In late 2008 ACTA called for an autumn

venue and Blackpool answered eagerly.

Liverpool’s Heart and Lung Hospital added

enthusiastic support by holding their Thoracic

meeting on the same site; the De Vere Hotel. In

November 2009 the show came to town and

ran alongside BBC’s ‘Strictly Come Dancing’.

On Thursday 5th Dr Jon Kendall

welcomed everyone and introduced his

stars. Liverpool set the pace as Professor Peter

Slinger reviewed the intricacies of one lung

ventilation in difficult airways. With

characteristic mastery and humour he brought

clarity to the topic.Toronto’s forte in thoracic

anaesthesia was also highlighted with his

encouragement to visit their online bron-

choscopy tutorial www.thoracicanesthesia.com.

Dr Stephen Pennyfather then negotiated a safe

passage through the perils of carinal resections

in an assured and pragmatic presentation.After

an interval Dr Andy Roscoe’s update in

optimising lung transplantation led onto Mr

Richard Page’s revelations regarding LVRS.

Their individual tasks covered a lot of ground

in considerable depth. Dr Omar Al Rawi took

up the baton and uncovered the joys of lung

resections after pneumonectomy. Replete with

knowledge delegates then adjourned for lunch

and to review the trade exhibition.This enabled

valued industry partners and delegates to

exchange useful information. During lunch and

throughout the day the Bristol Thoracic

Anaesthesia Training Simulator ran at intervals.

As an effective interactive tool it caught

immediate interest and consideration in

national advancement.

The afternoon was, as anticipated,

educational and engaging. Dr David

Counsell’s intimate knowledge of NAP III

NewsNEWSLETTER OF THE ASSOCIATION OF CARDIOTHORACIC ANAESTHETISTS

No.31Ma

y 20

10

ACTA

1

ACTA Autumn Meeting in Blackpool 5th November 2009 - De Vere Hotel

Professor Peter Slinger addresses ACTA 2009 in Blackpool

Dr David Counsell returns ‘home’ to Blackpool.Continued over page.

ensured its distillation into practical measures.

Later Dr Jon Kendall’s case reviews explored

valuable and focussed learning. A break

heightened anticipation for the scheduled

debate. In this the counsel of perfection in

analgesia for thoracotomies was sought. Pitted

against each other were Professor Jon

Richardson (pro paravertebral block) and

Professor Peter Slinger (pro epidural). Both

crafted their evidence with skill before an

appreciative audience. With little to choose

between them until the rebuttals it was

perhaps at this stage that Professor Richardson

gained ground. In the end he took the debate

from a gracious Professor Slinger who had

played an excellent ‘away game’. In a drinks

reception which followed delegates and faculty

had a convivial conclusion to a successful day.

Later that evening separate groups met for

sponsor promoted educational activity, ACTA

business and a faculty dinner in Lytham.

Friday 6th began with free papers

presentations. Well prepared material

from an abundance of talent at all levels upheld

tradition. Poster presentations were also

available for review throughout the day. The

dedication of all was impressive and

adjudication was revealed upon the meeting’s

conclusion.

Lectures began on a theme of improving

perioperative outcome. Innovation

featured cerebral oximetry while methodology

centred on the SCA’s FOCUS project.

Professor Grocott revealed cerebral

oximetry’s concept, development and

application. This significantly aids rapid

detection of unheralded incidents that can have

devastating outcomes. Professor Hemmerling

amplified this with its use in thoracic

anaesthesia. Both illustrated its value-added

role in immediate correction of cerebral

circulatory compromise. Dr Martinez surveyed

the SCA’s FOCUS initiative in risk reduction.

Allied to this she outlined Johns Hopkins LENS

approach to mapping ways forward in team

working. This had borne tangible results that

were on the eve publication. Following panel

questioning delegates retired for lunch. During

refreshment industry partners fuelled interest

by fielding products and queries.

Afterwards Professor Hemmerling

reprised his expertise; this time on new

drugs and new targets. With a wealth of

material in laboratory and clinical work he

revealed rational approaches to modern drug

usage. On conclusion he kindly invited trainees

to Montreal for laboratory and clinical work

under his supervision. He was followed by his

compatriot Professor Lichtenstein whose

group pioneered transcatheter aortic valve

replacement in Vancouver. A stepwise and

graphic presentation with impressive results

delivered in a modest fashion belied

outstanding dedication and skill. With so

much to ponder coffee beckoned before the

final session. After this Dr Royston’s update

on antifibrinolytics was a tour de force. Given

recent concern in this field it was refreshing to

2

Drs Saunders & Knowles Chair a session at the ACTA meeting In Blackpool.

Professor Lichtenstein returns to us from Canada for ACTA 2009

Audience participation at ACTA Blackpool.

Dr Royston continues the debate at ACTA Blackpool

3

have the story told by someone privy to and

able to analyse data in a meaningful fashion.

Rarely can education and amusement be

combined to effect. However this delivery

scored on all fronts. In fact he left many asking

for more and on this upbeat tempo the

programme concluded.

Dr Gavin then presented the Hargadon

Prize for the best free paper to medical

student Arian Green for his excellent project

on Intraoperative Epiaortic Ultrasongraphy. In

the poster presentation first prize went to the

Bristol team for a particularly well structured

work using their Thoracic Simulator. Following

this interested members convened for the

ACTA business meeting.

