2. 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

3. 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

4. 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

5. Data overview – hospital participation

6. Organisation of vascular services

7. Size of vascular unit Large Intermediate Remote
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

8. Size of vascular unit

9. Availability of imaging during the daytime

10. Availability of imaging out of hours

11. Recommendation
Trusts should ensure the availability outside normal working hours of radiology services including CT scanners.

12. Numbers of elective open operations 2002/03

13. Numbers of emergency open operations

14. Outcome of elective cases by volume of cases

15. Outcome of emergency cases by volume of cases

16. 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

17. Recommendation
Clinicians, purchasers, Trusts and Strategic Health Authorities should review whether elective aortic aneurysm surgery should be concentrated in fewer hospitals.

18. Vascular surgical on-call rotas

19. 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?

20. Interventional radiology on-call rotas

21. Destination after AAA repair

22. 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)

23. Recommendation
Major elective surgery should not take place unless all essential elements of the care package are available.

24. Outcome of elective open repair
Overall mortality was 6.2%

25. Outcome after emergency admission with ruptured AAA, all patients

26. Palliative care vs. operation on emergency admission with AAA

27. Outcome after emergency admission with unruptured AAA, all patients

28. Patient information
How much information should be given to patients on the organisation of vascular services?
How should this information be provided?

29. Surgical open repair

30. Mode of admission

31. Age

32. Age and outcome

33. Waiting times

34. Cancellations 1 in 25 patients cancelled because no ward bed
1 in 6 patients cancelled because no critical
care bed

35. 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.

36. Recommendation
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.

37. Preoperative assessment clinic

38. 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

39. Recommendation Trusts should ensure that clinicians of
the appropriate grade are available to
staff preoperative assessment clinics for
aortic surgery patients.

40. Length of operation

41. Grade of surgeon

42. Specialty of surgeon
<1%
25%
75%

43. Membership of Vascular Society and outcome

44. Surgeons workload

45. 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

46. Emergency surgery
Unscheduled admission

47. Age and outcome

48. 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

49. Time to operation

50. Length of operation

51. Grade of surgeon

52. Specialty of surgeon

53. Membership of the Vascular Society and outcome

54. Surgeons workload

55. Workload and outcome
The best results were seen among patients operated on by surgeons who also performed the most elective aneurysm repairs

56. 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

57. 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.

58. Anaesthesia

59. Use of beta blockers in AAA patients
Elective open operations
Emergency open operations 26%

60. Use of statins in AAA patients
Elective open operations
Emergency open operations 31%

61. Preoperative investigations – large units

62. Preoperative investigations – intermediate sized units

63. Most senior anaesthetist at the start – elective open operations
Range 81% - 94%

64. Most senior anaesthetist at the start – emergency open operations
In 27 cases a consultant assumed responsibility after the start of anaesthesia – overall 97%
Range 70% - 88%

65. Information about the numbers of cases done by anaesthetists

66. Recommendation
Trusts should ensure that anaesthetists can identify the major cases that they have managed in order to support audit and appraisal.

67. Numbers of elective open operations, 2002/03

68. Outcome and volume, elective operations, in this study

69. Numbers of emergency open operations, 2002/03

70. Outcome and volume, emergency operations, in this study

71. 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.

72. 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

73. Recommendation
Trusts should ensure that they have robust systems for the postoperative care of epidural catheters with accompanying appropriate documentation.

74. Destination after elective open surgery

75. Management of temperature, all open patients

76. Mechanical ventilation of the lungs after elective open surgery

77. 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.

78. Endovascular aneurysm repair

79. Demographics

80. Reason for decision to treat with endovascular repair

81. Status of aneurysm

82. Length of procedure

83. Destination after the procedure

84. Complications

85. Outcome
All patients on whom we had data were alive at 30 days (47/53)

86. The care of patients who did
not undergo surgery

87. Demographics

88. 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

89. 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

90. Effect of size of vascular unit

91. 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