functioning as a team? the 2002 report of the national confidential enquiry into perioperative...
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FUNCTIONIN
G AS A
TEAM?The 2002 Report
of the National
Confidential
Enquiry
into
Perioperative
Deaths
Study method
• April 2000 to March 2001• Deaths on day of or within 3
days of surgery• First occurrence for each
surgeon
Sample size
Total deaths reported21 991
Included20 736
Excluded1255
Died within 3 days7184 (35%)
Died between 4 & 30 days13 552 (65%)
Surgical Qs analysed2114
Anaesthetic Qs analysed1911
Reporting all deaths
• 70/216 trusts/groups> 25% difference in number of deaths from 99/00
• 46% of cases reported more than 3 months after death
• Approximate 4% of cases mis-reported
• Unable to trace consultant anaesthetist in 5% of sample cases
Facilities
• Questions previously in individual clinical questionnaires
• Information needed by hospital
• 81% return rate• Data questionable in some
cases
Recovery facilities
• Previous anecdotal evidence of delays caused to operating lists due to lack of recovery beds
• 237 hospitals had less than 1.5 recovery beds/theatre
Staffing of ICUs
• 32% had less than 7 sessions/week
• 12% of ICUs had no funded consultant sessions
• ICS guideline - 10 fixed + 5 flexible
• NCSC regulations - patients to be seen twice daily by consultant
Recommendation
Management should ensure that an appropriate number of funded sessions for consultants trained in critical care are allocated to the ICU to allow appropriately qualified medical staff to be available to the ICU at all times
FUNCTIONIN
G AS A
TEAM?The 2002 Report
of the National
Confidential
Enquiry
into
Perioperative
Deaths
Age profile
05
10152025303540
0 to 9 10 to19
20 to29
30 to39
40 to49
50 to59
60 to69
70 to79
80 to89
>90
Age (years)
Per
cen
tag
e
2000/01
1994/95
1999/00
ASA profile
0%10%20%30%40%50%
1 2 3 4 5
ASA
Pe
rce
nta
ge 2000/01
1994/951999/00
Referrals to the surgical team
• 295 patients (14%) were transferred from another hospital before their final operation
• 402 (19%) were referred by a medical specialty in the same hospital
Preoperative care
• 88% (430/487) of hospitals reported pre-admission assessment clinics
Nurses 266 62%
Nurses & doctors 121 28%
Doctors 36 8%
Not answered 7 2%
Total 430
Patients in this sample
• 234 of 356 day case or elective admissions were assessed in a pre-admission clinic
• Only 15 were reported to have had action taken as a result of the clinic visit
Health professional who assessed the patients
Nurse 129 55%
PRHO 77 33%
Surgical SHO 72 31%
Anaesthetic consultant 31 13%
Surgical consultant 9 4%
Physician 8 3%
Pre-admission assessment
• Protocols for assessment and referral by the clinic need to be explicit
• Anaesthetists should be involved in the development of the assessment guidelines
• Findings of morbidity/mortality reviews should be considered when reviewing protocols
A 71-year-old female with no previous medical problems was admitted at 03.00 with an acute abdomen. At this time a HO assessed her and noted that she was shocked. The results of her serum biochemistry investigations were creatinine 471 micromol/l and a base excess of-11.8 mmol/l. At 07.40 she was reviewed by a surgical SHO who confirmed the admission findings. At 09.30 she was referred to a surgical registrar and consultant. At 11.30 she was reviewed by a consultant anaesthetist who agreed to take her to the ICU for resuscitation. A bed was available there at 14.00. Laparotomy started at 16.50.
Delay once admitted
National protocols should be formulated to identify which inpatients would benefit from a more detailed preoperative cardiovascular assessment, including echocardiography
Recommendation
When a formal preoperative medical assessment is indicated, an experienced physician, preferably a consultant, must make it. It is the responsibility of that physician to fully understand the operative risks of the patient’s medical condition
Recommendation
Anticipated risk of death
2000/01 1994/95
Not expected 12% 13%
Small but significant risk 17% 18%
Definite risk 53% 60%
Expected 15% 9%
Drug prescribing
Recommendation
There need to be national guidelines for clinical prescribingin hospitals in order to reduce the risk of drug error
Monitoring
Direct BP 929 49%
CVP 922 48%
PA pressure 97 5%
Cardiac output 56 3%
Monitoring
• Should pulmonary artery pressure and cardiac output be measured more often?