In keeping with tradition a gala dinner was

held later that evening. Royal Lytham Golf

Club was the chosen venue and drinks were

served amongst trophies and memorabilia of

hallowed players. Diners then had anecdotes

and stories interjected throughout the meal by

none other than Frank Carson.Although it was

in fact Frank’s birthday (now in his ninth

decade) he agreed to join us. Later when

everyone had sung ‘Happy Birthday’ he left for

his own family celebration. Floral tributes were

presented to Andrea Graham for her vital role

in coordinating events and the evening finished

as diners returned to the De Vere Hotel by bus.

However an impromptu detour allowed

visitors a glimpse of the Illuminations as a

memory to savour with their Blackpool Rock!

For any anaesthetic wanting a more tangible

reminder of ACTA Blackpool 2009 Richard

Villaraino’s DVD record of the meeting can be

obtained on receipt of an appropriate SAE c/o

Andrea Reid at the Lancashire Cardiac Centre.

Otherwise Blackpool also extends another

invitation to the 4th David Sharpe Memorial

Symposium on Friday 1st & Saturday 2nd

October 2010; “Heart Failure; 21st Century

Management”; http://www.lancashirecardiac-

centre.nhs.uk/dsms/

It only remains for the organisers to wish

Brighton all the best this coming autumn;

http://bumblefish.net/home.html .

Jon Kendall & Chris Rozario.On behalf of the Organising CommitteeACTA Blackpool 2009

ACTA dinner was at Royal Lytham & St.Anne’s Golf Club.

4

Editorial

Perfusion Update

Welcome to you all to the Spring 2010edition of our ACTA News.You will of

course notice the absence of Peter Alston’ssmiling face from this section of the newsletter.He has, as you all know, taken over the reins asour Chairman and one of his first acts asChairman was to pass on the editor’s positionto myself !. I hope I will not disappoint you andI shall endeavour to continue the splendidwork of Peter, and all the previous editors.Youwill have to suffer my ‘mugshot’ attached to thiscolumn for the next few years. I must say I feelhonoured to hold such an eminent position inour organisation. I always wanted to be theeditor of a newspaper and I feel a bit likeCitizen Cane. I hope all you budding writersout there will contribute to ACTA news. Iknow you all supported Peter and othereditors in the past and I hope you will continueto give your support.

This is my first year as a member of theACTA committee and I hope I will not

disappoint you. My first ACTA meeting was alsoin Cambridge in 1986. It was my first visit toCambridge and I was of course very impressedby the city and the beautiful colleges. I was veryimpressed by the friendliness of the membersof the society and I felt a bit in awe of some ofthe senior members with the knowledge theyhad of cardiac anaesthesia and anaesthesia ingeneral.

Iwas at this stage a first year registrar and Iwas almost proficient at arterial lines at this

stage ! I had been allowed out for a day fromWythenshawe to be educated in Cambridge!I have enjoyed attending ACTA meetings eversince. I have also had the privilege of beinginvolved in the organising of two ACTAmeetings. The first I held in the Lake Districtand the second , which was mainly organised byChris Rozario, was held last November here inBlackpool.

We have once again many fine articles foryou to read in this edition. I hope you

will find them of interest and useful in helpingyou to keep abreast of the latest developmentsin the world of cardiac anaesthesia and relatedspecialities. If you wish to send articles and/orcomment to me in the future, please usenoelgavin@btinternet.com .

I hope, with your help, to develop the ACTAnews over the next few years. I wish to

include information, gossip, new developments,weird stories, strange happenings etc from thecardiac centres around the UK and Ireland. Insimple terms, tell us about yourselves and yourcardiac centre.

So, anything of interest,send it on. I hope tosee many of you all atfuture meetings.

Noel GavinEditor ACTA news.

Bill PallisterTraveling Fellowship

Award

Applications are invited for the BillPallister Travelling FellowshipAward.

An amount of £5,000 is available duringany single calendar year, and will usuallybe paid to a single applicant but may bedivided between applicants, at thediscretion of the education committee.The award is intended to support atrainee or consultant within three yearsof appointment to travel to an overseascentre of interest.

Awards will not normally be made toassist with attendance at training courses(for example transoesophageal echocourses) or conferences unless there is aclear benefit to the wider membership ofthe Association.

Recipients of awards will be expected towrite a report for the ACTA Newsletterand give an oral or poster presentation atan ACTA Spring or Autumn ScientificMeeting within 12 months of completingtheir overseas visit.

Applications should include an outline ofyour intended fellowship and it should besubmitted to the Honorary Secretary bythe 31st December each year.Applications will be adjudicated by theACTA Education Committee andannounced during the Spring ScientificMeeting. The application form may bedownloaded from the ACTA website.

Applicants need to have been anACTA member in good standing forat least 12 months by the closingdate of applications on 31December each year.

If the Award is to be used to part-fund aneducational activity, ACTA will requirewritten confirmation that the rest of thefunding required is available before anymoney is released.

The Editor.

Bill Pallister.

