National Confidential Enquiry Into Perioperative Deaths Research Articles

Drowning in antibiotics.

The National Confidential Enquiry into Perioperative Deaths (NCEPOD) report recommended that 'fluid prescribing be given the same value as drug prescribing', yet fluid prescription is commonly delegated to junior doctors despite being a notoriously challenging topic. When antibiotics are given as an infusion they are diluted in 100ml of fluid, which is often unaccounted for when thinking about a patient's fluid requirements. This closed-loop audit aimed to assess first, intravenous (IV) fluid therapy and second, electrolyte prescribing compliance with National Institute for Health and Care Excellence (NICE) guidelines, with and without the additional fluid given with antibiotic administration. Two retrospective audits were performed. Total fluid and electrolyte volume received with and without antibiotic fluids was correlated with recommendations in the NICE guidelines. Between cycles 1 and 2, potassium chloride with sodium chloride and glucose (PSG) was introduced as an alternative to IV maintenance fluid, and bolusing of antibiotics was mandatory. When analysing total fluid volume input per day, 10.4% and 7.45% of patients met their fluid requirement accurately in the first and second cycles, respectively. Within cycle 1, the mean total additional fluid that was given over 3 days with antibiotics was 1,572.73ml. In cycle 2, this decreased to 469.44ml when antibiotics were given as a bolus. In this closed-loop audit we noted that patients receiving IV fluids and IV antibiotics received too much additional fluid when the antibiotic dilution fluid was taken into account. Additional fluid was reduced alongside the proportion of electrolyte complications when bolusing of antibiotics was introduced. We recommend that that all nurses are trained to give antibiotics as a bolus because it can help to reduce fluid-related complications.

Comparative outcome analysis of trauma and non-trauma emergency laparotomy using a modified NELA tool format

Background: Emergency laparotomy (EL) encompasses a diverse range of procedures that general surgeons commonly perform for both trauma and non-trauma related conditions in South Africa (SA). Despite differences in the underlying pathology and influence of the surgical procedure, these patients share one care pathway for preoperative, operative and postoperative care. This study reviewed patients undergoing trauma EL and non trauma EL in a general surgery setting at a rural KwaZulu-Natal tertiary hospital to compare results between the groups using a modified National Emergency Laparotomy Audit (NELA) tool format. Methods: Consecutive adult patients undergoing midline EL at Ngwelezana Hospital between 1 March and 31 May 2018 were included. Patient factors analysed were demographic data (age, gender) and risk factors: National Confidential Enquiry into Perioperative Deaths (NCEPOD) grade, American Society of Anesthesiologists (ASA) grade, and comorbidity. Process of care factors included grade of the physician, time to surgery, time of surgery and duration of surgery. The primary outcome measure was mortality. Secondary outcome measures were intensive care unit (ICU) admissions, complications, and length of stay (LOS) > 14 days. Results: The study included 110 participants who met the inclusion criteria representing a total of 174 laparotomies. The trauma EL group had lower ASA grades (p = 0.003), less comorbidities (p = 0.002), more often went to theatre within six hours (42/56; 75.0%) (p 14 days (16/56; 28.6%) (p = 0.037). Conclusion: The trauma EL group represents a high-risk group for morbidity and mortality at Ngwelezana Hospital.

Safety in out-of-hours operating in trauma and orthopaedics at a district general hospital.

INTRODUCTION According to the National Confidential Enquiry into Perioperative Deaths (NCEPOD), out-of-hours operating in trauma and orthopaedics should be reserved for life or limb threatening cases only. The aim of our study was to determine the nature of non-emergency work carried out in our trust at night in 2015. The overall efficacy and clinical safety of the services provided was evaluated. METHODS Surgical activity undertaken after 9pm was reviewed along with patient ASA (American Society of Anesthesiologists) grade, grade of operating surgeon and any complications that occurred following the procedure. Furthermore, the clinical urgency and safety of cases was assessed based on whether there was any record of life or limb threatening indications at the time of admission. RESULTS Overall, 131 procedures were performed after 9pm, with 102 performed between 9pm and midnight, and 29 after midnight. Consultants performed 16 cases and the remaining 115 cases were operated on by middle grades or specialty trainees. A fifth (20%) of the cases were genuinely life or limb threatening. A total of 123 procedures were classed as having good outcomes. The complication rate was 8%. CONCLUSIONS In our study, 80% of the procedures performed after 9pm could not be categorised as life or limb threatening. Appropriate NCEPOD classification would ensure that only life or limb threatening cases were listed for theatre after 9pm. Alternative methods of operating within working hours should be considered.

We still need to operate at night!

IntroductionIn the past the National Confidential Enquiry into Peri-operative deaths (NCEPOD) have advocated a reduction in non-essential night-time operating in NHS hospitals. In this study a retrospective analysis of the emergency general surgical operative workload at a London Teaching centre was performed.MethodsAll general surgical and vascular emergency operations recorded prospectively on the theatre database between 1997 and 2004 were included in the study. Operations were categorised according to whether they commenced during the daytime(08:01–18:00 hours), evening(18:01–00:00 hours) or night-time(00:01–08:00 hours). The procedure type and grade of the participating surgical personnel were also recorded. Bivariate correlation was used to analyse changing trends in the emergency workload.ResultsIn total 5,316 emergency operations were performed over the study period. The numbers of daytime, evening and night-time emergency procedures performed were 2,963(55.7%), 1,832(34.5%), and 521(9.8%) respectively. Laparotomies and complex vascular procedures collectively accounted for half of all cases performed after midnight whereas they represented only 30% of the combined daytime and evening emergency workload. Thirty-two percent (n = 166) of all night-time operations were supervised or performed by a consultant surgeon. The annual volume of emergency cases performed increased significantly throughout the study period. Enhanced daytime (r = 0.741, p < 0.01) and evening (r = 0.548, p < 0.01) operating absorbed this increase in workload. There was no significant change in the absolute number of cases performed at night but the proportion of the emergency workload that took place after midnight decreased significantly throughout the study (r = -0.742, p < 0.01).ConclusionA small but consistent volume of complex cases require emergency surgery after midnight. Provision of an emergency general surgical service must incorporate this need.

