method two month data collection period (feb-mar 2004) nhs and independent hospitals in england,...
TRANSCRIPT
![Page 1: Method Two month data collection period (Feb-Mar 2004) NHS and independent hospitals in England, Wales, N Ireland, Guernsey, Isle of Man and Defence Secondary](https://reader035.vdocuments.net/reader035/viewer/2022062322/56649ea25503460f94ba6705/html5/thumbnails/1.jpg)
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Method
• Two month data collection period (Feb-Mar 2004)
• NHS and independent hospitals in England, Wales, N Ireland, Guernsey, Isle of Man and Defence Secondary Care Agency
• Adults >=16 years of age• Open repair; endovascular repair;
diagnosed but not treated and died in hospital
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Method (cont)
• Expected sample size was 1129 operated cases and 106 non-operated cases
• Questionnaire sent to combination of surgeon, anaesthetist and radiologist
• No casenote review• Organisational questionnaire for each
hospital• Risk stratification planned using a
published model• Multidisciplinary advisory group
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Data overview – hospital participation
• 226 hospitals identified as possibly undertaking AAA repair
• 188 completed organisational questionnaires
• 181 eligible to take part in study (163 NHS and 18 independent)
• 87% participation rate for clinical questionnaires
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Data overview – hospital participation
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Organisation of vascular services
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Size of vascular unit
• Large• 500,000 patients, 4 surgeons,
potential for vascular surgical on-call rota
• Intermediate• <500,000 patients, fully equipped for
vascular surgery, not enough surgeons for on-call rota
• Remote• Remote, small catchment population
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Size of vascular unit
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Availability of imaging during the daytime
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Availability of imaging out of hours
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Recommendation
Trusts should ensure the availability outside normal working hours of radiology services including CT scanners.
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Numbers of elective open operations 2002/03
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Numbers of emergency open operations
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Outcome of elective cases by volume of cases
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Outcome of emergency cases by volume of cases
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Published evidence
• Improved outcomes for unruptured AAA when higher volumes performed by:• surgeons• hospitals
• US recommendation – hospitals should perform 50 cases/year
• 19/181 hospitals in this study performed 50 or more cases/year
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Recommendation
Clinicians, purchasers, Trusts and Strategic Health Authorities should review whether elective aortic aneurysm surgery should be concentrated in fewer hospitals.
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Vascular surgical on-call rotas
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Vascular anaesthetic on-call rotas
• 3% (5/178) of hospitals reported that they had an anaesthetic on-call rota for vascular surgery
• Should large vascular units implement anaesthetic vascular on-call rotas?
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Interventional radiology on-call rotas
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Destination after AAA repair
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Use of recovery areas after elective surgery
• 4 hospitals reported that the recovery area was the preferred destination
• 9% of elective patients were reported to have been cared for in recovery areas for a substantial period of time (from the anaesthetic questionnaire)
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Recommendation
Major elective surgery should not take place unless all essential elements of the care package are available.
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Outcome of elective open repair
Overall mortality was 6.2%
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Outcome after emergency admission with ruptured AAA, all patients
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Palliative care vs. operation on emergency admission with AAA
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Outcome after emergency admission with unruptured AAA, all patients
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Patient information
• How much information should be given to patients on the organisation of vascular services?
• How should this information be provided?
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Surgical open repair
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Mode of admission
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Age
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Age and outcome
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Waiting times
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Cancellations
• 1 in 25 patients cancelled because no ward bed
• 1 in 6 patients cancelled because no critical care bed
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Recommendation
Patients with an aortic aneurysm requiring surgery must have equal priority with all other patients with serious clinical conditions for diagnosis, investigation and treatment.
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Trusts should take action to improve access to Level 2 beds for patients undergoing elective aortic aneurysm repair so as to reduce the number of operations cancelled and inappropriate use of Level 3 beds.
Recommendation
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Preoperative assessment clinic
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Comorbidities
• Cardiac history and signs associated with increased risk of death
• Diabetes carried no additional risk of death in this study
• Increased risk of death among morbidly obese or cachectic patients
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Trusts should ensure that clinicians of the appropriate grade are available to staff preoperative assessment clinics for aortic surgery patients.
