National Confidential Enquiry Into Patient Outcome And Death Research Articles

1088 Acute Pancreatitis: ‘Treat the Cause’-in Compliance with NCEPOD Recommendations

Abstract Aim The objective of this study was to facilitate in identifying remediable factors in the quality of care provided to patients being treated for acute pancreatitis and assess compliance to the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) guidelines. Method All emergency surgical admissions for patients aged 16 or older, diagnosed with acute pancreatitis at the period between August and October 2021 were included. A retrospective analysis in juxtaposition with 8 cardinal NCEPOD recommendations: management of co-morbidity & involvement of relevant specialists, adherence to antibiotic policies, assessment of risk of malnutrition, exclusion of gallstones in all index presentations, early surgical intervention, alcohol liaison support, further investigation - MRCP / ERCP and retrospective morbidity & mortality discussions. Each of the domains were scored based on adherence to the above standards, and subsequently coded as Red–Needing Urgent Attention, Amber–Scope for Improvement and Green–Satisfactory Compliance. Results A total of 79 patients were included in this study. Compliance towards the recommendation of routine nutritional assessment of patients was found to be in the RED category, scoring 23.7%. Management of medical co-morbidity & inclusion of specialists, early surgical intervention and alcohol liaison support were all found to be in the AMBER category, scoring 44.8%, 28.0% and 57.1% respectively. The rest of the recommendations showed satisfactory levels of compliance. Conclusions Many patients did not receive adequate nutritional assessment. The RED and AMBER areas will need urgent attention. To minimise the risks of severe morbidity and mortality from acute pancreatitis, we envisage a better compliance to NCEPOD recommendations.

WTP4.12 Treating the cause of Acute Pancreatitis: lessons from NCEPOD guidelines

Abstract Aim The objective of this study was to facilitate in identifying remediable factors in the quality of care provided to patients being treated for acute pancreatitis and assess compliance to the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) guidelines. Method All emergency surgical admissions for patients aged 16 or older, diagnosed with acute pancreatitis at the period between August and October 2021 were included. A retrospective analysis in juxtaposition with 8 cardinal NCEPOD recommendations: management of co-morbidity & involvement of relevant specialists, adherence to antibiotic policies, assessment of risk of malnutrition, exclusion of gallstones in all index presentations, early surgical intervention, alcohol liaison support, further investigation - MRCP / ERCP and retrospective morbidity & mortality discussions. Each of the domains were scored based on adherence to the above standards, and subsequently coded as Red–Needing Urgent Attention, Amber–Scope for Improvement and Green–Satisfactory Compliance. Results A total of 79 patients were included in this study. Compliance towards the recommendation of routine nutritional assessment of patients was found to be in the RED category, scoring 23.7%. Management of medical co-morbidity & inclusion of specialists, early surgical intervention and alcohol liaison support were all found to be in the AMBER category, scoring 44.8%, 28.0% and 57.1% respectively. The rest of the recommendations showed satisfactory levels of compliance. Conclusion Many patients did not receive adequate nutritional assessment. The RED and AMBER areas will need urgent attention. To minimise the risks of severe morbidity and mortality from acute pancreatitis, we envisage a better compliance to NCEPOD recommendations.

Trends in Long-Term Ventilation Care in U.K. Children and Young People-Further Consideration Required for Pediatric Critical Care Services.

The objective was to compare specific data from the 2020 National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report "Balancing the Pressures" with two previous U.K. studies and to examine changes in the pediatric population requiring long-term ventilation (LTV) as well as the types delivered. We believe that the new data presented will facilitate future service planning. A subset of confidential enquiry data derived from a study by a nationally funded quality improvement organization (NCEPOD: www.ncepod.org.uk ) was compared with two previous U.K. datasets. Healthcare providers across England, Wales, and Northern Ireland-inpatient and community settings. Children and young people (CAYP) 0-16 years old receiving LTV between April 1, 2016, and March 31, 2018. None. When comparing the NCEPOD data with that last published in the United Kingdom, the number of CAYP requiring LTV more than doubled between 2008 and 2018 (933-2,093). There has also been a particular increase in the proportion of children that were under two when they were commenced on LTV (26-39.2%). Children are now more likely than previously to be receiving LTV to manage upper airway obstruction and CNS conditions. There has also been an approximate doubling of those receiving LTV over the whole 24-hour period (9.4-18.4%). The increased numbers and changing characteristics of babies and children requiring LTV over the last 3 decades in the United Kingdom have implications for all healthcare sectors but particularly for providers of critical care services.