The Good Practice Guide has been publishedand the incorporation into the WHO checklisthas been met with varying success.Unfortunately the SCTS has devolvedresponsibility to the individual trusts.Apparently some surgeons are refusing to sign.This is not what was agreed by the members ofthe working party which included surgeons andhad been approved by the SCTS and agreed to.Our Chairman is writing to the President ofthe SCTS about this and I have taken it up withthe surgical members of the working party andperfusion group. (If the surgeons refuse to signthen we have agreed that we are not taking thesole responsibility and also shouldn’t sign)

MSC, Modernising Scientific Careers is still inprogress. You’d have thought that thegovernment would have learned from MMCbut unfortunately not. The proposed training

scheme is for all physiological technicians,including Perfusionists, echocardiologists andICU technicians. It is proposed that there willbe a common entry for all then they will rotatebetween the various specialties and then havefinal training in their chosen career path. Thishas serious implications for the training ofPerfusionists, who have a robust trainingscheme at present. They are engaging in initialtalks though the consultation document hasn’tbeen agreed. However they are involved in theprocess, as it is better to be involved than havethings happen without being able to influencethings.

Will keep you posted!

DonnaGreenhalgh

After four years of editing it, I am in thenovel position of having to write the

chairman’s report for ACTA News.Animperfect memory not withstanding, it is mybelief that I first attended a Spring Meeting ofACTA in Cambridge in 1986 and have been amember of ACTA for the last 25 years. I amnow honoured to be the Chairman of theprofessional body that has had a fundamentalrole in my career as a cardiothoracicanaesthetist.With my fellow committeemembers, I have the pleasure to advanceACTA’s role for all cardiothoracicanaesthetists in the UK and Ireland.

Before beginning the report, I must firstacknowledge the important contribution

to ACTA of my predecessor J-P van Besouwwho stepped down in November after fiveyears on the committee and the last two aschairman. His chairmanship has made mysuccession easy as J-P ensured that importantroles devolved to all the committee membersand the succession of these roles was wellplanned.The end result J-P’s work is that thecommittee has been and remains highlyfunctional.As chairman, I will continue thispattern of working for the committee andthank J-P for all his work for ACTA.

With J-P departure and the election of anew member there has been some

reorganisation of the committee. Noel Gavinwas elected to the committee and has takenover from me as the editor of ACTA News. Ihope that you will give him as much assupport as editor as you did me. Give itscentral importance to ACTA, it has also beenplanned that in November, Noel or AlistairMacfie will take over from Jon Mackay asTreasurer. Jon continues in his role asmembership secretary and Ravi will continueto coordinate future ACTA meetings.AlistairMacfie remains Secretary as well as leadingthe Thoracic Committee. Donna Greenhalghwill continue to lead the Echo Committee andrepresent ACTA at the Society of ClinicalPerfusion Scientists of Great Britain andIreland formerly the Society of Perfusionsists.

The Autumn Meeting of ACTA organisedby Chris Rozario and colleagues from the

Lancashire, was held at the DeVere Hotel inBlackpool on Friday 6th November.An ACTAThoracic Meeting organised by JonathonKendal and colleagues from the LiverpoolHeart and Chest Hospital preceded thismeeting on the Thursday. Both were verysuccessful meetings and I congratulate themfor their very effective collaboration. Giventhe recession, getting over thirty companiesto take trade stands was most impressivework.

There is no Spring Meeting this year as thecommittee made a decision three years

ago not to have one this year to allowmember to attend the 25th Annual Meeting ofEACTA which is being held in Edinburgh fromthe 9-11th June.The programme for EACTAhas been changed this year to include morelectures and few parallel scientific sessions.There are also a large number of notablespeakers from all over Europe,Australia andthe USA covering a wide range of topicsrelated to cardiac, thoracic and vascularanaesthesia. Clearly, many of you have alreadysupported the meeting as this year’s meetinghas attracted the highest ever number ofabstracts submitted to an EACTA Meeting.Asorganiser, I hope to be able to welcome manyof you to Edinburgh for EACTA 2010.

If you are coming to EACTA and have aninterest in TOE then I hope that you have

also planned to attend ACTA Echo Meeting inSt Andrews on Tuesday 8th June. DonnaGreenhalgh has organised an excellentprogramme that includes Jack Shanewise,Fabio Guaracino and other notable expertson TOE.Alternatively, for those of you with aninterest in thoracic anaesthesia, Geoff Bowlerhas organised an Association of AnaesthetistsSeminar on Thoracic Anaesthesia in Edinburghalso on Tuesday 8th June and one of thespeakers is Paul Myles.

The Autumn Meetings of ACTA will beheld on 18th and 19th of November in

Brighton and is being organised by MarcoMaccario and colleagues from the RoyalSussex County Hospital. I am looking forwardto the meeting dinner as it is being held in thehistoric Royal Pavilion. Please put the dates inyour diary and reserve study leave so that youmay attend.

Over the last few years, there has been anincreasing call from the membership for

ACTA to have a greater focus oncardiothoracic critical care.The increasingimportance of critical care to ACTA membershas been recognised by the committee overthe years and for this reason, it has supportedmeetings specifically on cardiothoracic criticalcare. In addition,ACTA highlighted critical careas a key area for review to the NationalCardiac Benchmarking Collective. However,the committee came to the conclusion thatmembers wish ACTA to give critical care aneven greater focus.To this ends, a meeting wasorganised by Tim Strang in Manchester inJanuary that was chaired by Alistair Macfie.ACTA members from over 20 centresattended and it was agreed that it would bevaluable to form a sub-group.The committeesupports this move and agrees that it shouldbe constituted along the lines of the Echo andThoracic sub-committees.Alistair Macfie willrepresent the committee on this committee.

