National Hip Fracture Anaesthesia Network

1. National Hip Fracture Anaesthesia Network The First Year Richard Griffiths (Peterborough) Kirsty Forrest (Leeds) John Holloway (Poole)

2. HIPFA Brief run through the activities since last year Update on some important new evidence Reports from two network members on varied experience of dealing with problems A look at a minimum dataset Results of first national audit

4. National Hip Fracture Anaesthesia Network Japanese meta-analysis Is Operative Delay Associated with Increased Mortality of hip fracture patients? Shiga et al Toho University Tokyo Japan ASA San Francisco September 2007

5. National Hip Fracture Anaesthesia Network Surgical repair within 24 hours recommended (try within 48 hours) Royal College of Physicians London However, a 25% of patients have significant co-morbidity

6. National Hip Fracture Anaesthesia Network Shiga et al Toho University Tokyo Japan ASA San Francisco September 2007 15 studies , observational, 252,336 patients Mean age 81 yrs Female 77.4% Cut off of 24-72 hrs (mean 48) to define delay

7. National Hip Fracture Anaesthesia Network Shiga et al continued Delayed surgery increased 30 day all cause mortality significantly by, 44% 1 year all cause mortality increased by 33%

8. National Hip Fracture Anaesthesia Network Shiga et al For every 1,000 patients who undergo delayed surgery instead of early surgery there would be 29 more deaths after 30 days And 52 more deaths after a year

9. National Hip Fracture Anaesthesia Network “Preoperative hematocrit levels and postoperative outcomes in older patients undergoing noncardiac surgery” JAMA 2007 297 pages 2481-2488

10. National Hip Fracture Anaesthesia Network Retrospective study 310,311 aged over 65, non-cardiac surgery 1.6% increase in 30 day postoperative mortality with every 1% increase or decrease in Hct value from normal < 39% and > 51% WHO definition of anaemia 1968

11. HIPFA Age Anaesthesia Manchester May 2007 Article in RCOA Bulletin Aim to promote best practice in the anaesthesia community for hip fracture patients In the future to co-ordinate audit and research efforts

12. HIPFA How many acute Trusts in the UK are in the network? To date there are 53 represented This includes Northern Ireland, Scotland and Wales

13. Have I got news for you

14. HIPFA Network is owned by every member Experience across UK is very different Presentations on the “Leeds Experience” Followed by “Life on the South Coast”

15. Leeds experience Leeds Teaching Hospitals NHS Trust is the largest in the UK There has been a recent reorganization of service provision, all Orthopaedic and Trauma surgery for the City of Leeds Catchment population 720,000 All centralized to Leeds General Infirmary Approx 800 NOFs/year

16. Woman, 95, had hip op cancelled EIGHT times in a week Marjorie Fox 25 September 2007, By KATIE BALDWIN Health Reporter Hospital bosses have apologised after a 95-year-old woman's hip operation was cancelled EIGHT times in a week. Marjorie Fox went without food for hours as she was prepared for surgery at Leeds General Infirmary, only for it to be cancelled later. The pensioner was on morphine because she was in so much pain after falling and breaking her hip. Now her family have hit out at the hospital for the delays which they say affected other elderly patients too. Mrs Fox's niece Mary Emsley, above right, said: "At her age to have her wait all that time is wrong. It's not a one-off – it's been going on a long time." Hospital managers have apologised for the postponed ops, admitting the delays were "unacceptable", but said it was a busy week rather than an ongoing issue."They were fasting her every day – and some days all day. Eight times she was due to go down for the op and eight times it was cancelled." Mrs Emsley, from Horsforth, said she understood several other elderly patients from that ward were also waiting for the same operation at the same time but only one was being seen each day. Mrs Fox, originally from Otley, eventually had surgery a week after being admitted. A spokesman for Leeds Teaching Hospitals NHS Trust said: "We're extremely sorry Mrs Fox's operation was postponed so many times – her treatment clearly fell below our usual high standards. "Although there was a marked increase in the number of patients requiring orthopaedic surgery during the week in question, the number of delays to Mrs Fox's treatment is unacceptable." He added there was no increased risk to Mrs Fox because of the delay. Toby Branfoot, lead trauma surgeon for the hospitals trust, added that theatre scheduling could cause problems, as they could operate on young, healthy patients late at night but not complex cases.

17. Hip Fractures: wait from admission to operation LGI & SJUH (July, August, September 2006) LGI (July, August, September 2007) Total No patients Average wait (days) Median wait (days) Range days) % at 24 hour standard* % at 48 hour standard• LGI ‘06 81 3.26 2 0-16 30.9 56.8 SJUH ‘06 69 1.46 1 0-10 68.1 91.3 LGI ‘07 143 3.81 3 0-16 15.4 35.7 *Standard of fit patients getting to theatre within 24 hours of admission 1 CEPOD www.ncepod.org.uk The extremes of age 1999. 2 Scottish intercollegiate Guidelines Network Jan 2002 www.sign.ac.uk •Standard of patient getting to theatre within 48 hours of admission British Orthopaedic Association, British Geriatric Society-BOA Sept 2007

18. What have we got? • Trauma coordinators x 3 • 4/5 wards (scattered) • Orthogeritricians • Guidance for echo/anticoagualtion • Weekly ‘operational’ meeting • 30 lists a week in 2/3 theatres – with dedicated evening trauma and weekend lists