Deaths from alcohol-related liver disease in the UK: an escalating tragedy

In 2013, the UK National Confidential Enquiry into Patient Outcome and Death (NCEPOD) published Measuring the Units.1 This report on UK hospital deaths from alcohol-related liver disease in 2011 highlighted the avoidable nature of many of these deaths and found that care was less than good in more than half of the cases reviewed; basic omissions in patient care and missed opportunities were common, including the identification of patients with decompensated liver disease and initiation of simple urgent investigation and treatment.

The Epic™ diabetes audit

Background: The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) Highs and Lows (2018) report1 highlighted a lack of clinical continuity of diabetes management across the different specialties in the perioperative pathway, resulting in diabetes management of patients falling between gaps in the surgical pathway. We sought to review our hospital’s performance against several recommendations made in the report.

The Effect of Weekend Surgery on Outcomes of Emergency Laparotomy: Experience at a High Volume District General Hospital.

AimsEmergency laparotomies (ELs) are associated with significant morbidity and mortality. Delays to the theater are inevitably associated with worse outcomes. Higher mortality has been reported with admissions over the weekend. The aim of this study is to compare the delays and outcomes of emergency laparotomies performed on weekdays (WD) and weekends (WE) at a high-volume, large district general hospital.MethodsA retrospective review of a prospectively maintained database was performed for all patients who underwent general surgical emergency laparotomy between June and October 2021. Patient outcomes were compared between delayed and non-delayed surgeries as per the NCEPOD (National Confidential Enquiry into Patient Outcomes and Death) classification. The primary outcome compared was the 30-day post-operative mortality and morbidity determined by the Clavein-Dindo class ≥2.Secondary outcomes included the time from booking to anaesthesia start time, i.e., time to theatre (TTT), delay in surgery, out-of-hours (OOH) surgery, and unplanned return to theatres.ResultsOf the 103 laparotomies included, 33% were performed over the weekend. The most common indication for emergency laparotomy was bowel obstruction (53.4 %), followed by perforation (28.2%). There was no significant difference in mortality, the TTT (p = 0.218), delay in surgery with respect to the NCEPOD category of intervention (p = 0.401), postoperative length of stay (p = 0.555), number of cases operated OOH as well as unplanned return to theatres. There was a significant difference in the morbidity of patients between the two groups (Clavein-Dindo class ≥2, p = 0.021).ConclusionWith consistent consultant involvement, an equivalent standard of weekend emergency surgical service can be delivered.

Nutritional assessment and management in acute pancreatitis: Ongoing lessons of the NCEPOD report.

Acute pancreatitis (AP) is a medical emergency that is common, poorly understood and carries a significant risk of death. The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) undertook a comprehensive report into the current management of AP in the UK. The study aimed to provide a more detailed analysis of the findings related to nutritional assessment and support. The data presented here were analysed from the core dataset used in the NCEPOD study. Adult patients admitted between January and June 2014 with a coded diagnosis of AP were included. A clinical and organisational questionnaire was used to collect data and submitted case notes subjected to peer review. Nutritional data, including assessment and provision of support, were analysed. One hundred and forty-seven out of 168 (87.5%) hospitals had a nutrition team in place. A screening nutritional assessment was performed in only 67.4% (368/546) of patients. Subsequent referral to a dietitian and nutrition team input occurred in 39% (201/521) and 25% (143/572) of patients, respectively. Supplemental nutrition was considered and used in 240/555 (43.2%) patients. Overall management of the patients' nutrition was considered adequate by the case reviewers in only 281/332 (85%) of cases and by the clinicians in 77% (421/555) of cases. Many patients do not receive adequate nutritional assessment and, in up to 23% of cases, nutritional intervention is not adequate. Pancreatic exocrine insufficiency is likely under recognised and undertreated. Nutritional strategies to support early intervention and to support clinicians outside of tertiary pancreatic centres are warranted.

