Are there any projects underway in NZ re: having a reference point re: advice about starting / stopping medications perioperatively? We are having issues around flozins and cardiac meds in particular. It would be great to have at least regional (if not national) site where you can search by drug name and get advice re: what to do with the drug around the time of surgery. Perhaps somebody somewhere started something already? We (Te Toka Tumai / anaesthesia/ quality committee) would be keen to look at collaborating!
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You can use the NZ Formulary url: https://nzformulary.org/
Janelle
Hi Janelle,
We are currently talking while Pt is still in hospital. Not entirely sure how nz formulary would help - our surgical wards are still on paper prescribing/ dispensing 
The whole thing came out where the ward was continuing to withhold cardiac meds and our RMOs don’t have clear guidance or a “go to” place for advice around that. Does that make sense?
This would be super helpful. It is hard to know whose remit it would best fall under, however. It kind of overlaps multiple domains:
- Professional College (ANZCA) & Society (NZSA)
- Pharmacy (both hospital and community)
- Te Whatu Ora
- Perioperative Care Facilities (i.e. hospitals)
- Private healthcare providers
- Safety & Quality
Do any other @pharmacists or @perioperative-informaticians have any thoughts to add? I’ll also canvas the thoughts of the NZSA’s perioperative medicine network on this.
Hi Era
From experience I’ve only seen patients being told to only stop their blood thinning medications 24 hours pre-op, with the surgical teams using Clexane as coverage until discharged, when they restart using the bridging regimen.
NZF is our “go to” reference as per Janelle.
Hi all
Previous surgical pharmacist here, agree this would be really helpful. Although in my experience trying to write local guidelines in the past, there would need some wider consensus (eg from ANZCA) as some are a bit controversial or depend on various factors. The recent flozin guideline is the first time I’ve seen a clear recommendation.
In case you haven’t come across them, both uptodate and dynamed (available through UoA library) have evidence summaries which go through each of the drug classes:
https://www.dynamed.com/management/perioperative-medication-management
But I agree that it would be much easier to type in a drug name and find advice, rather than scroll through an article.
As an aside, I’m doing the clinical decision support paper with UoA right now and we had to prototype a CDS system - mine was a system that would check the NZePS data for evidence of flozin dispensing for elective surgeries and provide guidance to preadmission clinic, admission nurse, anaesthetist etc on when to stop and management post-admission (eg checking ketones etc) based on those guidelines. Totally intellectual exercise but happy to share if it would help anyone think through how a system could work. Key is involving preadmission as they often have the first contact with the patient and best opportunity to advise what to stop and when.
-Katie
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Kia ora
All hospitals have their own protocols for perioperative management of medications and standardising this nationally (and eventually all medication protocols!) is what I think we should be aiming for.
The burden of each hospital maintaining these protocols is huge and we do not routinely assign clinicians dedicated time to undertake the reviews. With current workforce shortages, the problem is compounding.
Hosting the info in NZF would be sensible as it is a readily available national-wide reputable source with an adequate user feedback system. Add a new category for each monograph calling it “peri-operative management”.
How we could do this is by engaging a medical writing agency and granting them access to each hospital’s protocol suite. They can then compare and contrast the recommendations and identify the medications that are not routinely treated the same and take those meds to the respective societies
to generate a consensus statement.
Lauren
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Yep totally agree - hosting as a subsection on NZF would be best for future proofing with EHRs etc because most systems should be looking to integrate with NZF
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No nationally consistent guidance I am aware of. As noted in the thread already, currently each hospital/district typically have their own guidance. There are efforts at Te Whatu Ora National Office currently to harmonize non-clinical documents (e.g. HR, Finance delegations etc) however, it is unclear how the clinical documents might be harmonised/managed. I understand that Te Whatu Ora’s Office of the Chief Clinical Officers are aware and considering - and there is now a national clinical governance group established which may go in some way to support such issues.
In general, agree - ideally we have a one-stop/single source of truth that is easily accessible at the required time, simple-to-understand and follow. Then as we get more sophisticated in our data/digital systems - “right touch” e-clinical decision support systems which don’t overalert but does alert if/where significant and appropriate.
Ngā mihi
Jerome
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Hi Shane,
Apologies in advance as I don’t know your context re: only dealing with stopping anticoagulants. It’s wider than that for us (my context: anaesthetist, large tertiary centre with out of region referrals as well). So things that have haunted us:
Gliflozins
Anticoagulants / antiplatelet drugs
Entresto
less so but still something to consider: leflunomide and similar “impedes tissue healing / what shall we do with it”
There is also different advice, for example after bariatric surgery some meds are recommended to be stopped, and so on.
Our guidelines do exist, but someone has to know to look it up on anaesthesia guidelines page if they are unsure and this is suboptimal. Controlled documents (guidelines when more than one tribe is involved) also need to be known about to look up.
