1. Improving the quality of medical and surgical care NCEPOD Dr Marisa Mason

2. Improving the quality of medical and surgical care Method  Topic selection  Clinically led  Organisational data  Clinical data  Multidisciplinary peer review  Care reviewed and graded  Opinion based  Overall quality of care assessed on a 5 point scale

3. Improving the quality of medical and surgical care Reports

4. Improving the quality of medical and surgical care Reports

5. Improving the quality of medical and surgical care Common themes  Organisational facilities  Centralisation of services  Multidisciplinary care  Improving data quality to measure change

6. Improving the quality of medical and surgical care Evidence

7. Improving the quality of medical and surgical care Changing the way we operate  16% of patients had an indication for ICU or HDU care but did not receive it Hospitals should identify, quantify and improve inadequacies in their critical care facilities

8. Improving the quality of medical and surgical care Changing the way we operate Surgeons and anaesthetists should partake in multidisciplinary audit, specialists meeting together to discuss improvements in care.

9. Improving the quality of medical and surgical care Who Operates When II All essential services (including emergency operating rooms, recovery rooms, high dependency units and intensive care units) should be provided on a single site wherever emergency/acute surgical care is delivered

10. Improving the quality of medical and surgical care AAA 11 large units and 61 intermediate sized units reported doing 10 or less emergency repairs in 2002/3

11. Improving the quality of medical and surgical care AAA

12. Improving the quality of medical and surgical care AAA Authorities should review whether elective aortic aneurysm surgery should be concentrated in fewer hospitals. 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.

13. Improving the quality of medical and surgical care AAA Strategic Health Authorities and Trusts should co-operate to ensure that only surgeons with vascular expertise operate on emergency aortic aneurysm patients, apart from exceptional geographical circumstances. Anaesthetic departments should review the allocation of vascular cases so as to reduce the number of anaesthetists caring for very small volumes of elective and emergency aortic surgery cases. Trusts should ensure that anaesthetists can identify the major cases that they have managed in order to support audit and appraisal.

14. Improving the quality of medical and surgical care Surgery in the Elderly This report makes depressing reading. Too often it suggests a pattern of “one size fits all medicine” being applied to a heterogenous population with varying needs and falling short in ways which are both predictable and preventable.

15. Improving the quality of medical and surgical care Surgery in the Elderly

16. Improving the quality of medical and surgical care Abdominal surgery Advisors judged the operation not to be performed in a timely manner in 41/190 cases in this group Junior staff failed to seek advice about patient management or surgery in 39/186 of patients Input from Care for the Elderly was infrequent and markedly less than in patients admitted with a #NOF

17. Improving the quality of medical and surgical care Surgery in the Elderly Routine daily input from Care of Older People should be available to elderly patients undergoing surgery and is integral to inpatient care pathways in this population. (Trusts, Clinical Directors and Commissioners) There is an ongoing need for provision of peri-operative level 2 and 3 care to support major surgery in the elderly, and particularly those with co-morbidity. (Commissioning Leads, Trusts, Clinical Directors)

18. Improving the quality of medical and surgical care Surgery in the Elderly Delays in surgery for the elderly are associated with poor outcome. They should be subject to regular and rigorous audit in all surgical specialities, and this should take place alongside identifiable agreed standards.

19. Improving the quality of medical and surgical care Knowing the Risk Reasons for delay: Lack of surgeon Lack of anaesthetist Lack of theatre space. The delay affected outcome in 9 patients.

20. Improving the quality of medical and surgical care Knowing the Risk  ‘Who Operates When 1997’ (51%)  ‘Who Operates When II 2003’ (63%)  ‘Caring to the End 2009’ (87%)  ‘CEPOD’ theatre availability had dropped to 72.5% in this study

21. Improving the quality of medical and surgical care Knowing the Risk In patients undergoing intra abdominal surgery there was a fivefold increase in mortality for non-elective cases.

22. Improving the quality of medical and surgical care Knowing the Risk  Intra-operative monitoring for high risk patients rarely included cardiac output monitoring despite the evidence base  8.3% of high risk patients who should have gone to a higher care level area postoperatively did not do so  Critical care was the post operative location for 1 in 5 high risk patients. Most high risk patients return to ward care  Advisors’ opinion was that care was good in less than half the cases – and not just in this study

23. Improving the quality of medical and surgical care What has changed... and the knock-on effect leaving the recs unmet  Centralisation of services – what about the emergency that pitch up elsewhere - and is this done in isolation, specialty by specialty  Introduction of networks – good but often informal therefore more emphasis is needed on formalising them  Development of protocols – the need to be standardised across hospitals and used!

24. Improving the quality of medical and surgical care What has changed... and the knock-on effect leaving the recs unmet  Reduction in inappropriate out of hours surgery by junior staff – ‘CEPOD’ theatres – if ‘some’ specialist surgery is centralised elsewhere will they decline and they still don’t exist everywhere – leading to delays  Some improvement in facilities – ICU beds – there has been an increase, but they need to be used effectively – local activity needs to be known – multidisciplinary working  Increase in audits/data collections –national and local but the data needs to be used effectively to plan services

25. Improving the quality of medical and surgical care What can you do  Encourage Trusts to act on our recommendations  Encourage using audit and improve data collection – if hospitals are clear on their activity then forward planning will be easier  Encourage multidisciplinary working  Remove the perception that is all too difficult by highlighting common issues across different hospitals in your area  Remove the perception that is too expensive – if the data is known the service can be planned accordingly

26. Improving the quality of medical and surgical care What can NCEPOD do  Recommendation checklists  Organisational data – could be combined  Audit toolkits

27. Improving the quality of medical and surgical care Thank you