266 The Effect of the COVID-19 Pandemic on Emergency Theatre Mortality, Time to Intervention and Length of Stay in the First Phase of National Lockdown at a District General Hospital

AimThis study aimed to investigate the patient population requiring emergency surgery during the first phase of lockdown due to COVID-19 in the United Kingdom and compare it to the equivalent population in the same calendar period for 2019. Thus, we aimed to evaluate the impact of the pandemic on emergency operations.MethodWe retrospectively reviewed patients undergoing surgery in emergency theatres at our district general hospital between March 23rd and May 11th in 2019 and 2020. Data collected included demographics (age/gender), National Confidential Enquiry into Patient Outcome and Death (NCEPOD) category and operation. The primary outcome was 90-day post-operative mortality; secondary outcomes included time to intervention and length of inpatient stay.Results132 (2020) versus 141 (2019) patients were included with no significant difference in age (p = 0.676) nor sex (p = 0.230). There was no difference in overall 90-day postoperative mortality (p = 0.196). Notably, time to intervention was faster for NCEPOD code 3 patients in 2020 than in 2019 (p = 0.027). Time to intervention in 2020 was longer for those dying within 90 days post-operatively compared to survivors (p = 0.02). There was no difference in length of stay between the years, both overall and when conducting subgroup analyses by NCEPOD category or procedures (fractured neck of femur (p = 0.776), laparoscopies (p = 0.866), laparotomies (p = 0.252)), except for upper limb trauma (p = 0.007).ConclusionsPatients were appropriately prioritised with no overall change in mortality or length of stay. A national validation audit assessing outcomes of emergency operations during these challenging times would further elucidate risks posed to surgical patients requiring urgent care.

554 - Evaluation of CPR Decisions on an Older Adult Psychiatric Ward, A Quality Improvement Project

BackgroundThe National Confidential Enquiry into Patient Outcomes and Death (NCEPOD) stated that CPR status must be considered and recorded for all acute hospital admissions. Compliance with this recommendation and with Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) form documentation in an inpatient psychiatric hospital was assessed. Multidisciplinary team (MDT) opinions surrounding DNACPR were also explored with an aim to educate staff, improving frequency and quality of future discussions.Research ObjectiveEnsure patient suitability for CPR is discussed at admission, that discussions are documented and forms completed in line with Trust policy and national guidelines.MethodResuscitation Council UK guidelines were used as a standard, namely recommendations for clear and full documentation of CPR decisions triggered by a new admission to hospital. A retrospective study of admissions to the older adult psychiatric ward over a four-month period was carried out, identifying 25 patients fulfilling the inclusion criteria. Demographics and CPR consideration at the initial consultant ward round were documented. Completed DNACPR forms were audited for compliance with Trust guidance. Following data collection, 14 staff interviews using standardised questions were completed to gauge understanding of DNACPR. Answers were analysed and education was identified as key. Bite-sized teaching for MDT staff on DNACPR was carried out and response to the intervention assessed using these same standardised questions.Preliminary Results of the Ongoing Study1 patient out of 25 had a CPR discussion documented from their initial consultant review. 12% had documentation of DNACPR consideration throughout the entirety of admission. The 1 DNACPR form subsequently completed had 91% compliance with Trust policy. Qualitative results from staff interviews were insightful with 50% knowing where DNACPR forms werekept, 29% feeling confident discussing DNACPR and 93% feeling able to contribute to team decisions.Following a bite-sized education session these figures increased to 100% having awareness and confidence discussing CPR suitability.ConclusionDNACPR considerations are infrequent and staff interviews suggest this may be due to lack of confidence and knowledge surrounding CPR. Bite-sized education may play a significant role in informing the MDT and ensuring vital DNACPR considerations are not forgotten about in the psychiatric setting.

Pediatric perioperative cardiac arrest.

Paediatric peri-operative mortality is an objective outcome measure of the safety of anaesthesia and surgery. Information on paediatric peri-operative cardiac arrest is limited in terms of incidence, risk factors and outcome. The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) recommend hospitals anaesthetising children collect data on post-operative outcomes.1 Anecdotally, heterogeneity exists between trusts in record keeping and finding data for reflective practice is challenging.

