1. 1989 Microsoft released ‘Office’ suite Berlin Wall comes down George Bush snr. becomes President USSR pulls out of Afghanistan First NCEPOD Report

2. The Origins

3. Recent Reports

4. www.ncepod.org

5. Method Organisational data Prospective data Peer Review

6. 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

7. 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.

8. 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

9. Case collection Prospective data –Clinical form Retrospective case data –Patient identifier spreadsheet –ONS data Peer review data –Case note extracts Organisational data

10. Thank You www.ncepod.org

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

12. Organisational Data

13. Theatre availability 1800-2359 183(83%) 2359-0759 183(83%)

14. Previous NCEPOD Reports WOW I199751% WOW II200363% Caring to End200987% Knowing the Risk201172.5%

15. 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 2003 15

16. Critical care provision

17. Systems for recognition 90.2% 9.8%

18. 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

19. Prospective Data

20. Age Mean age 56 Gender 55% Female

21. Body Mass Index

22. ASA grade

23. Urgency of surgery

24. Comorbidities

25. Risk assessment What we did –Subjective assessment View of anaesthetist Why –Ease –Prospective –Own assessment

26. Risk assessment

27. Risk and age

28. Risk and ASA status

30. 30 day outcome

31. 6 month outcome data

32. Pre-admission assessment

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

34. 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%

35. Postoperative location High risk patients

36. 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

37. 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%

38. 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

39. 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

40. 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

41. 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

42. Peer Review Data

43. Method Prospective dataset19,097 Designated high risk 3,734 Qualitative review829

44. Descriptive Data

45. Age

46. Body Mass Index Data taken from Table 4.1

47. ASA grade

48. Comorbidities Data taken from Table 4.3

49. Urgency of surgery Data taken from Table 4.4

50. Outcome data

51. Risk Assessment

52. Anaesthetists vs. Advisors 22.5% electiveNot high risk 14.6% non-electiveNot high risk Subjective view

53. Objective view – Lee Index High risk 2752 / 18829 (14.6%) In line with available literature

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

55. Pre-operative Assessment

56. Planned admissions

58. Enhanced recovery programme Only 19/550 documented

59. Comorbidities

60. Comorbidities - Optimisation

61. Documented mortality risk

62. Pre-operative Care

63. Pre-operative hypovolaemia & mortality

64. Pre-operative fluid optimisation

65. Location of fluid management

66. Pre-operative fluid management and mortality

68. Postoperative Care

69. Correct postoperative location

70. Effect of correct location on outcome

71. Standards of care

72. 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

73. 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.

74. 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.

75. www.ncepod.org