• There were 18 cases where national guidelines for minimal monitoring were breached
Recommendation
There are national agreed standards for anaesthetic monitoring. The absence of an essential anaesthetic monitor constitutes an unacceptable clinical risk that must be the subject of audit
FUNCTIONIN
G AS A
TEAM?The 2002 Report
of the National
Confidential
Enquiry
into
Perioperative
Deaths
Involvement of the consultant surgeon in decision making
0
20
40
60
80
100
Involvement
Per
cen
tag
e
2000/01
1994/95
Grade of most senior operating anaesthetist
0%
20%
40%
60%
80%
Consultant NCCG SHO
Grade of anaesthetist
Pe
rce
nta
ge
2000/01
1994/95
1999/00
Grade of most senior operating surgeon
0%
20%
40%
60%
80%
Consultant NCCG SHO
Grade of surgeon
Pe
rce
nta
ge
2000/01
1994/95
1999/00
Recommendation
The decision to operate in complex cases can benefit from the formal involvement of others apart from the surgeon. Critical care specialists should be more directly involved
Decision-making & team working77 year-old woman under the care of a physician with nausea, vomiting & constipation. Four days later - perforated viscus. Surgeon arranged laparotomy. SHO anaesthetist called consultant who asked for a second opinion. Surgeon declared that he was only a technician and could not make any decisions. Surgery done - Hartmann’s procedure for faecal peritonitis. Patient died in ICU several hours later.
Problems with diagnosis
• There were 12 deaths due to acute appendicitis
• The diagnosis needs skill and experience
Appendicitis
21 year-old man seen in A&E by SHO with abdominal pain & vomiting. Tachycardia, pyrexia, urine normal & high white cell count. Sent home as UTI. 5 days later readmitted moribund with peritonitis. Cardiac arrest. ICU. Laparotomy - gangrenous appendix & widespread peritonitis. Died 24 hours later.
Recommendation
Failure to diagnose acute appendicitis can still cause death in fit young adults. It is essential that experienced clinicians are available to ensure that cases are not missed
Patients admitted under the care of physicians
79 year-old woman admitted under care of a physician with abdominal pain & vomiting. 4 days later an abdominal X-ray film showed intestinal obstruction. Operation for strangulated femoral hernia & small bowel resection. Transferred to HDU but died.
Preoperative preparation & timing of surgery
• Physicians need to raise their awareness of surgical conditions existing or developing inpatients under their care–Planning–Co-operation– Teamwork
Medical Records
Patient admitted with abdominal pain & constipation. Had been previously investigated. Patient unclear about his condition. Notes & X-rays not available. 3 days later perforated colon & laparotomy done. Original x-rays still not available. In fact 2 weeks before, a barium enema & flexible sigmoidoscopy had diagnosed an obstructing carcinoma of colon.
Recommendation
Non-availability of a patient’s previous notes at the time of an acute admission is a major administrative failure and should be exposed as such
FUNCTIONIN
G AS A
TEAM?The 2002 Report
of the National
Confidential
Enquiry
into
Perioperative
Deaths
Destination after surgery
2000/01 1994/95
ICU 36% 33%
HDU 7% 3%
Ward 42% 46%
Died in theatre 11% 12%
Died in recovery 4% 4%
Postoperative ward care
• Problems of
–Poor record keeping–Hypotension–Oliguria
Postoperative ward care
A 76-year-old ASA 3 female without recognised co-existing medical disorders had a mastectomy and axillary clearance. Three days later she was found collapsed with diarrhoea, hypotension and hypoxia. There were no entries in the medical notes between her clerking on admission and this collapse, at which time the entry was “low BP all the time since mastectomy”. By this time the patient was in fast atrial fibrillation, dehydrated and in renal failure. Despite aggressive resuscitation she died later that day.
Postoperative ward care
An 87-year-old female had a cholecystojejunostomy to relieve jaundice caused by a carcinoma of the head of the pancreas. She was otherwise fit. At 04.00 on the second postoperative night the urine output decreased, but this was not reported to the on-call doctor until 07.00, by which time it had been 4 ml/hour for two hours. No action was taken. The SpR ward round took place at 09.00, at which time the patient showed clear signs of hypovolaemic shock. Blood results showed a haemoglobin level of 3.7 gm/dl.
Postoperative ward care
An 85-year-old man had a gastrectomy. He suffered from type II diabetes mellitus and mild angina. He was reviewed on the second postoperative day because of poor urine output and hypotension. Blood gas analysis revealed a PaO2 of 5.2 kPa and a base excess of -7.6 mmol/l. He had a positive fluid balance since operation of 6 litres. He had a raised JVP, a pleural effusion, and his cardiac rhythm had changed to atrial fibrillation. The medical SpR thought that a cardiorespiratory cause for his deterioration was unlikely but that he might have suffered an intra-abdominal event. A laparotomy was performed later that day. No new pathology was found.