O33 Outcomes of patients undergoing emergency surgery during the first phase of national lockdown in the United Kingdom due to COVID-19 pandemic: experience at a district general hospital

Abstract Introduction This study aimed to assess the impact of the COVID-19 pandemic on emergency operations during the first phase of lockdown in the United Kingdom, compared to the equivalent population in the same calendar period in 2019. Method We retrospectively reviewed patients undergoing surgery in emergency theatres at our district general hospital between March 23rd and May 11th in 2019 and 2020. Data collected included demographics, National Confidential Enquiry into Patient Outcome and Death (NCEPOD) category and procedure. The primary outcome was 90-day post-operative mortality; secondary outcomes included time to intervention and length of inpatient stay. Result 132 patients (2020) versus 141 (2019) patients were included with no significant difference in age (P = 0.676), sex (P = 0.230), or overall 90-day postoperative mortality (P = 0.196). Notably, time to intervention was faster for NCEPOD code 3 patients in 2020 than 2019 (P = 0.027). Time to intervention in 2020 was longer for those dying within 90 days post-operatively compared to survivors (P = 0.02). There was no difference in length of stay between years, both overall and when comparing subgroups by NCEPOD category or procedures (fractured neck of femur (P = 0.776), laparoscopies (P = 0.866), laparotomies (P = 0.252)), except for upper limb trauma (P = 0.007). Conclusion This study is amongst the first describing the general case mix in emergency theatres in the UK. Patient pre-operative characteristics and demographics did not change. Our data confirms patient prioritisation according to NCEPOD recommendations and streamlining of surgical services, with no difference in overall mortality, time to intervention or length of stay compared to 2019. Take-home Message At this district general hospital, patients were appropriately prioritised, and our results show adaptation of hospital practice to emerging national guidelines during the first phase of lockdown. A national validation audit assessing morbidity and mortality outcomes for all NCEPOD patients may be facilitate further understanding of risks posed to patients requiring urgent surgery during these unprecedented times.

Bridging the gap: improving liaison psychiatry documentation quality to meet the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) treat as one recommendations at newcastle hospitals

AimsThis project aimed to assess and improve the quality and frequency of documentation from Psychiatric Liaison Team (PLT) to ward-based medical colleagues against the Treat as One recommendations. From experience, we hypothesised that written documentation of information crucial to patient care is not consistently meeting standards. This communication breakdown directly affects patient safety, potentially introducing additional risks to our already vulnerable patient group.Effective communication between PLT and our medical colleagues bridges the gap in providing continuity of care and ensures patients’ mental and physical health needs are met in acute trusts. The NCEPOD found that there remains many barriers to high quality mental healthcare provided to patients in general hospitals and recommended 7 elements that PLT documentations should encompass.MethodWe audited initial PLT assessments and the resulting documentation to determine if these met the 7 standards set by NCEPOD. Baseline audit undertaken from 21-27/09/2020 encompassing 130 patient referrals to PLT.A period of time was allotted to implement robust changes to improve the service. This included a streamlined e-template that automatically populates in the acute hospital eRecord system which prompts clinicians to document according to the NCEPOD standards, structured clinician training and education, and the nomination of “Treat as One Guardians” in the team to ensure that acute trust documentations are present during daily multidisciplinary meetings.The cycle was then completed on 22-28/02/2021 with a re-audit capturing 55 referrals.ResultImplementation of our recommended changes saw an increase from 58% of documentations with ≥50% NCEPOD elements to 98% in the re-audit.We also saw an increase in number of the NCEPOD 7 elements included following intervention: formulation (0% to 8%), legal status and capacity (47% to 79%), risk assessment (2% to 28%), risk management (18% to 53%), and discharge plan (2% to 29%).Completion rate of acute trust documentation increased from 74% to 96%.Our interventions also led to more contemporaneous communication, significantly reducing mean time from assessment to documentation in both acute trust and mental health records from 6.02 to 3.53 hours, (p = 0.04) and 6.12 to 3.50 hours, (p = 0.05) respectively.ConclusionFollowing our interventions, the results showed improving trends in the frequency and quality of our documentation with secondary outcomes showing increased documenting efficiency. Our current practice is not yet optimal and retains potential to adversely affect our patients. We propose further investigating barriers to change using the quality improvement PDSA (Plan, Do, Study, Act) methodology to continue innovating.

