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National Hip Fracture Anaesthesia Network The First Year Richard Griffiths (Peterborough) Kirsty Forrest (Leeds) John Holloway (Poole) HIPFA Brief run through the activities since last year Update on some important new evidence

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National hip fracture anaesthesia network l.jpg

National Hip Fracture Anaesthesia Network

The First Year

Richard Griffiths (Peterborough)

Kirsty Forrest (Leeds)

John Holloway (Poole)


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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


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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


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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


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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


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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%


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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


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National Hip Fracture Anaesthesia Network

“Preoperative hematocrit levels and postoperative outcomes in older patients undergoing noncardiac surgery”

JAMA 2007 297 pages 2481-2488


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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


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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


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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



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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”


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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


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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.


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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


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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


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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


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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.


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Why still a problem?

  • Surgical specialties

    • Too many

    • With too much work to do

    • - Compared with other centres – low number of surgeons


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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


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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!!


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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.


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Poole Hospital Trauma ExperiencesA New Beginning

Dr John Holloway

Consultant Anaesthetist


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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



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# NOF workload

One of five busiest units

Circa 830 patients per year

Peak 10 per day


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Trauma lists

Two trauma theatres

Theatre 5 - am / pm / twilight lists

Theatre 4 - am / pm

Average 2.35 patients per list


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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


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A

Slow

Start!

Metastatic CA

Pleural effusions

2 x Cancellations


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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


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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)


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Medical cancellations

Fast AF

Chest infection!

INR

Na+ / K+

Clopidogrel


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Delays and deaths

≤ 48 hours – 59 (2 RIP)

≥ 49 hours – 72 (11 RIP)

10 RIP delay ≥ 81 hours



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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


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HIPFA

Enquiries from nurses and managers

Prompted by an article in the HSJ in January 2008

Although for anaesthetists, this is multi-disciplinary


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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


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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


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HIPFA

58 % ASA 3

11 % ASA 4


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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


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HIPFA First Data

Information is limited

Don’t know when anaesthesia gets involved?

Do know that grade of anaesthetist probably influences time of surgery


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64% of all cases done by consultants

Only 0.5% cases ST 1&2 primary anaesthetist


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HIPFA

What data do we want collected on a prospective basis?

This would form a minimum dataset and should be collected on every patient


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HIPFA

Suggestions from network members

Drug doses, especially for spinal block

The use of concomitant nerve blocks

What to do with clopidogrel?

How quickly can an ECHO be obtained?


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Minimal Data Set for Hip Fracture Anaesthesia

  • How can we develop on the success of the first HIPFA audit?

  • Coordinate national data collection, through the development of an appropriate database.

  • In its infancy.

  • Any further suggestions on pertinent data for collection welcome!


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Demographic, Personnel

and Timing Data

Anaesthetic Assessment

Data


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Reason for delaying

operation

Major co morbidity

contributing to delay


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Anaesthetic Technique Data:

Regional Anaesthesia

General Anaesthesia

Sedation

Invasive Monitoring

Postoperative Analgesia


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HIPFA First Data

Anaesthesia 2008,63,250-258

Survey of UK practice

Spinal preferred in 76% of UK anaesthetists

40% used sedation to position

Regional Anaesthesia in 44% of case


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Remember, all suggestions regarding suitable data to be collected welcome!

Involve your department and join the Hip Fracture Anaesthesia Network.

www.networks.nhs.uk/hipfa


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NHFD collected welcome!

Collects a lot of information,

But nothing about anaesthesia, the assessment or the process

I could not find the grade of anaesthetist or the ASA grade


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HIPFA collected welcome!

  • Next 12 months

  • Organize into regional sub-networks

  • Find a home as funding for NHS networks goes by October 2008

  • Secure funding for national database

  • NPSA? NCEPOD? NIAA? RCA?


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HIPFA collected welcome!

  • Aim for each patient in UK to be recorded on a national anaesthetic database

  • Anaesthesia for hip fracture to be “benchmark” procedure for departments

  • Could we also achieve the same with emergency laparotomy?