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The 2003 Report of the National Confidential Enquiry into Perioperative Deaths

WHO OPERATES WHEN? II. The 2003 Report of the National Confidential Enquiry into Perioperative Deaths. Study protocol and data quality. Study protocol. Randomly assigned 7-day period All operations performed by a surgeon or gynaecologist Performed in main operating theatre Exclusions

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The 2003 Report of the National Confidential Enquiry into Perioperative Deaths

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  1. WHO OPERATES WHEN? II The 2003 Report of the National Confidential Enquiryinto Perioperative Deaths

  2. Study protocol and data quality

  3. Study protocol • Randomly assigned 7-day period • All operations performed by a surgeon or gynaecologist • Performed in main operating theatre • Exclusions • X-ray rooms • obstetric delivery rooms or theatres • endoscopy rooms • A&E treatment rooms

  4. Participation • 557 (93%) hospitals • 72,343 cases (88% NHS, 12% independent) • 9457 out of hours cases followed up (65% responded) • 395 organisational questionnaires (71% responded)

  5. Data quality • 34 questions • 41 (7.3%) hospitals completed key fields (5) for all operations • ASA status missing in 33% • Grade of anaesthetist missing in 11% • Grade of surgeon missing in 13%

  6. Recommendation Provide adequate information systems to record and review anaesthetic and surgical activity

  7. Classification of operation Emergency Immediate life-saving operation, usually within one hour Urgent Operation as soon as possible after resuscitation, within 24 hours Scheduled An early operation not immediately life-saving, usually within 3 weeks Elective Operation at a time to suit both patient and surgeon

  8. Recommendation Revise NCEPOD classification to include more specific definitions and guidelines, which are relevant across surgical specialties (NCEPOD responsibility)

  9. Validation of organisational questionnaire • Co-ordinators visited 27 hospitals • 12 data fields reviewed for accuracy

  10. Validation of organisational questionnaire

  11. Validation of organisational questionnaire

  12. Facilities

  13. Type and Size of Hospital • Trusts may be configured in an almost infinite number of ways, with regard to: • number of hospitals • types • size • geography

  14. Number of operating theatres in NHS hospitals by number of surgical beds

  15. Operating theatres in Independent hospitals by surgical beds

  16. Operating theatres in hospitals by emergency admissions

  17. Trauma and Emergency Services • High quality timely care • Access to appropriate specialists • Access to technology and critical care • Access to 24 hour diagnostic services • Optimum training opportunities • Co-operation between hospitals

  18. Operating theatres by trauma sessions per week

  19. Operating theatres by emergency sessions per week

  20. Recommendation Ensure that SHAs together with NHS Trusts, collaborate to ensure all emergency patients have prompt access to theatres, critical care, and appropriately trained staff 24 hours per day every day of the year

  21. Availability of recovery staff 24 hours a day by operating theatres

  22. Recommendation Ensure that all operating theatres have sufficient numbers of trained recovery staff available whenever those theatres are in use

  23. Resuscitation training • In NHS hospitals 93% of responses indicated that recovery staff underwent resuscitation training at least annually • All staff in the independent sector received training at least annually

  24. Recommendation Provide regular resuscitation training for all clinical staff, which is in line with Resuscitation Council guidelines

  25. Monitoring equipment • In NHS hospitals 90% had a pulse oximeter and 80% an ECG monitor available for each recovery bay • In Independent hospitals 89% had a pulse oximeter and 85% an ECG monitor available for each bay

  26. Recommendation Ensure that all recovery bays have both a pulse oximeter and ECG monitor available This applies whether patients are having local or general anaesthetic or sedation The equipment used in recovery areas should be universally interchangeable and able to provide a printable record

  27. Audit • “Do operating theatres have clinical audit meetings?” • NHS 67% • Independent 51% • “Is the pattern of work in theatres examined?” • NHS 86% • Independent 96%

  28. Recommendation Ensure that systematic clinical audit includes the pattern of work within operating theatres

  29. Grade of surgeon for emergency or urgent operation; by theatres in hospital

  30. Grade of anaesthetist for emergency or urgent operation; by theatres in hospital

  31. The Medical Workforce in the NHS

  32. Numbers of doctors in post2001 vs 1996 INCREASE • Consultants 28% • Registrars 16% • SHO 2% • Associate specialists 19% • Staff grade 124%

  33. Consultants • Paediatric 68% • Oral and maxillofacial 3%

  34. Competence of doctors • Trainees • Staff grades and associate specialists • Consultants • “I am not sure that the assumption that consultant equals good, both surgically and anaesthetically, is in fact the truth any more”

  35. Recommendation Assess the competency of staff grade and Trust doctors and take this into account when allocating anaesthetic and surgical sessions.

  36. Competence of doctors • Trainees • Staff grades and associate specialists • Consultants • “I am not sure that the assumption that consultant equals good, both surgically and anaesthetically, is in fact the truth any more”

  37. Weekday 08:00 to 17:59 Weekday 18:00 to 23:59 Weekend 08:00 to 17:59 Weekend 18:00 to 23:59 Night 00:00 to 07:59 Grade of anaesthetist by time of week for all cases

  38. Weekday 08:00 to 17:59 Weekday 18:00 to 23:59 Weekend 08:00 to 17:59 Weekend 18:00 to 23:59 Night 00:00 to 07:59 Grade of anaesthetist by time of week for non-elective cases

  39. Weekday 08:00 to 17:59 Weekday 18:00 to 23:59 Weekend 08:00 to 17:59 Weekend 18:00 to 23:59 Night 00:00 to 07:59 Grade of surgeon by time of week for all cases

  40. Weekday 08:00 to 17:59 Weekday 18:00 to 23:59 Weekend 08:00 to 17:59 Weekend 18:00 to 23:59 Night 00:00 to 07:59 Grade of surgeon by time of week for non-elective cases

  41. Elective cases, as a percentage of all elective cases, by day of the week

  42. Fatigue • Trainees hours - controlled • Consultants hours - uncontrolled • Published work on fatigue is inconsistent • Is it better to have a fresh doctor or one who knows the patient well?

  43. Day case surgery

  44. Day case surgery • 53% of elective operations in the NHS were day cases • 43% in Independent hospitals • 40% of NHS day cases were performed in a dedicated day case unit

  45. Staffing in day case units “Junior trainees should be personally and closely supervised by experienced staff” (Royal College of Surgeons ) “Anaesthesia for day surgery should be a consultant-based service” (Royal College of Anaesthetists)

  46. Grade of anaesthetist caring for NHS day case patients

  47. Grade of surgeon caring for NHS day case patients

  48. Recommendation Review guidance on which staff should anaesthetise and operate on day case patients

  49. Supervision of trainees • Immediately available • Local • Distant • 5000 cases per year where SHO anaesthetists are without immediately available supervision

  50. Supervision of trainee anaesthetists

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