1989• Microsoft released ‘Office’ suite• Berlin Wall comes down• George Bush snr. becomes President• USSR pulls out of Afghanistan• First NCEPOD Report

The Origins

Recent Reports

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MethodOrganisational dataProspective dataPeer Review

Background

• 20,000 – 25,000 surgical deaths each year

• 80% of these deaths occur in high risk patients.

• Major source of mortality and morbidity

• Concerns around UK outcomes

Aim

To carry out a national review of

the peri-operative care of patients

undergoing inpatient surgery and

identify remediable factors for the

care of high risk patients.

Study population

• Over 16 years old undergoing inpatient

surgery between 1st and 7th March 2010

inclusive

• Exclusions

– Day cases, Obstetric, Cardiac, Transplant &

Neurosurgery cases

Case collection

• Prospective data– Clinical form

• Retrospective case data– Patient identifier spreadsheet– ONS data

• Peer review data– Case note extracts

• Organisational data

Thank You

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Data returns

Clinical forms returned 19,097

Cases matched with outcome 13,513

Cases returned for peer review 1,026

Cases suitable for peer review 829

Organisational Data

Theatre availability

• 1800-2359 183 (83%)• 2359-0759 183 (83%)

Previous NCEPOD Reports

• WOW I 1997 51%• WOW II 2003 63%• Caring to End 2009 87%• Knowing the Risk 2011

72.5%

WOW to WOW II

• 20% ops OOH by SHO

• 47% anaes’ OOH by SHO

• 51% hospitals had “CEPOD” theatres

• 25% of non-elective cases in CEPOD theatre

• 6% ops OOH by SHO

• 25% anaes’ OOH by SHO

• 63% hospitals had “CEPOD” theatres**

• 70% of non-elective cases

in CEPOD theatre

WOW I 1997 WOW II 2003

15

Critical care provision

Systems for recognition

90.2%

9.8%

Key findings – Organisational data

• 1 in 4 hospitals have no daytime CEPOD theatre

• 1 in 3 hospitals have PACU not open 24 hours

• 1 in 4 hospitals with 24/7 PACU cannot provide ventilatory support and management

• 1 in 10 hospitals do not comply with NICE CG 50

• 1 in 3 hospitals do not have a critical care outreach service

Prospective Data

Age

• Mean age 56 • Gender 55% Female

Body Mass Index

ASA grade

Urgency of surgery

Comorbidities

Risk assessment

• What we did

– Subjective assessment

• View of anaesthetist

• Why

– Ease

– Prospective

– Own assessment

Risk assessment

Risk and age

Risk and ASA status

Risk and ASA status

30 day outcome

6 month outcome data

Pre-admission assessment

High risk intra abdominal surgery

mortality

Intra abdominal surgery high risk 8.5%

low risk 0.7%

Gut resection high risk 11.1%

low risk 1.9%

Postoperative locationAll patients

6.7% went to HDU / ICU

? Ideal location – Yes 97.9%, No 2.1% (353)

Mortality Ideal location 1.4%

Not ideal 5.0%

Postoperative locationHigh risk patients

Key findings

• 20% of patients included were thought to be high risk

• 30 day mortality 1.6% – 6.2% (high risk), 0.4% (low risk)

• 1 in 5 high risk elective patients not seen in pre admission assessment clinic – (4.5% vs. 0.7% mortality)

• 19 in 20 high risk patients did not have intra operative cardiac output monitoring

Key findings

• 4 in 5 high risk patients went to ward level care postoperatively

• 79% of deaths were in the high risk group (165/208)

• High risk, non-elective patients who are returned to ward care had a mortality rate of 9.1%

Recommendations

There is a need to introduce a UK wide system that allows rapid and easy

identification of patients who are at high risk of postoperative morbidity

and mortality.

Recognition

Recommendations

Decision to operate (particularly non-elective) should be made at consultant level, involving surgeons and those providing intra and post operative care.

Mortality risk made explicit to patient and recorded.

Once a decision to operate has been made there is a need to provide a package of full supportive care.

Planning and information

Recommendations

Better intra operative monitoring for high risk patients is required. The

evidence base supports peri operative optimisation and this relies on

extended haemodynamic monitoring. NICE MTG 3 relating to cardiac output

monitoring should be applied.

Intra operative care

Recommendations

The postoperative care of the high risk surgical patient needs to be improved. Each Trust must make provision for sufficient critical care beds or pathways of care to provide appropriate support in the postoperative period.

Each Trust should analyse the volume of work considered to be high risk and quantify the critical care requirements of this cohort. Reporting to Trust board annually.

Post operative care

Peer Review Data

Method

• Prospective dataset 19,097

• Designated high risk 3,734

• Qualitative review 829

Descriptive Data

Age

Body Mass Index

Data taken from Table 4.1

ASA grade

Comorbidities

Data taken from Table 4.3

Urgency of surgery

Data taken from Table 4.4

Outcome data

Risk Assessment

Anaesthetists vs. Advisors

• 22.5% elective Not high risk

• 14.6% non-elective Not high risk

Subjective view

Objective view – Lee Index

• High risk 2752 / 18829 (14.6%)

• In line with available literature

Where does risk lie?

• Operative factors 3%

• Patient factors 62%

• Both 35%

Higher risk = OlderHigher ASA

Comorbidities

Pre-operativeAssessment

Planned admissions

Enhanced recovery programme

Only 19/550 documented

Comorbidities

Comorbidities - Optimisation

Documented mortality risk

Pre-operativeCare

Pre-operative hypovolaemia & mortality

Pre-operative fluid optimisation

Location of fluid management

Pre-operative fluid management and mortality

PostoperativeCare

Correct postoperative location

Effect of correct location on outcome

Standards of care

Key findings

• Care of patients good only 48% of time

• Lack of consensus on risk

• Mortality rarely mentioned

• No plan to optimise nutritional status

• Poor fluid management increases mortality

• Cardiac output monitoring rarely used

• 8.3% should have gone to high care

Recommendations

All elective high risk patients should be seen and fully investigated in pre-assessment clinics. Arrangements should be in place to ensure more urgent surgical patients have the same robust work up.

Greater assessment of nutritional status and its correction should be employed in high risk patients.

Recommendations

High risk patients should have fluid optimisation in a higher care level area pre-operatively.

The adoption of enhanced recovery pathways for high risk elective patients should be promoted.

Given the high incidence of postoperative complications demonstrated, and the impact that this has on outcome, there is an urgent need to address postoperative care.

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