Transcript Document

WHO
OPERATES
WHEN?
The 2003 Report
of the National
Confidential Enquiry
into Perioperative
Deaths
II
Study protocol and data quality
Study protocol
• Randomly assigned 7-day period
• All operations performed by a surgeon
or gynaecologist
• Performed in main operating theatre
• Exclusions
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X-ray rooms
obstetric delivery rooms or theatres
endoscopy rooms
A&E treatment rooms
Participation
• 557 (93%) hospitals
• 72,343 cases
(88% NHS, 12% independent)
• 9457 out of hours cases followed up
(65% responded)
• 395 organisational questionnaires
(71% responded)
Data quality
• 34 questions
• 41 (7.3%) hospitals completed key
fields (5) for all operations
• ASA status missing in 33%
• Grade of anaesthetist missing in 11%
• Grade of surgeon missing in 13%
Recommendation
Provide adequate information systems
to record and review anaesthetic and
surgical activity
Classification of operation
Emergency
Immediate life-saving operation, usually within one hour
Urgent
Operation as soon as possible after resuscitation, within 24 hours
Scheduled
An early operation not immediately life-saving, usually within 3 weeks
Elective
Operation at a time to suit both patient and surgeon
Recommendation
Revise NCEPOD classification to
include more specific definitions and
guidelines, which are relevant across
surgical specialties
(NCEPOD responsibility)
Validation of organisational
questionnaire
• Co-ordinators visited 27 hospitals
• 12 data fields reviewed for accuracy
Validation of organisational
questionnaire
Validation of organisational
questionnaire
Facilities
Type and Size of Hospital
• Trusts may be configured in an almost
infinite number of ways, with regard to:
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number of hospitals
types
size
geography
Number of operating theatres in NHS hospitals by number of
surgical beds
Operating theatres in Independent hospitals by surgical beds
Operating theatres in hospitals by emergency admissions
Trauma and Emergency Services
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High quality timely care
Access to appropriate specialists
Access to technology and critical care
Access to 24 hour diagnostic services
Optimum training opportunities
Co-operation between hospitals
Operating theatres by trauma sessions per week
Operating theatres by emergency sessions per week
Recommendation
Ensure that SHAs together with NHS Trusts,
collaborate to ensure all emergency patients
have prompt access to theatres, critical
care, and appropriately trained staff 24
hours per day every day of the year
Availability of recovery staff 24 hours a day by operating
theatres
Recommendation
Ensure that all operating theatres have
sufficient numbers of trained recovery
staff available whenever those
theatres are in use
Resuscitation training
• In NHS hospitals 93% of responses
indicated that recovery staff underwent
resuscitation training at least annually
• All staff in the independent sector
received training at least annually
Recommendation
Provide regular resuscitation training
for all clinical staff, which is in line with
Resuscitation Council guidelines
Monitoring equipment
• In NHS hospitals 90% had a pulse
oximeter and 80% an ECG monitor
available for each recovery bay
• In Independent hospitals 89% had a
pulse oximeter and 85% an ECG
monitor available for each bay
Recommendation
Ensure that all recovery bays have
both a pulse oximeter and ECG
monitor available
This applies whether patients are having local or
general anaesthetic or sedation
The equipment used in recovery areas should be
universally interchangeable and able to provide a
printable record
Audit
• “Do operating theatres have clinical audit
meetings?”
• NHS
• Independent
67%
51%
• “Is the pattern of work in theatres
examined?”
• NHS
• Independent
86%
96%
Recommendation
Ensure that systematic clinical audit
includes the pattern of work within
operating theatres
Grade of surgeon for emergency or urgent operation; by
theatres in hospital
Grade of anaesthetist for emergency or urgent operation; by
theatres in hospital
The Medical Workforce
in the NHS
Numbers of doctors in post
2001 vs 1996
INCREASE
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Consultants
Registrars
SHO
Associate specialists
Staff grade
28%
16%
2%
19%
124%
Consultants
• Paediatric
• Oral and maxillofacial
68%
3%
Competence of doctors
• Trainees
• Staff grades and associate specialists
• Consultants
• “I am not sure that the assumption that
consultant equals good, both surgically and
anaesthetically, is in fact the truth any more”
Recommendation
Assess the competency of staff grade
and Trust doctors and take this into
account when allocating anaesthetic
and surgical sessions.