The National Cardiac BenchmarkingCollective report on the survey of

cardiac critical care provision that wasundertaken last year is in preparation. Inaddition, it is planned that new questions willbe developed focusing on other aspects ofpatient care.Jon Mackay continues to provide our inputinto the National Cardiac BenchmarkingCollective and my thanks go to him for hiswork.

Those members who undertake paediatriccardiac anaesthesia may well be aware of

if not involved, in the Safe and SustainableChildren’s Cardiac Surgery ServicesProgramme that is being run by NationalSpecialised Commissioning Group.Thisprogramme was set up to examine the waythat children’s heart surgery services andinterventional cardiology services areprovided in England, with a view toreconfiguration. Clearly, the outcome of thisprogramme is likely to have an importantimpact on members, as a likely outcome isthat some centres will close and others willhave to expand capacity. Kate Grebenik hasbeen representing ACTA in the programmeand she has written a report of theprogramme to date that is published in thisissue. One important issue relevant to ACTAmembers that this process has thrown-up isexactly what are the requirements to trainpaediatric cardiac anaesthetists.Views ofpaediatric cardiac anaesthetists appear todiffer depending on whether their backgroundis predominantly paediatric or cardiacanaesthesia.The committee will continue toapply its attention to this matter.

Higher awards are being subjected to thescrutiny of the Health Minster in

Scotland, Nicola Surgeon, who has announceda freeze in the amounts of awards and calledfor schemes to be evaluated and harmonisedacross the UK. In England,ACTA is supportingmembers applications to the ACCEA for silverand bronze and bronze awards in the 2010.Next year’s applications will have to havesupporting evidence for statements andoutcome data. John Gothard and J-P havestepped down from the higher awardscommittee and have our thanks for theirwork over the years. Donna Greenhalgh nowchairs the committee and Ravi Gill has joinedit.

ACTA was fortunate to be a beneficiary of BillPallister’s estate to the sum of £55,000.Thishas enabled the creation of an annualeponymous Travelling Fellowship Award forsum of £5,000.This year the Committeedecided to support two applications; DrKirstin Wilkinson for educational work inNepal and Nick Schofield to assist with travelexpenses to Australia to gain specialised

5

CHAIRMAN’S Report

Continued over page.

6

experience.We look forward to hearingreports of their activities and to receivingfuture applications for this excellent newaward.The deadline for the next round ofapplications for the Travelling FellowshipAward is the 31st December.

The Good Practice Guide in ClinicalPerfusion was published last July but its

implementation has been slow and patchyacross the UK.There have also been reportsthat in places where it has been instituted,some surgeons have refused to sign thepatient specific prescription for CPB.This is amatter that will require to be discussed withthe SCTS. Other perfusion matters are thatthe Department of Health is keen developgeneric training for a number of allied healthprofessions including perfusionists. However,the Society of Clinical Perfusion Scientist hasreservations about this approach to training.

Following last year’s successfulcollaboration with the National Institute

of Academic Anaesthesia (NIAA) awarding theACTA Research Grant, it is planned to do soagain this year. I was involved in the reviewprocess and it was not only thorough but alsofar better than we had achieved previously.This year unlike previous years, the committeehas decided that the grant will be madeunrestricted that is non-members may apply.The rationale for doing this is that whoever isawarded the grant will get additional fundingfor supporting facilities from the NHIR andthis can be equivalent to 40% of the grantvalue. However, as in the previous years, theresearch question will have to be highlyrelevant to cardiothoracic anaesthesia.Thecommittee will assess the outcome to thisapproach to awarding the Research Grantbefore deciding on its continuation.This year’sResearch Grant will be advertised with thesecond round of applications to the NIAAlater in the year and applications will have tobe completed on-line. I will notify of the exactdate for submission of application once it hasbeen set. Ravi Gill will be taking overrepresentation of ACTA at the NIAA later inthe year.

The purpose of the committee is to servethe best interests of ACTA’s members.

So, if you have any comments, criticisms orsuggestions about our work, then pleasecommunicate them to me or anothermember of the committee.

R Peter AlstonACTA ChairmanMarch 2010peter.alston@ed.ac.uk

In January, twenty eight representatives ofcardiothoracic units in the UK battled theirway through deep snow to attend the inauguralmeeting of the cardiothoracic intensivists inACTA subgroup ( or as it was agreed CIA forshort). The meeting was hosted byWythenshawe Hospital and the local organiserTim Strang hospitably showed interestedparties round the impressive facilities. Themeeting was chaired by Alistair Macfie fromGlasgow, ACTA honorary secretary and aftersome discussion on the terms of reference ofthe CIA group it was agreed that Alistair wouldlead the group initially which would alloweffective representation of CIA on the ACTAcommittee.

The aims of the CIA group are:

• To improve clinical standards in cardiacintensive care including developing policiesand guidelines.

• To enhance recognition of cardiac intensivecare as a subspecialty in the UK through thedevelopment of links with the Royal Collegeof Anaesthetists, the Intercollegiate Board forIntensive Care Medicine and the Society forCardiothoracic Surgery.

• To standardise training in cardiac intensivecare including the development of a syllabus.

• To develop a standard for training andrevalidation in ICM for cardiac anaesthetists.

• To promote education in the field of cardiacintensive care including running educationalmeetings.

