Clearing patients for surgery is common practice in primary care, internal medicine and anesthesiology. Many medical providers in these fields see patients coming daily and bringing paperwork from a surgeon asking for clearance. But, although common, just making decision whether or not a patient is "safe" to proceed to the operating room is not enough. And certainly not so simple.
Several evidence-based guidelines help and assist providers in making these complicated decisions a lot easier. But, neither of available medical apps included information on the mortality risk in patients from the surgery itself.
In 2014, researchers from The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) published a study in the British Journal of Surgery, revealing the results of Surgical Outcome Risk Tool (SORT). This tool predicts the 30-day mortality from surgery, based on a number of variables including the type of surgery, surgery severity, physical status, age of patient, etc. The study had been validated on an observational cohort of over 19,000 patients in the UK (aged 16 or over) who had surgery as part of an inpatient stay.
Researchers from NCEPOD, along with doctors from the UCL/UCLH Surgical Outcomes Research Centre (SOuRCe), then developed the medical app with a same name (Surgical Outcome Risk Tool), which takes the calculation derived from the study to create a useful guidance tool for informing the surgical teams, as well as patients and their families. The app however excludes obstetrics, neurosurgery, cardiac, and transplant surgery.
Upon starting the app, you are supposed to accept the disclaimer that you understand the purpose and use of this app, i.e. healthcare professionals shouldn't rely on it alone (without reviewing it). The app should be used along with their clinical judgment and knowledge, as a part of their overall toolkit.
Also, the percentages provided by the SORT are only estimates taking into account the general risks of the procedure and some information about the patient, but should not be confused with a patient-specific estimate in an individual case that may influence the risk of death significantly. The disclaimer is accessible again via checklist icon on the top, once you start the app.
Design of the app is elegant and modern, and it's mostly text-based. You have an option to choose the condition from the list of procedures, or via search option. While search option is quicker if you know what you're looking for, search via procedure groups offer better insight in app structure, which is well detailed. Medical providers could choose from 13 procedure groups, listed alphabetically from abdomen to vascular system. Tapping on each procedure gives you a list of more specific subgroups, with a list of procedures within each.
By tapping the procedure, you get to the core of this app - a calculator, presented in a simple, uniform and easy-to-follow fashion. There is a Surgery Severity (Minor, Intermediate, Major, XMajor/Complex) for each procedure, which is auto-populated, depending on the procedure it's been chosen.
For this review, we used the real life case of 60-year-old male patient undergoing a needle biopsy of lung for suspected colorectal lung metastasis. Colorectal cancer was successfully treated three years ago and there was no sign of cancer until recently, i.e. until routine checkup of lungs after patient reported persistent cough and mild chest pain. A checkup revealed suspicious shadow spots on the lungs. A bronchoscopy wasn't successful in collecting a tissue sample, so a needle biopsy had been recommended. Patient has a mild hypertension, and no sign of stroke or heart disease.
We used this information to test the SORT app. First, we chose 'Thorax and intra-thoracic organs' procedure group, and then 'Bronchi/lungs/pleura' subgroup, where Needle biopsy of lung is listed.
Procedure is auto-populated with minor surgery severity (unlike, for example, lung resection with resection of chest wall which has Complex severity).
Next thing we had to choose is ASA-PS grade depending on patient's health records and history. There is an explanation for each section below the calculator. From a scale of 1-5 (from healthy patient to moribund patient not expected to survive without a surgery) we've chosen grade 2, i.e. patient with mild systemic disease.
After that, we had to decide on surgery's urgency, which was in this case Expedited. There was a gastrointestinal surgery and patient had a cancer within past 5 years. Finally, we had to choose patient's age which is given in just three options <65, 65-79 and >=80.
Mortality risk within 30 days of surgery (or in this case a procedure) was 0,86%.
If, for example, needle biopsy failed to show any reliable results, a chest wall resection could be ordered, which is procedure that is far more complicated. In our patient, it increased a mortality risk, which was now 1.25%.
Good thing about SORT app is that remembers the data you've entered the last, which is handy if you're comparing the procedures and the mortality risk of each.
What bothered us was inability to print the results, or at least save them in the app. Also, SORT app doesn't provide any reference links, except the contact (Letter icon) for sending a feedback or learn more about the app creators.
Overall, this is very good tool created to make a complicated decisions regarding surgery clearance a lot easier. However, it should be used as a reference and it shouldn't replace an opinion and decision of medical professional.
Benefit: General Surgeons, Anesthesiologists, Nurse Anesthetists, Residents, and any other providers who perform pre-op evaluations and counsels patients and their families about the surgery risk.