Evidence based development of bedside clinical drug rules for surgical patients

Surgical adverse events constitute a considerable problem. More than half of in-hospital adverse events are related to a surgical procedure. Medication related events are frequent and partly preventable. Due to the complexity and multidisciplinary nature of the surgical process, patients are at risk for drug related problems. Consistent drug management throughout the process is needed. The aim of this study was to develop an evidence-based bedside tool for drug management decisions during the pre- and postoperative phase of the surgical pathway. Tool development study performed in an academic medical centre in the Netherlands involving an expert panel consisting of a surgeon, a clinical pharmacist and a pharmacologist, all experienced in quality improvement. Relevant medication related problems and critical pharmacotherapeutic decision steps in the surgical process were identified and prioritised by a team of experts. The final selection comprised undesirable effects or unintended outcomes related to surgery (e.g. pain, infection) and comorbidity related hazards (e.g. diabetes, cardiovascular diseases). To guide patient management, a list of bedside surgical drug rules was developed using international evidence-based guidelines. 55 bedside drug rules on 6 drug categories, specifically important for surgical practice, were developed: pain, respiration, infection, diabetes, cardiovascular diseases and anticoagulation. A total of 29 evidence-based guidelines were used to develop the Bedside Surgical Drug Rules tool. This tool consist of practical tables covering management regarding (1) the most commonly used drug categories during surgery, (2) comorbidities that require dosing adjustments and, (3) contra-indicated drugs in the perioperative period. An evidence-based approach provides a practical basis for the development of a bedside tool to alert and assist the care providers in their drug management decisions along the surgical pathway