• To collect data for clinical governance andbusiness management such as qualityindicators and benchmarking.

• To promote the development of research inthe cardiac intensive care setting

A presentation was made by Alistair Macfie onthe terms of reference and aims of CIA andthese proposals were debated extensively.Thisranged from how many representatives eachunit should have to what associations CIAshould have. The consensus was that themajority of cardiothoracic intensivists are alsoanaesthetists and CIA should be closely alignedwith ACTA. The issue of how manyrepresentatives did not reach unanimous

agreement but two seemed a reasonablecompromise. This can be reviewed in thefuture.

An excellent presentation was made by ChrisRigg from Hull on the development of acurriculum for training in cardiothoracicintensive care.This was very well received.

Tim Palfreman from Leeds presented a detailedand thoughtful exploration of clinicalgovernance arrangements in CICU. His clinicalgovernance toolkit would be a good templatefor most units to work towards. The exacttraining requirements for newly appointedconsultants with sessional commitments tocardiothoracic intensive care was discussedand the recent pronouncement by the RoyalCollege of Anaesthetists was highlighted.h t t p : / /www. rcoa . a c . uk /doc s /AnnexE -Advancedleveltraining.pdf

The desirability and availability of posts tosupport dual accreditation was discussed. TimStrang then shared his experience of attractingadvanced ICM trainees to CICU and stated thedesire that cardiothoracic intensive care didnot evolve in a way that lost the input ofcardiothoracic anaesthetists.

It was decided that educational meetings wouldbe held annually and CIA would aim to developeducational links with the Intensive CareSociety and the Society of Cardio-ThoracicSurgeons.

The issue of audit and data collection wasraised by Kamen Valchanov from Cambridgeand the development of a validated dataset forcardiothoracic ICU was supported. ICNARC isalready used by some units and could beadopted if the dataset could be validated forcardiothoracic surgical patients. Funding asalways was an issue for software purchase andprovision of administrative support for datainput. A pilot study of ICNARC incardiothoracic ICU was supported.

It is expected that representatives attendingCIA meetings will have the responsibility todisseminate information to their colleagues andfeedback their views to the CIA group. Finally,the next CIA meeting will be held at theEACTA meeting in Edinburgh.

Cardiothoracic IntensivistsChairman’s Report continued...

Chris Rigg,Alistair MacFie,Tim Strang,Tim Palfreman.

7

Kate Grebenik Feb 14 2010

Background to the Review

In 2001 following the enquiry into events atBristol Children’s Hospital the NHS

commissioned a review of paediatric cardiacsurgery in the UK. The ensuing publication -the Report of the Paediatric and CongenitalCardiac Services Review Group 2003 (knownas the Monro report) made recommendationson the structure and standards for paediatricsurgical centres. The recommendations of thisreport were accepted by Ministers except forthe one on minimum volumes of surgicalprocedures per centre. Ministers’ view wasthat the 300 minimum figure recommended inthe Report was not evidence-based, and thatrobust outcome data collection by theCongenital Cardiac Database did not supportclosure of any centres.

In May 2008 the National Health ServiceManagement Board (NHSMB) asked the

National Specialised Commissioning Group(NSCG) to undertake a further review of theprovision of paediatric cardiac surgicalservices in England.They were asked todevelop proposals for a safe and sustainablesurgical service for children with congenitalheart disease in England and to makerecommendations to NHSMB and Ministerswith a view to reconfiguration of the existingservice which is currently located in 11centres (Bristol, Southampton, Oxford,London x 3 (Royal Brompton, Great OrmondStreet and Guys & St Thomas’s), Birmingham,Leicester, Liverpool, Leeds and Newcastle).

Safe and Sustainable Review

The NHSCG set up a Steering group forthe ‘Safe and Sustainable Review’ chaired

by Dr Patricia Hamilton, immediate pastPresident of the Royal College of Paediatricsand Child Health.This group has

representation from the British CongenitalCardiac Association (2 surgeons and 2cardiologists), the Society of CardiothoracicSurgeons of Great Britain and Ireland, thePaediatric Intensive Care Society, the RoyalCollege of Paediatrics and Child Health, theRoyal College of Nursing, the Children’sHeart Federation, as well as Commissionersand Public Health officials. I have been amember of this group as a representative ofACTA.The most contentious issue (andbasically the hub of the Review) is therecommended number of surgeons and casesfor viable and sustainable surgical centres.

The NSCG commissioned a literaturereview to examine the relation between

volume and outcome in paediatric cardiac

surgeryi.The conclusion of this review wasthat whilst confirming an association betweenvolume and outcome in paediatric cardiacsurgery, there was not sufficient evidence tomake firm recommendations regarding the cutoff point for minimum volume of activity forpaediatric cardiac procedures overall, or forspecific high complexity procedures at eitherinstitutional or surgeon level.

Mindful of the impact of the EuropeanWorking Time Directive (WTD) and the

need for reasonable on call rotas, theSteering Group has agreed on a minimumnumber of four surgeons for each surgicalcentre. From this follows a minimum annualvolume of surgical activity of 4-500 cases.Given the annual number of surgical cases inthe under 16 age group is fairly static at about3600 this implies a reduction in the number ofsurgical centres to no more than 7 (from thecurrent 11). Catheter lab procedures will alsobe affected by this as no interventions ordiagnostic catheters will be performed atcentres without surgical cover.

