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Method. Two month data collection period (Feb-Mar 2004) NHS and independent hospitals in England, Wales, N Ireland, Guernsey, Isle of Man and Defence Secondary Care Agency Adults >=16 years of age Open repair; endovascular repair; diagnosed but not treated and died in hospital. Method (cont).

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method
Method
  • Two month data collection period (Feb-Mar 2004)
  • NHS and independent hospitals in England, Wales, N Ireland, Guernsey, Isle of Man and Defence Secondary Care Agency
  • Adults >=16 years of age
  • Open repair; endovascular repair; diagnosed but not treated and died in hospital
method cont
Method (cont)
  • Expected sample size was 1129 operated cases and 106 non-operated cases
  • Questionnaire sent to combination of surgeon, anaesthetist and radiologist
  • No casenote review
  • Organisational questionnaire for each hospital
  • Risk stratification planned using a published model
  • Multidisciplinary advisory group
data overview hospital participation
Data overview – hospital participation
  • 226 hospitals identified as possibly undertaking AAA repair
  • 188 completed organisational questionnaires
  • 181 eligible to take part in study (163 NHS and 18 independent)
  • 87% participation rate for clinical questionnaires
size of vascular unit
Size of vascular unit
  • Large
      • 500,000 patients, 4 surgeons, potential for vascular surgical on-call rota
  • Intermediate
      • <500,000 patients, fully equipped for vascular surgery, not enough surgeons for on-call rota
  • Remote
      • Remote, small catchment population
recommendation
Recommendation

Trusts should ensure the availability outside normal working hours of radiology services including CT scanners.

published evidence
Published evidence
  • Improved outcomes for unruptured AAA when higher volumes performed by:
    • surgeons
    • hospitals
  • US recommendation – hospitals should perform 50 cases/year
  • 19/181 hospitals in this study performed 50 or more cases/year
recommendation17
Recommendation

Clinicians, purchasers, Trusts and Strategic Health Authorities should review whether elective aortic aneurysm surgery should be concentrated in fewer hospitals.

vascular anaesthetic on call rotas
Vascular anaesthetic on-call rotas
  • 3% (5/178) of hospitals reported that they had an anaesthetic on-call rota for vascular surgery
  • Should large vascular units implement anaesthetic vascular on-call rotas?
use of recovery areas after elective surgery
Use of recovery areas after elective surgery
  • 4 hospitals reported that the recovery area was the preferred destination
  • 9% of elective patients were reported to have been cared for in recovery areas for a substantial period of time (from the anaesthetic questionnaire)
recommendation23
Recommendation

Major elective surgery should not take place unless all essential elements of the care package are available.

outcome of elective open repair
Outcome of elective open repair

Overall mortality was 6.2%

patient information
Patient information
  • How much information should be given to patients on the organisation of vascular services?
  • How should this information be provided?
cancellations
Cancellations
  • 1 in 25 patients cancelled because no ward bed
  • 1 in 6 patients cancelled because no critical

care bed

recommendation35
Recommendation

Patients with an aortic aneurysm requiring surgery must have equal priority with all other patients with serious clinical conditions for diagnosis, investigation and treatment.

recommendation36
Recommendation

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.

comorbidities
Comorbidities
  • Cardiac history and signs associated with increased risk of death
  • Diabetes carried no additional risk of death in this study
  • Increased risk of death among morbidly obese or cachectic patients
recommendation39
Recommendation

Trusts should ensure that clinicians of

the appropriate grade are available to

staff preoperative assessment clinics for

aortic surgery patients.

postoperative complications within 30 days of surgery
Postoperative complications within 30 days of surgery
  • 21% had an infective complication, most commonly of the chest and wound
  • 7% had a myocardial infarct, nearly half these patients died
emergency surgery
Emergency surgery
  • Unscheduled admission
comorbidities48
Comorbidities
  • Higher risk of death in patients with cardiac disease, diabetes, morbid obesity or cachexia
  • Mortality increased among patients not fully conscious, though 2/7 patients with GCS below 9 did survive
workload and outcome
Workload and outcome
  • The best results were seen among patients operated on by surgeons who also performed the most elective aneurysm repairs
postoperative complications within 30 days of surgery56
Postoperative complications within 30 days of surgery
  • 1 in 5 patients had a chest infection
  • Graft complications were more common than

in elective repairs

  • 21 of 37 patients who had an MI died
  • Renal impairment also carried a high risk

of mortality

recommendation57
Recommendation

Strategic Health Authorities and Trusts should co-operate to ensure that only surgeons with vascular expertise operate on

emergency aortic aneurysm patients,

apart from in exceptional geographic circumstances.

use of beta blockers in aaa patients
Use of beta blockers in AAA patients

Elective open operations

Emergency open operations 26%

use of statins in aaa patients
Use of statins in AAA patients

Elective open operations

Emergency open operations 31%

most senior anaesthetist at the start emergency open operations
Most senior anaesthetist at the start – emergency open operations

In 27 cases a consultant assumed responsibility after the start of anaesthesia – overall 97%

Range 70% - 88%

recommendation66
Recommendation

Trusts should ensure that anaesthetists can identify the major cases that they have managed in order to support audit and appraisal.

recommendation71
Recommendation

Anaesthetic departments should review the allocation of vascular cases so as to reduce the number of anaesthetists caring for very small numbers of elective and emergency aortic surgery cases.

epidural analgesia
Epidural analgesia
  • 92% (345/377) of open elective operation patients received an epidural catheter
  • 168 received aspirin in the 7 days before surgery
  • 61 received fractionated heparin within 6 hours of surgery
  • In 55 cases the anaesthetist did not know when the catheter was removed
recommendation73
Recommendation

Trusts should ensure that they have robust systems for the postoperative care of epidural catheters with accompanying appropriate documentation.

recommendation77
Recommendation

Anaesthetic departments and critical care units should review together whether vascular surgery patients who routinely receive postoperative mechanical ventilation could be managed in a Level 2 High Dependency facility breathing spontaneously.

outcome
Outcome
  • All patients on whom we had data were alive at 30 days (47/53)
slide86

The care of patients who did

not undergo surgery

demographics88
Demographics
  • 36% were female, vs. 29% of the emergency operated patients
  • 43% were known to have an AAA, vs. 26% of the emergency operated patients
selection of patients
Selection of patients
  • It was not possible to test the NCEPOD data against the Hardman criteria
  • Patients aged 80 years or over
    • 55% of patients aged 80 or over received surgery vs. 90% of patients under 80 years
    • Of 68 patients who received surgery
      • 37% discharged alive within 30 days
      • 9% alive but still in hospital
other associations with decision to provide operative not palliative care
Other associations with decision to provide operative, not palliative, care
  • Membership of Vascular Society
  • Presence of a surgical vascular on-call rota
  • NCEPOD has confirmed the difficulty of drawing robust conclusions about the decision to provide palliative care