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1989• Microsoft released ‘Office’ suite• Berlin Wall comes down• George Bush snr. becomes President• USSR pulls out of Afghanistan• First NCEPOD Report
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The Origins
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Recent Reports
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www.ncepod.org
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MethodOrganisational dataProspective dataPeer Review
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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
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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.
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Study population
• Over 16 years old undergoing inpatient
surgery between 1st and 7th March 2010
inclusive
• Exclusions
– Day cases, Obstetric, Cardiac, Transplant &
Neurosurgery cases
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Case collection
• Prospective data– Clinical form
• Retrospective case data– Patient identifier spreadsheet– ONS data
• Peer review data– Case note extracts
• Organisational data
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Thank You
www.ncepod.org
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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
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Organisational Data
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Theatre availability
• 1800-2359 183 (83%)• 2359-0759 183 (83%)
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Previous NCEPOD Reports
• WOW I 1997 51%• WOW II 2003 63%• Caring to End 2009 87%• Knowing the Risk 2011
72.5%
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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
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Critical care provision
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Systems for recognition
90.2%
9.8%
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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
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Prospective Data
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Age
• Mean age 56 • Gender 55% Female
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Body Mass Index
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ASA grade
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Urgency of surgery
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Comorbidities
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Risk assessment
• What we did
– Subjective assessment
• View of anaesthetist
• Why
– Ease
– Prospective
– Own assessment
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Risk assessment
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Risk and age
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Risk and ASA status
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Risk and ASA status
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30 day outcome
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6 month outcome data
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Pre-admission assessment
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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%
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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%
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Postoperative locationHigh risk patients
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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
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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%
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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
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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
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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
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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
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Peer Review Data
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Method
• Prospective dataset 19,097
• Designated high risk 3,734
• Qualitative review 829
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Descriptive Data
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Age
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Body Mass Index
Data taken from Table 4.1
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ASA grade
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Comorbidities
Data taken from Table 4.3
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Urgency of surgery
Data taken from Table 4.4
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Outcome data
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Risk Assessment
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Anaesthetists vs. Advisors
• 22.5% elective Not high risk
• 14.6% non-elective Not high risk
Subjective view
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Objective view – Lee Index
• High risk 2752 / 18829 (14.6%)
• In line with available literature
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Where does risk lie?
• Operative factors 3%
• Patient factors 62%
• Both 35%
Higher risk = OlderHigher ASA
Comorbidities
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Pre-operativeAssessment
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Planned admissions
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Enhanced recovery programme
Only 19/550 documented
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Comorbidities
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Comorbidities - Optimisation
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Documented mortality risk
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Pre-operativeCare
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Pre-operative hypovolaemia & mortality
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Pre-operative fluid optimisation
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Location of fluid management
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Pre-operative fluid management and mortality
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PostoperativeCare
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Correct postoperative location
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Effect of correct location on outcome
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Standards of care
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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
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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.
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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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www.ncepod.org