A subgroup from the Steering Group wasasked to produce a set of standards for

paediatric cardiac surgical centres.These havetaken into account the critical framework ofinterdependencies laid out within thedocument ‘Commissioning Safe andSustainable Specialized Paediatric Services:A Framework of Critical Inter-Dependencies’.Each standard has a designation ranging from‘mandatory red’ (i.e. must be in place fordesignation as a cardiac centre), through‘mandatory amber’ (robust plans to achievethe standard within 12 months, or alternativeagreed timescale, must be in place), thenhighly desirable, desirable and value-added.The standards document is currently in itsfinal redraft prior to being signed off.

The standards group also requested adefinition of training for paediatric

cardiac anaesthetists.Together with Ian James,

Neil Morton and in consultation withmembers of the Congenital CardiacAnaesthesia Network, we have produced aguide for training in paediatric cardiacanaesthesia which attempts to lay down aminimum training requirement for newconsultants – this document is currently beingassessed by the specialist societies and theCollege.

The next stage of the Review process isthat the current centres will be assessed

for compliance with the standards –recognising that no centre currently fulfils allof the standards.This process will take placeduring May and June 2010.The assessmentteam will be led by Sir Ian Kennedy and willinclude a number of clinicians. It will report tothe NSC in July 2010.

Approximate timing of the subsequentevents is as follows:

The Steering Group will consider theassessment report and submit its advice

to the NSCG.The NSCG will then makerecommendations for reconfiguration, whichwill be presented for public consultation fromSeptember to December.After consideringthe public responses, the NSCG will make itsfinal decision on reconfiguration in Jan 2011.However the programme may still be taken tojudicial review if there is a huge outcry at theconclusion. In the current financial climate Iwonder if there will be sufficient moneyavailable for the necessary expansion of someunits if others are to close?

1 Ewart, HE.The relation between volume and

outcome in paediatric cardiac surgery.

(Oxford: Public Health Resource Unit, 2009).

Report on the ‘Safe and Sustainable’ review ofPaediatric Cardiac Surgical Services.

25th Annual Meetingof the

European Associationof Anaesthetists

Edinburgh InternationalConference Centre

Wednesday 9th to Friday11th June 2010.

Day registration now open!

More information athttp://www.eacta.org/

8

The background to this collaborative ofspecialist UK cardiothoracic centres can befound in the May 2009 ACTA Newsletter.http://www.acta.org.uk/ACTAS4Newsletters.aspTwenty seven of the 35 eligible UK centresparticipated in this voluntary bottom-upprogramme for the 12 month period endingMarch 2009.

Cardiac Critical Care (CICU), Primary PCIand Quality Accounting were the ‘special’topics for the 4th year of the collaborative.ACTA linkmen and CICU leads were heavilyinvolved in developing and collatinginformation for the first topic with the NCBCSteering Group. Availability of CICU is oftenthe key determinant of cardiac surgicalactivity. Critical care activity, staffing andendurable models of care are of majorinterest to clinicians, nurses and managers.

Twenty-three of the twenty-sevenparticipating NCBC centres completed thefinal 2008-09 CICU questionnaire. Provisionaldata was reported at the multidisciplinaryNCBC Annual Conference held at the King’sFund, London in November 2009.

In order to benchmark different levels ofworkload and use of resources, NCBC usedthe total number of major cardiac procedures,excluding transplants undertaken in the yearending March 2009 as the denominator.Although SCTS data suggests some variabilityin types of operation and predicted mortalitybetween centres, the cardiac surgicalpopulation and types of operation undertakenare relatively homogeneous. In contrast,thoracic surgical populations and operationsare much more heterogeneous andcomparisons between centres are moredifficult.

The median number of ‘pumps’ amongstparticipating units was 1050 - ranging from666 & 732 in Oxford and North Staffs to2000 & 2065 at Liverpool and Papworth.

Practically all Trusts now have dedicatedCardiac Critical Care Units.The mediannumber of open cardiac critical care beds(Level 2 & 3) during 2008/09 was 17, rangingfrom 9 in North Staffordshire to 60 atBrompton & Harefield. Reported percentagesof Level 3 beds ranged from 40% in Blackpoolto 100% in Central Manchester and Leeds.Annual number of pumps per CICU bed is apossible marker of efficiency particularly inthose Units predominately occupied byroutine cardiac surgical patients.The median annual number of pumps perstaffed (level 2 or 3) CICU bed was 60.Sheffield was an efficient outlier and reported1163 pumps going through 12 CCCU beds -or 97 pumps per CICU bed. Sheffield has anactive fast track programme and ~300 lowrisk cardiac surgical patients per year are fast-tracked through Recovery directly intomonitored Level 1 ward beds.

The median numbers of consultant (cardiactheatre & CICU) PAs and Critical CareNurses (Funded Establishment per 1000pumps were also examined. The mediannumber of adult cardiac anaesthetist (cardiactheatre & CICU) PAs per 1000 pumps was 72.Liverpool – a large Unit with no transplantactivity - was particularly efficient with anindex figure of 41 clinical consultant PAs per1000 pumps. Smaller Units and those withless trainee support unsurprisingly requiredgreater numbers of PAs. The median numberof Critical Care Nurses (FundedEstablishment per 1000 pumps) was 90.