A quality improvement project: documentation of liaison psychiatry patient reviews in the John Radcliffe Hospital, Oxford

AimsAssess how current practice reflects recommendations from the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) Treat as One: bridging the gap between mental and physical healthcare report (January 2017).Develop template for electronic documentation of liaison psychiatry reviews and implement for trial period.Re-audit after trial period to assess for change in quality of documentation.BackgroundThe John Radcliffe Hospital (JR) is a tertiary centre and has a large liaison psychiatry department with 14 consultants. Patient reviews by the liaison team are documented using a blank note type, on an electronic system used by all specialties within the hospital trust. The NCEPOD Treat as One report makes recommendations for the content of documentation of liaison psychiatry reviews which aim to improve communication between specialties.Method86 patients referred to liaison psychiatry at the JR in September 2018 were randomly selected. Four liaison psychiatry consultants appraised the quality of documentation of anonymized reviews by consultant colleagues. The audit tool was a questionnaire containing 12 questions developed by the four consultants based on the NCEPOD Treat as One report. Data were collated from these questionnaires. The template for electronic documentation was developed to reflect the report recommendations and after discussion with the liaison psychiatry team. The template has been implemented and is used for all initial patient reviews.ResultThe 12 questions of the audit tool can be divided into two groups: assessment and management. As part of the assessment, the majority of reviews included a primary diagnosis (77.9%) and reason for referral (66.3%). Other aspects of the assessment were documented in the minority of reviews: mental capacity (19.8%), need for DOLS (2.3%), risks (27.9%) and risk management (7%). Regarding the management, the majority of reviews included: clear plan with numbered/bullet points (61.6%), medication changes (51.4%), useful plan (73%) and answered the reason for referral (69.8%). Other aspects of the management were documented in the minority of reviews: each action point assigned (47.7%) and non-medical MDT advice (18.6%).ConclusionThe main area for improvement in documentation of assessment agreed by the liaison team is risk. The main areas agreed for improvement in documentation of management are medication changes, assigning action points to individuals, and including advice for non-medical MDT members. The next step is re-audit, planned for March 2020.

COVID-19 pandemic did not affect emergency theatre patient demographic and length of stay in the first phase of UK countrywide lockdown in a district general hospital.

We aim to identify any changes in outcome for patients undergoing nonelective surgery at the start of the UK pandemic in our district general hospital. This was a single-centre retrospective cohort review of a UK district general hospital serving a population of over 250,000 people. Participants were all patients undergoing a surgical procedure in the acute theatre list between 23 March to 11 May in both 2019 and 2020. Primary outcome was 90-day postoperative mortality. Secondary outcomes include time to surgical intervention and length of inpatient stay. A total of 132 patients (2020) versus 141 (2019) patients were included. Although overall 90-day postoperative mortality was higher in 2020 (9.8%) compared with 2019 (5.7%), this difference was not statistically significant (p=0.196). In 2020, eight patients tested positive for COVID-19 either as an inpatient or within 2weeks of discharge, of whom five patients died. Time to surgical intervention was significantly faster for NCEPOD (National Confidential Enquiry into Patient Outcome and Death) code3 patients in 2020 than in 2019 (p=0.027). There were no significant differences in mean length of inpatient stay. We found that patients were appropriately prioritised using NCEPOD classification, with no statistically significant differences in 90-day postoperative mortality and length of inpatient stay compared with the 2019 period. A study on a larger scale would further elucidate the profile and outcomes of patients requiring acute surgery to generate statistical significance.

Predictive Variables for Length of Stay and Complications in Patients Undergoing Major Lower Limb Amputations: Where are we Falling Down?