Recommendation
If a medical team is involved in a patient’s perioperative care it should also be involved in any morbidity/mortality review of the case and receive a copy of the discharge summary and, where available, the autopsy report
FUNCTIONIN
G AS A
TEAM?The 2002 Report
of the National
Confidential
Enquiry
into
Perioperative
Deaths
Avoiding or diminishing postoperative complications
•Careful patient selection•Preoperative preparation•Anticipation•Early recognition
Some patients are too ill for anaesthesia & surgery
Unanticipated intraoperative complications
0
10
20
30
40
50
60
Incidence
Per
cen
tag
e
2000/01
1994/95
Recommendation
Where perioperative complications contribute to the cause of death, these should be recorded on the death certificate
Recommendation
Complications may arise following endoscopic surgery. Remedial actions should be rehearsed
Complications after endoscopic surgery
62 year-old woman. Laparoscopically assisted vaginal hysterectomy, sacral colpopexy & colposuspension for urinary incontinence & prolapse. Problems after surgery. Admitted 2 weeks later but discharged. Continued to be unwell. 2 months later readmitted & ureteric damage diagnosed. Died on table during corrective surgery.
0
20
40
60
80
Yes
Per
cen
tag
e
2000/01
1994/95
Autopsy rate
0
20
40
60
80
100
Hospital Coroner
Per
cen
tag
e
2000/01
1994/95
Type of autopsy
Coroner’s autopsy rate following referral
0
20
40
60
80
100
Autopsy rate
Per
cen
tag
e
2000/01
1994/95
The Autopsy
• Cases in which no autopsy was performed may not have been fully investigated
Lack of autopsy
Fit 75 year-old man being treated for small recurrences of bladder tumour. Following day had massive haematemesis and died. Surgeon anticipated autopsy but Coroner’s officer refused and pressurised trainee surgical staff into writing a death certificate. Consultant surgeon complained but no autopsy done.
• Some of the autopsies were unsatisfactory and did not explain the death. Problems included:–Brevity– Failure to examine operation site– Lack of clinicopathological
correlation– Lack of histology
The Autopsy
The Quality of the Autopsy Report (1)
0
20
40
60
80
100
Per
cen
tag
e
2000/01
1994/95
The Quality of the Autopsy Report (2)
0
10
2030
40
50
60
Per
cen
tag
e
2000/01
1994/95
2%10%Failure to explain death (poor autopsy)
2%5%Failure to explain death (good autopsy)
1%6%Major Discrepancy
72%75%Confirmation of clinical findings
1994/952000/01
Clinical diagnosis compared with autopsy findings
Receipt of autopsy report by clinical team
0
20
40
60
80
100
Reports received
Per
cen
tag
e
2000/01
1994/95
Problems with communication
Surgeon: ‘Our coroner does not permit communication between his pathologist and the surgeon unless the surgeon has a specific question’
Problems with communication
Surgeon: ‘I would like permission to forward a copy of the postmortem report on my patient to NCEPOD’
Coroner: ‘In my opinion NCEPOD is not an “interested party”. If they require a copy they need to apply directly to my office’
The clinicians perspective of the Autopsy
• The autopsy is a fundamental part of the on-going examination of clinical practice
• Coroners must understand their role in supporting this requirement
Communication
• Arrangements for communication between clinicians and pathologist should be formalised
• Clinicians should provide a case summary, including contact details for further discussion
• Pathologists and clinicians should hold multidisciplinary audit meetings
Recommendation
Autopsies should be the subject of a formal external audit process. Clinicians should be involved in evaluating the quality of reports and the basis of conclusions drawn, including the cause of death
FUNCTIONIN
G AS A
TEAM?The 2002 Report
of the National
Confidential
Enquiry
into
Perioperative
Deaths
Issues for consideration
• Increased remit• Name• Data collection methods• Case control• Feedback• Dissemination of findings &
recommendations
Future studies
• Who Operates When II? - Publ. Nov 2003
• Gastrointestinal Endoscopy - Publ. 2004
• Critical Care & the Medical Patient - Publ. 2004
• Emergency admissions - Publ. 2005
• Ruptured AAAs - Publ. 2005
FUNCTIONIN
G AS A
TEAM?The 2002 Report
of the National
Confidential
Enquiry
into
Perioperative
Deaths