If NZ formulary is the way to go, then we do need to consider regional variation in terms of advice given - for example places that do less epidurals/ high risk regional blocks will have potentially slightly different advice than those who do more of them. Also different surgical team structures in terms of how Pt’s are followed up can also affect guidance.
Hope that makes sense!
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Hi all,
I have taken another look at the NZF.
If you use the Search area and enter empagliflozin you will get a series of results. Scrolling down through the results you will come to “Management of diabetes mellitus during surgery”
Alternatively you can reach this same spot by going down the contents on the opening page to 6. Endocrine System > 6.1 diabetes mellitus > 6.1.7 “Management of diabetes mellitus during surgery”
This information is quite comprehensive, I expect each patient needs to be considered with their own health background so there would not be a ‘one size fits all’ but the information provided would enable a shortcut to the answer ??
I have also looked at the Health Pathways system that was initiated in Canterbury post the earthquake devastation of many Health Centres. This system is available in the South Island via the Canterbury area set up and in Southern DHB with “Southern customisation”. It operates in a similar way to the NZF but the information for Surgery as in this case is no where near as comprehensive as the NZF.
Hi Janelle,
Thank you for the update. I’ll have a look at the NZ formulary. It sounds more like comprehensive guidance. My worry is that if it’s too extensive, it might not work for us either as we do rely on quick guides and tables in a lot of our advice. I strongly suspect we are not alone. We had a number of patients who are on the waitlist for surgery, have been cleared by us and in the few months between our clearance and their date of surgery, GP or diabetes service starts them on flozin with zero advice re stopping it before major surgery (3 days needed). Not pointing fingers, but clearly the disjointed-ness of reviews / no clear flag re: imminent surgery, means that Pts get cancelled on the day which is terrible.
Hi Katie,
That’s an awesome project! The difficulty is not if Pt is on flozin when we see them in anaesthesia clinic - they get clear written guidance. It’s when we (and everyone else) clears them for surgery and THEN they get prescribed flozin in the intervening months. Any chance you could work in an alarm step where once patient is given a surgery date (usually at least a week before when lists are finalised) that THAT is when the booker/surgical team are made aware they have now been dispensed flozin? And/or a backward loop to dispensing pharmacy that Pt is on waiting list for surgery?
Yes, that’s exactly the idea - the creation of surgical booking in PAS would trigger an NZePS lookup for recent flozin dispensing and then begin an alert pathway (with a variety of options, eg alerting surgical team through clinical portal or directly to patient through a patient portal if one existed in that area). As I said, still largely theoretical but reassuring to hear you can see the application 
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Hehe, I think I know the course/ design brief (have done this Uni paper some years back 
Practical pearl - build in a second NZePS look up trigger in your system - one at the point of booking into PAS as you currently have and the second one at allocation to specific theatre list on specific date. A system that has a safety catch in its design (that registers the dynamic nature of both the surgical waiting lists and prescription changes) is bound to score brownie points for multidisciplinary foresight 
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The other class of drugs causing perioperative concern at the moment is the GLP-1 agonists, due to the increased risk of regurgitation and pulmonary aspiration that the gastroparesis they induce leads to.
This hasn’t quite got to ‘recommendation’ status in Aus or NZ, but this is getting close. Here is the recently released US ASA guidance on it:
Hi all,
Apologies for the late one - just recently joined this chat with recommendation from @katied.
Just wanted to add another resource if anyone’s not aware of it:
Its a quick search website that gives advice on how to manage medications.
Hope this helps.
Thanks Stephen - from a quick look at it, it has some good solid stuff. I find the Medicines Monographs page particularly useful.
There are a couple of issues against me giving it a full-hearted recommendation:
-
the search isn’t wonderful for new drugs
-
the advice is quite formal and seems to not be particularly agile. For instance, the GLP-1 and SGLT-2 pages both state that they are out of date and under review (which is good), but have been so for a while (less good).
Thanks @eras for your post. This is an opportunity for Te Whatu Ora as a national organisation to provide a repository of nationally endorsed guidelines.
Under the DHB system, each DHB had its own system for creating and maintaining guidelines. I’ve attached examples of our Southern periop diabetes guidelines, and also one I acquired from Waitemata some time ago now (2018). There’s a fair bit of work creating and maintaining these, so a national based document would be ideal (even if there are some regional modifications)
In Christchurch, CDHB has had the Hospital Health Pathways which privide an easy to use interface for RMOs on the ward to look up these type of guidelines electronically. This is for inpatient use (where Health Pathways is for outpatients and used by primary care).
The question is then under the national Te Whatu Ora - where does the governance for a nationally based Hospital Health Pathways sit?
In Te Whatu Ora Southern (Dunedin/Invercargill/Queenstown) the repository for these documents (called MIDAS) sits with the Patient Safety and Risk team. This is likely to vary across different former DHBs though.
Perioperative Diabetes Formulary.docx.pdf (1.9 MB)
Waitemata Management-of-Diabetes-Jun-2018.pdf (936.0 KB)
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