Introduction - Alarming rates of 30-day mortality have been documented in major lower limb amputations initially by the Vascular Surgeons of Great Britain and Ireland meeting in 2009 (17%) and the National Confidential Enquiry into Patient Outcomes and Death (NCEPOD) report from 2014 (12.4%)1. The Vascular Surgery Society (VSS) released another quality improvement framework in 2016 which hopes to reduce the rate of mortality following major amputations to less than 10% in the United Kingdom (UK)2. This study aimed to assess the outcomes of major lower limb amputations conducted in one tertiary vascular centre in the UK. The secondary aims included assessment of pre-operative and peri-operative data to identify area for care improvement. Methods - All major lower limb amputations between March 2016 and March 2017 were prospectively collected. Major lower limb amputation was defined as either above, through or below knee. Admission and perioperative demographics were retrospectively collected at the time of decision to amputate. Patients were followed up until 30-days post-op. Primary outcome was 30-day mortality. Secondary outcomes included 30-day major morbidity, time until physiotherapy discharge, time until medically fit and time until hospital discharge. Data was analysed using SPSS version 22 using appropriate significance testing and logistic regression. Results - N=80 (Above knee 48; through knee 5; below knee 27). Mean age at admission was 66.1 years (95% CI 62.7-69.4). 28.8% were female. Of those with known status, 33.8% of patients were insulin dependent diabetics and 23.0% were non-insulin dependent. 61.8% were known hypertensives. 74.6% had a smoking history. 90.9% were American Society of Anaesthetics grade 3 or above (severe systemic disease). 30-day mortality was 2.5% (n=2) with and 30 major morbidity of 13.8% (n=11). Binary logistic regression predicting mortality or morbidity was not possible due to the low number of events. When tested independently only magnesium was a predictor of 30 day mortality (p<0.005). All other factors were non-significant (including haemoglobin, creatinine, albumin and waterlow score). No pre-operative factors were significant predictors of 30 day morbidity. Median length of stay was 20 days (IQR 31) with post-op length of stay 15 days (IQR 26). Median post-op time until discharged from physiotherapy was 7 days (IQR 18) and time until medically fit was 9 days (IQR 13). There was a significant difference in pre-operative and 5 day post-operative waterlow scores (p=0.017; 22.3 vs. 24.3) with no significant change thereafter to 15 days post-operative (p=0.308; 24.7 vs. 25.8). Conclusion - This study found a lower level of 30-day mortality than previously observed in national audits. Patients with major lower limb amputation have a significant burden of co-morbidities. Only pre-operative magnesium was a predictor of mortality but this should be hesitantly used due to the low number of events and non-significance in regression modelling. Despite patients being medically fit for discharge a little over a week after major lower limb amputations, there is a significant delay in discharge. This may be due to the additional social care needs required and exploring the reason for this should be a target of further research.

Major Lower Limb Amputation: A Review of Current Standards in One Vascular Centre

Introduction: There is a need to improve outcomes and care in the perioperative period amongst patients who are having major lower limb amputations. The aim of this audit was to determine adherence to the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) recommended standards for the management of patients undergoing major lower limb amputations. Methods: 50 patients requiring major lower limb amputation in a District General Hospital were audited, with further detailed analysis possible in 19 cases where the full records were available. The age range (median) was 49 – 93 (75). 72% were male and 28% were female. The data was collected and analysed using Microsoft Excel 2013 ™. Results: Of the 50 cases audited, 20% (10) of the amputations were performed on a planned operating list and 88% (37) of patients had their operation within normal working hours. A consultant surgeon or trainee with a Certificate of Completion of Training (CCT) performed the operation in 72% (36) of these cases. On detailed review of 19 cases, 68% (13) were reviewed by a consultant within 14 hours of arrival to hospital and 47% (9) were reviewed by a Vascular Consultant within 24 hours of admission. 68% (13) had the amputation within 48 hours and 5% (1) were elective; it is unknown if a local review took place to determine why the rest, 5 cases and all urgent, were not performed within 48 hours. There was multidisciplinary team (MDT) involvement in the decision to operate in 16% (3) of cases. In 26% (5) of the cases were an MDT was not used, this was due to urgency of the operation. There is evidence of discussion with a consultant vascular surgeon in 4 of these cases. However, we were unable to determine whether these 5 cases were reviewed by a consultant Anaesthetist. Discharge planning and rehabilitation was discussed as soon as the need for amputation was identified in 21% (4) of cases. Only 1 case had a named amputation or discharge coordinator. 21% (4) of cases had physiotherapy from the first day post-amputation. A total of 19 (38%) of patients were known to have diabetes pre-operatively. On detailed review of 10 of these patients whose notes were available, the following results were obtained; 50% (5) had both pre-operative and post-operative review, and 30% (3) only had pre-operative review. 7% (7) of the patients had their insulin prescribed according to the National Patient Safety Agency (NPSA) guidelines. It was unclear whether hospital guidelines had been used to manage uncontrolled blood glucose levels in any of these cases. There was an 80% achievement for each of the following standards; nutritional state assessment within 48 hours of hospital admission, pre-operative screening for Methicillin-resistant Staphylococcus aureus (MRSA), pre- and post-operative falls assessment and risk reduction measures. We noted a 30-day post-amputation survival rate of 80%. Conclusion: There are still improvements that need to be made to help improve outcomes for patients undergoing major lower limb amputation. The key areas are early consultant review, involving an extensive MDT in the decision to operate, perioperative optimisation of patients with diabetes, and proactive discharge-planning facilitated by an amputation coordinator.

The Shock Index is not accurate at predicting outcomes in patients with upper gastrointestinal bleeding.