Recommendation
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Length of operation
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Grade of surgeon
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Specialty of surgeon
75%
25%
<1%
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Membership of Vascular Society and outcome
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Surgeons workload
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Postoperative complications within 30 days of surgery
• 21% had an infective complication, most commonly of the chest and wound
• 7% had a myocardial infarct, nearly half these patients died
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Emergency surgery
• Unscheduled admission
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Age and outcome
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Comorbidities
• Higher risk of death in patients with cardiac disease, diabetes, morbid obesity or cachexia
• Mortality increased among patients not fully conscious, though 2/7 patients with GCS below 9 did survive
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Time to operation
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Length of operation
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Grade of surgeon
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Specialty of surgeon
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Membership of the Vascular Society and outcome
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Surgeons workload
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Workload and outcome
• The best results were seen among patients operated on by surgeons who also performed the most elective aneurysm repairs
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Postoperative complications within 30 days of surgery
• 1 in 5 patients had a chest infection
• Graft complications were more common than in elective repairs
• 21 of 37 patients who had an MI died
• Renal impairment also carried a high risk of mortality
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Recommendation
Strategic Health Authorities and Trusts should co-operate to ensure that only surgeons with vascular expertise operate on emergency aortic aneurysm patients, apart from in exceptional geographic circumstances.
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Anaesthesia
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Use of beta blockers in AAA patients
Elective open operations
Emergency open operations 26%
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Use of statins in AAA patients
Elective open operations
Emergency open operations 31%
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Preoperative investigations – large units
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Preoperative investigations – intermediate sized units
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Most senior anaesthetist at the start – elective open operations
Range 81% - 94%
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Most senior anaesthetist at the start – emergency open operations
Range 70% - 88%
In 27 cases a consultant assumed responsibility after the start of anaesthesia – overall 97%
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Information about the numbers of cases done by anaesthetists
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Recommendation
Trusts should ensure that anaesthetists can identify the major cases that they have managed in order to support audit and appraisal.
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Numbers of elective open operations, 2002/03
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Outcome and volume, elective operations, in this study
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Numbers of emergency open operations, 2002/03
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Outcome and volume, emergency operations, in this study
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Recommendation
Anaesthetic departments should review the allocation of vascular cases so as to reduce the number of anaesthetists caring for very small numbers of elective and emergency aortic surgery cases.
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Epidural analgesia
• 92% (345/377) of open elective operation patients received an epidural catheter
• 168 received aspirin in the 7 days before surgery
• 61 received fractionated heparin within 6 hours of surgery
• In 55 cases the anaesthetist did not know when the catheter was removed
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Recommendation
Trusts should ensure that they have robust systems for the postoperative care of epidural catheters with accompanying appropriate documentation.
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Destination after elective open surgery
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Management of temperature, all open patients
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Mechanical ventilation of the lungs after elective open surgery
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Recommendation
Anaesthetic departments and critical care units should review together whether vascular surgery patients who routinely receive postoperative mechanical ventilation could be managed in a Level 2 High Dependency facility breathing spontaneously.
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Endovascular aneurysm repair
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Demographics
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Reason for decision to treat with endovascular repair
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Status of aneurysm
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Length of procedure
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Destination after the procedure
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Complications
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Outcome
• All patients on whom we had data were alive at 30 days (47/53)
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The care of patients who did
not undergo surgery
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Demographics
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Demographics
• 36% were female, vs. 29% of the emergency operated patients
• 43% were known to have an AAA, vs. 26% of the emergency operated patients
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Selection of patients
• It was not possible to test the NCEPOD data against the Hardman criteria
• Patients aged 80 years or over• 55% of patients aged 80 or over
received surgery vs. 90% of patients under 80 years
• Of 68 patients who received surgery• 37% discharged alive within 30 days• 9% alive but still in hospital
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Effect of size of vascular unit
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Other associations with decision to provide operative, not palliative, care• Membership of Vascular Society• Presence of a surgical vascular on-
call rota• NCEPOD has confirmed the difficulty
of drawing robust conclusions about the decision to provide palliative care
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