Competence of doctors
• Trainees
• Staff grades and associate specialists
• Consultants
• “I am not sure that the assumption that
consultant equals good, both surgically and
anaesthetically, is in fact the truth any more”
Weekday 08:00
to 17:59
Weekday 18:00
to 23:59
Weekend 08:00
to 17:59
Weekend 18:00
to 23:59
Night 00:00
to 07:59
Grade of anaesthetist by time of week for all cases
Weekday 08:00
to 17:59
Weekday 18:00
to 23:59
Weekend 08:00
to 17:59
Weekend 18:00
to 23:59
Night 00:00
to 07:59
Grade of anaesthetist by time of week for non-elective cases
Weekday 08:00
to 17:59
Weekday 18:00
to 23:59
Weekend 08:00
to 17:59
Weekend 18:00
to 23:59
Night 00:00
to 07:59
Grade of surgeon by time of week for all cases
Weekday 08:00
to 17:59
Weekday 18:00
to 23:59
Weekend 08:00
to 17:59
Weekend 18:00
to 23:59
Night 00:00
to 07:59
Grade of surgeon by time of week for
non-elective cases
Elective cases, as a percentage of all elective cases, by
day of the week
Fatigue
• Trainees hours - controlled
• Consultants hours - uncontrolled
• Published work on fatigue is
inconsistent
• Is it better to have a fresh doctor or
one who knows the patient well?
Day case surgery
Day case surgery
• 53% of elective operations in the NHS
were day cases
• 43% in Independent hospitals
• 40% of NHS day cases were
performed in a dedicated day case unit
Staffing in day case units
“Junior trainees should be personally
and closely supervised by experienced
staff” (Royal College of Surgeons )
“Anaesthesia for day surgery should be
a consultant-based service”
(Royal College of Anaesthetists)
Grade of anaesthetist caring for NHS day case patients
Grade of surgeon caring for NHS day case patients
Recommendation
Review guidance on which staff should
anaesthetise and operate on day case
patients
Supervision of trainees
• Immediately available
• Local
• Distant
• 5000 cases per year where SHO
anaesthetists are without immediately
available supervision
Supervision of trainee anaesthetists
Recommendation
Review the level of supervision of
trainee anaesthetists working in their
own in dedicated day case units
Elective surgery in the NHS
Elective surgery in the NHS
•Elective
•Not classified
78%
8%
Elective surgery was largely performed
by career grade staff between the hours
of 08.00 and 18.00 on weekdays
NHS elective patients by grade of anaesthetist
NHS elective patients by grade of surgeon
Non-elective surgery in the NHS
Breakdown of NHS non-elective cases by session type
Recommendation
Ensure all essential services are
provided on a single site wherever
emergency/acute surgical care is
delivered
NCEPOD lists
• The situation is better but…
• not all hospitals have NCEPOD lists
• NCEPOD lists are not always staffed
• NCEPOD lists are not sufficient for the
workload of big hospitals
“We do not have an emergency
gynaecology theatre.”
“This 22 year-old patient … waited over
30 hours for appendicectomy due to
unavailability of theatre space during
daytime working hours.”
Grade of anaesthetist by time of day compared to WOW I
Grade of surgeon by time of day compared to WOW I
Grade of anaesthetist by time of day compared to WOW I
Grade of surgeon by time of day compared to WOW I
Recommendation
Debate whether, in the light of changes
in the pattern of junior doctors working,
non-essential surgery can take place
during extended hours
Out of hours cases in the NHS
Many consultants do not regard their
work outside the hours 08.00 to 18.00
as “out of hours”
“Normal working hours in the NHS … is
up to 21.00 for anaesthetic consultants.”
“17.00 on a Saturday, not out of hours.”
“13.00 on a Sunday is not out of hours.”
“In reply to your letter, firstly my
apologies for the delay in getting this
back to you but I have only just obtained
the hospital records.”
“I think it is outrageous that you are
asking me to justify best practice for
operating out of hours. Had I not
operated in this case I would have been
sued for negligence. We are
overwhelmed with bureaucracy and this
is just adding to the burden.”
Why were operations performed
out of hours?
• Most were justified on clinical grounds
• The daytime emergency theatre was
fully utilised
• There was no daytime emergency
theatre at all
Index cases in the NHS
GI bleeding
• Surgery or anaesthesia for GI bleeding
is less likely to be performed or
supervised by a consultant at the
weekend
• Patients may have life threatening
bleeding; many are old and have
significant co-morbidity
Other index cases
• Similar pattern seen for:
• Tendon repair
• Fractures of femur and forearm
• Appendicitis
Other index cases
• Consultant most likely present for:
• Spinal compression
• Emergency surgery for abdominal aortic
aneurysm
• Organ transplant
Ectopic pregnancy
• Surgery for ectopic pregnancy is by a
consultant in more than 50% of cases;
whatever the day or time
• Consultant anaesthetists are less
frequently involved
Death data
Death data
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April 2001 - March 2002
Decrease in late returns
Data quality still an issue
2 patients were still alive
Data returns take longer
The future
The future
• Expanded remit
• name change
• physicians incorporated
• Patient consent and confidentiality
• information governance
• Study selection and method
Studies in progress
• Therapeutic Endoscopy
• Medical Admissions into Intensive
Care
• Abdominal aortic aneurysm