19. Hip Fractures: wait from admission to operation LGI & SJUH (July, August, September 2006) LGI (July, August, September 2007) LGI (Jan, Feb, March 2008) Total No patients Average wait (days) Median wait (days) Range days) % at 24 hour standard* % at 48 hour standard• LGI ‘06 81 3.26 2 0-16 30.9 56.8 SJUH ‘06 69 1.46 1 0-10 68.1 91.3 LGI ‘07 143 3.81 3 0-16 15.4 35.7 LGI ‘08 137 3.22 3 0-42 16.1 45.3 *Standard of fit patients getting to theatre within 24 hours of admission 1 CEPOD www.ncepod.org.uk The extremes of age 1999. 2 Scottish intercollegiate Guidelines Network Jan 2002 www.sign.ac.uk •Standard of patient getting to theatre within 48 hours of admission British Orthopaedic Association, British Geriatric Society-BOA Sept 2007

20. Delayed Surgery • 75 out of 138 patients > 48 hours for surgery. • 8 patients < 48 hours had documented reasons for delay • total number of delays = 83 • There were 32 organisational delays • 48 medical delays • 1 anaesthetic delay • 1 delay due to lost x-rays • 1 patient declined surgery. • Of the 48 medical delays, • 13 were for reasons considered acceptable by the Scottish Intercollegiate Guidelines.

22. Why still a problem? • Surgical specialties • Too many • With too much work to do • - Compared with other centres – low number of surgeons

23. Too many specialist surgeons AR – spines PM – spines RD – spines PT – children BS – children NH - foot & ankle RM - foot & ankle DL - upper limb RH - upper limb Locum - athroplasty TS - arthroplasty & trauma PB -  arthroplasty PG - pelvis & complex trauma TB - complex trauma & limb reconstruction SB -  complex trauma & limb reconstruction RV - knees

24. Why still a problem? • Surgical specialties • Too many/not enough surgeons • Half day lists surgeons/anaesthetists • X ray • Not enough machines or radiographers • Laminar flow theatres • Not enough • HDU facilities • Not enough • Sterile services!!

25. Operations cancelled due to dirty equipmentPublished Date: 14 April 2008 HOSPITAL bosses have admitted dirty surgical equipment has caused the last-minute cancellation of operations. Leeds Teaching Hospitals NHS Trust is holding emergency meetings with its suppliers after it emerged contaminated instruments were returned by angry surgical staff on at least two occasions just as the operation was about to go ahead.The trust has admitted there were “problems” with its new contractor – which was only taken on last month – and has now apologised to affected patients. The row broke out after patient Helen Rygate, 46, had her hip operation cancelled twice. She said she had been told by her surgeon that the problem of dirty equipment was widespread. A spokesman for Leeds Teaching Hospitals NHS Trust said: “We sincerely apologise to Helen Rygate about problems with instruments which have meant that her operation at Chapel Allerton Hospital has been cancelled on two occasions.” The operating theatres previously had an in-house decontamination service but moved to a new, external supplier in March.“We acknowledge there have been some problems since then which we have been dealing with,” the spokesman added.

27. Poole Hospital Trauma ExperiencesA New Beginning Dr John Holloway Consultant Anaesthetist

28. Trauma Assessment and Co-ordination (TAC) team Started 1999 4 nurses Responsible for pre and post op co-ordination of trauma patients Especially # NOFs and other elderly trauma

29. TAC Team Office

30. # NOF workload One of five busiest units Circa 830 patients per year Peak 10 per day

31. Trauma lists Two trauma theatres Theatre 5 - am / pm / twilight lists Theatre 4 - am / pm Average 2.35 patients per list

32. My experience Attended trauma efficiency meeting!! Suggested a seamless trauma day with Associate Specialist Compress 3 lists to 1 Start 08.00 Finish 18.30 Theatre staff 07.30 – 19.00

33. A Slow Start! Metastatic CA Pleural effusions 2 x Cancellations

34. All day list 1st year 40.5 lists Average 8.4 patients per day 340 patients treated 131 # NOFs 5 overruns - average 10 minutes Max overrun - 30 minutes Cancellations for organisational reasons eliminated

35. Fractured Neck of Femur 131 – 1st year GA – 124 Spinal – 7 Fascia iliaca blocks – 114 Lumbar psoas – 9 (1 rescue) 3 in 1 – 3 (1 rescue)

36. Medical cancellations Fast AF Chest infection! INR Na+ / K+ Clopidogrel

37. Delays and deaths ≤ 48 hours – 59 (2 RIP) ≥ 49 hours – 72 (11 RIP) 10 RIP delay ≥ 81 hours

38. Team

40. HIPFA After one year 60 enthusiast connected by email with network space provided by NHS Networks Including one from Australia First “basic” audit of anaesthetic practice started in January 2008 A snap shot of what was happening in the network

41. HIPFA Enquiries from nurses and managers Prompted by an article in the HSJ in January 2008 Although for anaesthetists, this is multi-disciplinary

43. HIPFA First Data Data is still arriving so have to be patient before final report Limited mortality data yet Basic data Some useful information I will present the interesting parts

44. HIPFA First Data 20 hospitals (to 8/5/2008) Jan/Feb 2008 1,000 patients (double the largest ever RCT on hip fracture anaesthesia) 27% men 73 % women Average age = 81.5 years

45. HIPFA 58 % ASA 3 11 % ASA 4

47. HIPFA First Data Average time to operation = 49.3 hours Range 20 to 106 hours 40% patients postponed for surgery 56% of these cancellations were for “organisational” reasons Only 1.4% of cancellations by anaesthesia

48. HIPFA First Data Information is limited Don’t know when anaesthesia gets involved? Do know that grade of anaesthetist probably influences time of surgery

49. 64% of all cases done by consultants Only 0.5% cases ST 1&2 primary anaesthetist

50. HIPFA What data do we want collected on a prospective basis? This would form a minimum dataset and should be collected on every patient