Acute upper gastrointestinal bleeding (UGIB) remains a major cause of hospital admission worldwide. The recent UK National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report on severe gastrointestinal bleeding used the Shock Index to assess bleeding severity and found an association between Shock Index and mortality. However, this has never been prospectively validated as a predictor of outcome in UGIB. To compare the Shock Index with existing pre-endoscopic UGIB risk scores in predicting outcomes after UGIB METHODS: In an international, prospective study of 3012 consecutive patients with UGIB, we compared the Shock Index with existing scores including the Glasgow Blatchford score (GBS), admission Rockall score, AIMS65, and the newly described "ABC" score. Pre-determined endpoints were need for major (≥4 units red cells) transfusion, need for endoscopic therapy and 30-day mortality. The Shock Index was inferior to the GBS in predicting need for major transfusion (area under the receiver operator characteristic curve [AUROC] 0.655 vs 0.836, P<0.001) and need for endotherapy (AUROC 0.606 vs 0.747, P<0.001). The Shock Index was inferior to all other scores for 30-day mortality: for example, AUROC 0.611 vs 0.863 for ABC score (P<0.001). Adding the Shock Index to the ABC score did not improve accuracy of the ABC score in predicting mortality (AUROC 0.864 vs 0.863, P=0.95). The Shock Index performed poorly with AUROCs <0.66 and was inferior to existing pre-endoscopy scores at predicting major clinical endpoints after UGIB. We found no clear evidence that the Shock Index is clinically useful at predicting outcomes in UGIB. [Correction added on 20 December 2019, after first online publication: Summary section has been changed for clarification.].

Management of aneurysmal subarachnoid haemorrhage 17 years after the ISAT trial: a survey of current practice in the UK and Ireland

Introduction: In the last two decades and driven by the International Subarachnoid Aneurysm Trial (ISAT), the management of aneurysmal subarachnoid haemorrhage (aSAH) has undergone extensive change from predominantly neurosurgical (clipping) to predominantly neuroradiological (coiling) treatment. In 2013, the UK’s national Confidential Enquiry into Patient Outcome and Death (NCEPOD) recommended aSAH to be definitively treated within 48h of ictus. The aim of this survey was to assess how this recommendation is being followed across the UK and Ireland 17 years after ISAT and 6 years after the NCEPOD.Methods: An online survey consisting of 9 questions was electronically distributed to neurosurgical consultants and trainees. Missing or ambivalent data was collected or verified by emailing consultant neurosurgeons to ensure the coverage of all 32 neurosurgical units in the UK and Ireland.Results: Only 9 (28%) of units provide 7 days a week interventional neuroradiology service, but all 32 (100%) units have established networks with other neuroradiology centres to provide aSAH treatment within 48h of ictus assuming no delays in patient transfer. For aSAH patients requiring neurosurgical clipping, 27 (84%) of units provide (locally or through networks) aneurysm repair within 48h of ictus, whereas 5 (16%) units may breach this recommendation by keeping the aSAH patients that present after 5PM on Fridays and delaying their clipping to the subsequent Monday.Conclusion: Assuming no delays in patient transfer, 32 (100%) neurosurgical centres in the UK and Ireland meet the <48h ictus-to-treatment target for endovascular coiling and 27 (84%) units for neurosurgical clipping of aSAH.

Prehospital emergency anaesthesia: time taken to care for and respond to a critically injured patient

The 2007 National Confidential Enquiry into Patient Outcome and Death (NCEPOD) Trauma: Who Cares? report recommended that people trained to administer anaesthesia and intubate severely injured patients should be available in prehospital environments. Published articles, reference documents and guidance reports were reviewed to compare the management plans and standard operating procedures produced by an ambulance trust in England that provides prehospital emergency anaesthesia (PHEA). Documents reviewed all provide a common un-referenced patient injury list showing indications to perform PHEA but do not state a time frame within which it should be performed. No minimum time before PHEA is started and how long is acceptable to wait for a specialist resource to arrive before an ambulance can transport to a hospital were found. Further work is required to establish and formalise this time frame.

Standardising care of patients requiring non-invasive ventilation in response to NCEPOD – a chief registrar quality improvement project

In 2017, a nationwide review was performed by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) into the quality of care provided to patients requiring non-invasive ventilation (NIV), in response to rising mortality as measured by the British Thoracic Society (BTS). The