1989
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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
www.ncepod.org
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 1st and 7th 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
www.ncepod.org
Thank You
Data returns
Clinical forms returned
19,097
Cases matched with outcome
13,513
Cases returned for peer review
1,026
Cases suitable for peer review
829
Organisational Data
Theatre availability
• 1800-2359
• 2359-0759
183 (83%)
183 (83%)
Previous NCEPOD Reports
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•
•
•
WOW I
WOW II
Caring to End
Knowing the Risk
1997
2003
2009
2011
51%
63%
87%
72.5%
WOW to WOW II
WOW I 1997
WOW II 2003
• 20% ops OOH by SHO
• 6% ops OOH by SHO
• 47% anaes’ OOH by SHO
• 25% anaes’ OOH by SHO
• 51% hospitals had
“CEPOD” theatres
• 63% hospitals had
“CEPOD” theatres**
• 25% of non-elective cases
in CEPOD theatre
• 70% of non-elective cases
in CEPOD theatre
15
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
Risk and ASA status
30 day outcome
6 month outcome data
Pre-admission assessment
High risk intra abdominal surgery
mortality
Intra abdominal surgery
high risk 8.5%
low risk 0.7%
Gut resection
high risk 11.1%
low risk 1.9%
Postoperative location
All patients
6.7% went to HDU / ICU
? Ideal location – Yes 97.9%, No 2.1% (353)
Mortality Ideal location
Not ideal
1.4%
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
Recognition
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.
Recommendations
Planning and information
Decision to operate (particularly nonelective) 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.
Recommendations
Intra operative care
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.
Recommendations
Post operative care
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.
Peer Review Data
Method
• Prospective dataset
19,097
• Designated high risk
3,734
• Qualitative review
829
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% elective
• 14.6% non-elective
Not high risk
Not high risk
Subjective view
Objective view – Lee Index
• High risk 2752 / 18829 (14.6%)
• In line with available literature
Where does risk lie?
• Operative factors
3%
• Patient factors
62%
• Both
35%
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 preassessment 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 preoperatively.
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.
www.ncepod.org