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Surgery in Children David G. Mason Consultant Paediatric Anaesthetist, Oxford NCEPOD Clinical Co-ordinator
What is NCEPOD • Background to surgery in children • Aims of study • Methods • Impact
Aims • Undertake research into the way patients are treated, to identify ways of improving the quality of care • NCEOD publishes reports summarising key findings and recommendations arising from the information they gather • Aim to identify changes in clinical practice that will improve quality of care and ultimately improve patients' outcomes
Status of NCEPOD • Company limited by guarantee and a registered charity • Operates as an independent entity under the “umbrella” of the NPSA • Funded by NPSA/HSSE (NI)/Guernsey/Isle of Man/ Independents
Structure of NCEPOD • Steering Group • Trustees • Clinical Co-ordinators • Non-clinical Staff • Expert Groups • Advisors
Why does it work? • Medicine is a complex system which cannot be described by quantitative analysis alone • NCEPOD unashamedly uses qualitative analysis • Cases reviewed by those that understand problems at coalface • Interpretation of collected data by practising clinicians who understand pressures of clinical practice • Comment by those sympathetic to but not uncritical of current working practices
Confidentiality • Key part of the Enquiry protocol • Anonymised cases • Confidentiality agreement • Section 251 exemption
Background Children’s surgical services in UK • Many changes in the last 20 years • Clinical • Organisational • Specialisation and centralisation of children’s services • Modification of staff training • Not all beneficial to children’s surgical services in DGHs • Events following congenital cardiac surgery at the Bristol Royal Infirmary
Factors for changes • NCEPOD 1989 &1999 • Atwell JD, Spargo PM. The provision of safe surgery for children. Arch Dis Child 1992: 67: 345-349 • The Audit Commission report: Children first: a study of hospital services. 1993 • Kennedy Inquiry 2001 • Monro Report 2003 • Department of Health, National Service Framework for Children. 2004 • Healthcare Commission, Improving Services for Children in Hospital. 2007
NCEPOD reports • Surgeons and anaesthetists should not undertake occasional paediatric practice • Consultants who have responsibility for children need to maintain their competence in the management of children • Concentration of expertise with a Regional approach to the organisation of paediatric surgical services • Review of manpower planning for surgical & anaesthetic services of children • Better audit & review of mortality
Audit Commission / NSF / HCC • Provide access to care and treatment of the highest quality that is evidence based, effective and safe • Ensure care is provided within an environment suited to the needs of children and young people, with appropriate facilities to support families in caring for their child • Ensure care and treatment is provided by staff that are suitably trained and experienced in caring for children and families and that these staff are appropriately supported and developed • Establish clinical networks and improve ‘outreach’ from regional centres, particularly in surgical specialities, to maintain local expertise
Safe surgery for children • Audit of surgical practice • Centralisation of paediatric surgery • Transfer of children < 5 years of age, particularly for acute surgical conditions • Change in paediatric population • Longer survivors • Changes in surgical practice • Changes in society e.g. obesity
Congenital cardiac surgery • Standards were proposed (Monro) • Development of regional team working • Systematic clinical accountability • National audit • Child centred care • Clinical assessment • Consent • Medical and surgical care. • National Specialised Commissioning Group (2009) • Safe and Sustainable Paediatric Cardiac Surgery Services
Interpretation / misinterpretation • Arbitrary number of paediatric surgical / anaesthetic cases per year • Arbitrary age limits • Changes in surgical & anaesthetic training • Incomplete networks of care
Consequences of changes • Decline in the number of children who have surgery performed in DGHs • Change in paediatric surgical practice • Increase in referrals to tertiary centres • Deskilling of surgeons and anaesthetists in DGHs • Is a tipping point approaching in the care of the surgical child in DGHs? • Is the current organisation of CCD surgical care providing the best care? Cochrane H & Tanner S Trends in Children’s Surgery 1994-2005 statistical report 2007 DH Pye JK Survey of general paediatric surgery provision Ann R Coll Surg Engl 2008 90: 193-197
Aims of Study • Primary aim: • Determine the remediable factors in process of care of children 17 years and younger who die within 30 days of surgery • Secondary aim: • What impact have the changes in practice over the last 10 years had on the quality of care of children who require surgery?
Aims of Study • The primary aim would be met by addressing the following factors: • Preoperative care and admission • Intra-hospital transfer • Networks of care • The seniority of clinicians • Multidisciplinary team working (involvement of paediatric medicine) • Delays in surgery • Anaesthetic and surgical techniques • Acute Pain Management • Critical Care • Co-morbidities • Consent
Aims of Study • Secondary aims would be met by addressing the following issues: • To what extent has specialisation / centralisation of paediatric surgical services occurred? • How has staff training developed in last 10 years? • How do hospital facilities (infrastructure) affect care?
How? • Organisational Questionnaire • Clinical Questionnaires • Surgical • Anaesthetic • Peer review • Survey of practice
Impact • Add to the body of information on surgical and anaesthetic services for children thus guiding future service development and • Maybe answer the question: • What is the best organisational model for delivering surgical care for children in the UK?