Data was collected about the specialties andgrades of staff that provide Out of Hours(OOH) cover in the CICU. For the most partthe pattern is consistent across Trusts,however, because of the Working TimeRegulations (WTR), surgical trainingconsiderations, and, recruitment problems,several units are considering removingresident trainee cardiothoracic surgical coverfrom their hospitals at night. This has majorimplications for the provision ofcardiothoracic critical care services.Theremoval of resident trainee cardiothoracicsurgical cover has already occurred in somecentres.

Data were collected about the followingpossible markers of quality of care

• Average length of stay in critical care

• Percentage of patients who stay in criticalcare for longer than 48 hours

• Readmissions – the number of people (and%) who have to be readmitted to criticalcare

• The average length of stay of patients whohave to be readmitted to critical care.

The median percentage of critical carepatients staying longer than 48 hours was30%. This ranged from 9% in Newcastle to92% in an East Midlands Unit (a 10 foldvariation). The latter service has pressure onshared cardiology/cardiac surgery beds whichextend patients’ stays in CICU because of aninability to transfer out to a ward facility.

The median percentage for readmission was4%. This ranged from 0.4% in Bristol to 10.6%(a 26 fold variation). Of note is that Bristolhad a longer average length of stay (4.8 dayscompared with a median of 3.3 days).

Number of occupied beds per 1000 pumpswas also explored. The analysis suggests thatSouth Tees has the most efficient model ofcare (at 6.2 occupied beds for 1000 patients).At the other end of the spectrum, three Unitsincluding Bristol required >12 beds per 1000patients. Although less efficient than SouthTees, the latter Units may be offering a betterquality of care.

The large variation in bed occupancy rateswas greater than anticipated. Differences inpreoperative surgical risk between centres donot appear to account for this variability.Although there are differences in predictedpercentage mortality by EuroSCORE betweencentres, most NHS centres have predictedmortality rates by EuroSCORE of between 3-5%. (SCTS 6th National Adult CardiacSurgical Database Report, 2008).There was noobvious relationship between bed occupancyper 1000 cases and reported predictedmortality in the 6th NCAD report. Althoughtime periods differ slightly between ourrespective study periods, we believe that adultcardiac surgical populations and averageEuroSCORE are relatively stable in mostcentres. Different proportions of non cardiacsurgical patients may also contribute to thisvariability and will be studied in more detail infuture NCBC projects.

National Cardiothoracic Benchmarking Collaborative (NCBC)Update for spring 2010 ACTA Newsletter.

Jonathan Mackay

9

Given that CICU bed (or rather nurse)availability is frequently the majorfactor determining cardiac surgicalthroughput in most Units; this data haspotentially important implications foroptimal usage of finite resources.

This is just a snapshot of the 2009 NCBCdata. The full 2009 report is currently beingprepared and will shortly be available on-lineand in print to participating centres. TheACTA Committee and NCBC Steering Groupwould like to thank the ACTA linkmen forsubmitting detailed accurate data and theirmajor contribution to this exercise. Specialthanks also to Drs James Hillier for presentingpotential benefits of Bristol’s graduated caremodel and Chris Allsager for sharingLeicester’s attempts to integrate their cardiacand general ICU services with the King’s Funddelegates.

NCBC are currently recruiting centres for2010. More information can be obtained fromDr Rebecca Miles – Oxford HealthcareAssociates ohamailbox-ncbc@yahoo.co.uk

Jon MackayJ-P van BesouwACTA members of NCBC Steering Group

NCBCContinued

There has been quite a lot happening in EACTAover the past 18 months, so I thought it wastime for a more comprehensive update for thisedition of ACTA News.Apologies to any of youwho know all of this already.

Membership issuesThe linkage between EACTA and ACTA forcollection of joint subscription via ACTA directdebit was terminated in 2009. UK members ofEACTA who previously had a joint subscriptionneed to take steps to renew their EACTAmembership if they have not already done so.There is still a discounted 3-year membershipof EACTA, and the subscription includesdiscounted on-line access to the Journal ofCardiothoracic and Vascular Anaesthesia (papercopy costs an additional Euro 20).The databaseof UK members has a lot of out-of-dateinformation as a result of members changingjobs, homes or email addresses. It would behelpful if you could check/update your contactinformation with the EACTA secretariat ateacta@ovation.ie, or alternatively email yourdetails to me and I will check/amend asnecessary.

Annual meeting,Athens 2009The annual meeting in 2009 took place in theDivani Caravelle hotel, with over 400participants. The welcome reception was heldin the building that hosted the first of themodern Olympic games.At the RepresentativeCouncil meeting, John Gothard (Brompton)stood down as Hon Sec, and Peter Alston(Edinburgh) was nominated to replace him.

EACTA training accreditationIn 2007 the boards of EACTA and ESAproduced a consensus document for educationand training in anaesthesia for cardiothoracicand major vascular surgery (available on themembers only area of the EACTA website).This document allows for peer accreditation oftraining programmes by either organisation,such that Fellows who complete an accreditedprogramme may be given a certificate to thateffect by the training institution. Leipzigreceived approval for their program in 2008and Southampton gained approval in 2009. Tobe eligible for approval, the application to theEACTA Directory Board must address thebasic structure for a two-year Fellowshipprogramme outlined in the consensusdocument.

