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

Method Organisational data Prospective data Peer 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 1 st and 7 th 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

Data returns Clinical forms returned19,097 Cases matched with outcome13,513 Cases returned for peer review1,026 Cases suitable for peer review829

Organisational Data

Theatre availability (83%) (83%)

Previous NCEPOD Reports WOW I199751% WOW II200363% Caring to End200987% Knowing the Risk %

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 1997WOW II

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

30 day outcome

6 month outcome data

Pre-admission assessment

High risk intra abdominal surgery mortality Intra abdominal surgeryhigh risk8.5% low risk0.7% Gut resectionhigh risk11.1% low risk1.9%

Postoperative location All patients 6.7% went to HDU / ICU ? Ideal location – Yes 97.9%, No 2.1% (353) Mortality Ideal location1.4% Not ideal 5.0%

Postoperative location High 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 dataset19,097 Designated high risk 3,734 Qualitative review829

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% electiveNot high risk 14.6% non-electiveNot high risk Subjective view

Objective view – Lee Index High risk 2752 / (14.6%) In line with available literature

Where does risk lie? Operative factors3% Patient factors62% Both35% Higher risk = Older Higher ASA Comorbidities

Pre-operative Assessment

Planned admissions

Enhanced recovery programme Only 19/550 documented

Comorbidities

Comorbidities - Optimisation

Documented mortality risk

Pre-operative Care

Pre-operative hypovolaemia & mortality

Pre-operative fluid optimisation

Location of fluid management

Pre-operative fluid management and mortality

Postoperative Care

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.