixth), respectively (Table 2).
With simultaneous use of the expert’s experience (an anaesthesiologist considers that the consultation is needed) and Helios Score support (high and medium risk assessed by the nurse), 69 cases could have been be distinguished.
This group would include 71% of deaths (5/7) and 42% of complications (11/69). The percentage of unnecessarily ordered consultations would remain at the same level of 63%.
Differences between the simultaneous use of both predictive methods were not statistically significant.

Discussion

The expert’s experience is based on subconsciously or deliberately using different risk assessment scales, such as ASA, Goldman, Lee, and others [1, 5–8]. Clinical experience (the so-called “clinical nose”) often has higher sensitivity and specificity than the most optimally matched scales, because none of them is able to include all the parameters that affect the result.
However, scales are needed as a benchmark for less experienced clinicians. They can be used successfully by both a doctor and a nurse. An example of scaling the urgency of intervention is the EWS Score [9]. The Helios scale is widely used in the German HELIOS Kliniken Concern as a premedicational scale. Attempts to transfer it to Poland (Lublin) are also taking place [2]. It is an easy-to-use and universal scale. Our analysis shows that the nurse equipped with this tool equitably assessed the perioperative risk in patients, as well as the premedicating preoperative anaesthesiologist. It allows the detection of patients with increased perioperative risk, suggesting the need for specialist consultations, changing qualifications, or optimising treatment. In addition, we noticed that simultaneous but independent (an anaesthesiologist separately and nurse separately) use of two methods of risk assessment would significantly increase the sensitivity of detecting patients at high risk of death without increasing the percentage of costly specialist consultations.

Limitation

The typical limitation is the retrospective character of our analysis and lack of randomisation between assessed methods. Nevertheless, our analysis has a pioneering nature due to the lack of validation of HELIOS score in the Polish population.

Conclusions

The Helios Score allows nurses to adequately assess the risk of treating a vascular patient. Additional support with the Helios Score can increase the sensitivity of detecting patients with high operational risk.

Conflict of interest

The authors declare no conflict of interest.

References

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Address for correspondence:

Anita Rybicka PhD
Department of Nursing
Faculty of Health Sciences
Pomeranian Medical University in Szczecin
ul. Żołnierska 48, 71-210 Szczecin, Poland
E-mail: anitarybicka@onet.eu