Echo trainingEACTA and the European Association ofEchocardiography have developed a jointprogram for accreditation in TOE, with aEuropean examination, and Certification aftercompletion of a log-book and practical training.The first examination took place in Montpellier

in 2005, and takes place twice per year, at theEuroecho meeting in December and at theEACTA meeting in May-June. EACTA startedrunning its own annual echo course, usually inSeptember, in 2002.The course in Leicester in2009 had the highest number of delegates sofar, close to 200. EACTA Echo 2010 will takeplace in Berlin 11-14 September.

International collaborationAs well as European collaboration in echo andaccreditation of training programmes, EACTAhas pursued other initiatives for collaborationin cardiothoracic and vascular anaesthesia:

EACTS - The first formal contact between thetwo societies was in 2007. Subsequently, theratification of this relationship led to theorganization of joint sessions at EACTA Athens2009 (transcatheter valves), and EACTS Vienna2009 (treatment of the elderly surgical patient).

SCA - The International Congress onCardiothoracic and Vascular Anaesthesia inBerlin 2008 was organized jointly by EACTAand the SCA. During the meeting, a commonpathway was started for a joint organization offuture ICCVA meetings. From 2009 an EACTArepresentative is included within the SCAboard and a SCA representative within theEACTA board.

Research grantsThe closing date for the 2010 round of EACTAresearch grants is 31 October. Application isrestricted to EACTA members; funding of up toEuro 25,000, split between up to threeprojects, is available annually.

Future meetingsEACTA 2010, if you did not already know, willbe in Edinburgh in conjunction with the ACTAmeeting 9-11 June. Subsequent meetings will bein Vienna (2011), Amsterdam (2012) andBarcelona (2013).

David SmithUK Representative Council memberdavid.smith@suht.swest.nhs.uk

EACTA News

Aspirin and TranexamicAcid for CoronaryArtery Surgery(ATACAS)A randomised controlled trial

The ATACAS Trial is a large internationalstudy of aspirin and tranexamic acid forcoronary artery surgery.ATACAS will havea booth in the Trade Exhibition at thisyear’s EACTA meeting in Edinburgh, June9-11, and are seeking new centres to joinin their effort. If you are attending, pleasecome and say hello.The study providesfunding of around £350 per patientenrolled. If you are not attending theEACTA Meeting, you can find out moreinformation about ATACAS athttp://www.atacas.org.au/ or by emailingadmin@atacas.org.au.

You may read Paul Myles’s article in thelast edition of ACTA News, published inOctober 2009.

Editor.

10

Echo News March 2010

Another year speeding by, the main eventof this year for UK Echo is the ACTA

Echo meeting in St Andrews on the 8th June.This is being held in the Gateway conferencecentre close to the Old Course, home of golf,the famous beach where Chariots of Fire wasfilmed & the ancient town of St Andrews itself.

The programme has 3 sessions on 3D withDr Jack Shanewise on Mitral valve

assessment, Dr Sean Bennett on ventricularassessment and Dr Justiaan Swanevelder oncongenital lesion. Dr Mark Patrick is talkingabout echo on bypass, when traditionally weput the probe down.

The afternoon concentrates on echo in theICU, a hot topic at the moment. More on

that later. Dr Fabio Guarrancio onhaemodynamic assessment, Dr Raj Sharma onecho in renal failure & Dr Susanna Price onecho for weaning.There is a pro/con debate on“is 3D superior to 2D for mitral valve repair”,with Dr Steve Kondstadt for 2D & Dr AnitaMacnab on 3D.The final session is the “weakestecho” as featured in EACTA echo lastSeptember with yours truly aided and abettedby Dr John Kneeshaw.

Advanced accreditation for intensivists inecho is still under debate. The exact

format the exam is to take hasn’t been agreed.The logbook case mix will be different and canhave both TTE and some TOE images.The BSEhoped to run the first exam this year but thisis looking unlikely at the moment. The TOE subgroup met and have concerns over theadvanced accreditation in that if it is toodifficult to achieve it runs the risk ofdisenfranchising the intensivists. PerioperativeToe accreditation will still be available andbasic level provided by FEEL/FATE. We areliaising with a group of intensivists regardingtraining for echo in intensive care and the levelrequired.

The TOE exam this year will be onNovember 18th in Brighton prior to the

ACTA meeting on the Friday.The last exam sawmore cardiologists than anaesthetists sit theexam.The pass mark was 67%, which is similarto previous years.

Many are sitting the exam but notsubmitting a logbook. The exam is only

part of the accreditation process and tocomplete full accreditation this must besubmitted.

Nottingham are running their pre-examcourse this year and are also hosting the

second 3D meeting in April. This was anexcellent meeting last year and promises to beagain. Unfortunately it clashes with anAssociation meeting on echo for non cardiacsurgery and intensive care which I’m involvedwith so unfortunately, I will miss it.

EACTA in Edinburgh have an echo session aspart of their programme and is concentratingon the right ventricle. EACTA echo is in Berlinthis year in September, hosted by Johann Erb.

There has been a lot of correspondence onthe cleaning of TOE probes. While it is

ideal to sterilise each probe in a specificmachine most of us do not have the luxury ofspare probes to allow for an hour turnaroundtime. The currently available methods mostwidely in use are antisporicidal wipes, likeTristel with their tracking system and/orsheaths.

I hope to see you inSt Andrews.

Donna Greenhalgh