Preoperative assessment of the surgical patient

Consecutive publications by the UK National Confidential Enquiry into Perioperative Deaths (NCEPOD) have cited inadequate preoperative preparation, inappropriate intraoperative monitoring and poor postoperative care as contributing to perioperative mortality. Preoperative assessment is used to decide if a patient can withstand the physiological stresses of anaesthesia and surgery. Furthermore, an evaluation of potential interactions between concurrent diseases, surgery and anaesthesia offers an opportunity to improve physical condition before surgery, select appropriate perioperative care, and modify outcome.

Results of the centralisation of adult emergency oral and maxillofacial surgical services at the University Hospital, Birmingham

In 2001, the oral and maxillofacial surgical (OMFS) services for adults in Birmingham were centralised at the Selly Oak site of the University Hospital and the OMFS department was given access to the emergency operating theatre every day. We examined the effects of this on the emergency workload during the 6 months after centralisation and compared it with the emergency workload at the University Hospital during the 6 months before centralisation. The number of adult patients who attended the University Hospital as emergencies increased from 242 in the 6 months before centralisation to 545 in the subsequent 6 months (an increase of 127%). Of the latter 164 (30%) were admitted and operated on, 138 (84%) within 24 h of admission. Despite the large increase in the number of patients, 102 (74%) were operated on during normal working hours. After centralisation, all operations were done on multidisciplinary emergency lists compared with only 55% before centralisation. Centralisation did not reduce the access of patients to the emergency service and conformed with the guidelines of the National Confidential Enquiry into Perioperative Deaths (NCEPOD).

Orthopaedic trauma care: a two-tier system?

Orthopaedic trauma requiring surgical admission presents to our hospitals right throughout the week. However, the level of service provided to trauma patients appears to fluctuate with more surgery facilities available during weekday "office-hours" with reduced facilities at the weekend. The National Confidential Enquiry into Peri-operative Deaths (NCEPOD) in 1999 laid down guidelines for orthopaedic trauma surgery in elderly patients clearly stating that no elderly patient requiring an urgent operation should have to wait for more than 24 h once fit for surgery. We see no reason to exclude the younger population from such a directive and have hence applied the same standard of "surgery within 24 h of admission" as our index of appropriate practice. Audit of our consultant delivered performance confirmed that while an average 88% of "weekday service" patients admitted Sunday through Thursday achieved this standard, only an average of 64% of weekend service patients admitted on Friday or Saturday achieved the same standard. The purpose of this report is to increase awareness of what we believe to be a widespread dilemma. The day of the week should not dictate the treatment of the patient.

Balancing priorities in the management of hip fractures: guidelines versus resources.

About 60,000 patients are treated for hip fractures each year in the UK and the incidence is increasing. The majority of these patients are elderly and sick, and delay to operation may be fatal. The National Confidential Enquiry into Peri-Operative Deaths (NCEPOD) guidelines aim to improve quality of care for such patients. However, we present an audit highlighting the importance of balancing the implementation of such guidelines with available local resources to ensure that established priorities in the care of these patients remain paramount. The 2001 NCEPOD report recommends that pre-operative transthoracic echocardiography be performed in patients who have evidence of aortic stenosis in order to identify those requiring invasive monitoring and high dependency unit care postoperatively. We have assessed the impact of the implementation of these guidelines on surgery for fractured neck of femur at our hospital, auditing both delay to surgery and the effect of the investigation on subsequent management. In the period studied prior to the introduction of the NCEPOD guidelines, no patients underwent pre-operative echocardiography. Subsequent to their introduction, 10% of patients underwent the investigation, which in the current study did not alter management but did delay surgery by 4-8 days in all cases. For such guidelines to be implemented, adequate resources should first be provided. In the absence of these resources, clinicians must balance the need for adequate pre-operative assessment with the need for urgent surgery.

Paediatric anaesthesia: past, present and future.

Paediatric anaesthesia: past, present and future.

NCEPOD: reconciling recommendations with reality in the ICU

The structure and role of the NCEPOD The UK National Confidential Enquiry into Perioperative Deaths (NCEPOD), a registered charity established in the late 1980s, reviews clinical practice and identifies areas where changes in surgical and anaesthetic practices may improve patient outcome. NCEPOD is a largely government-funded, yet independent, body with a chief executive, a steering group, clinical coordinators (representing specialties such as anaesthesia, surgery, pathology, oncology) and administrative staff. NCEPOD relies on a network of reporters located at every NHS and private hospital in England, Wales, Northern Ireland, Guernsey, Jersey, Isle of Man and the Defence Secondary Care Agency. Reporters notify NCEPOD of all deaths occurring in hospital after surgery. While participation in NCEPOD is voluntary in the private sector, it is compulsory for NHS Trusts. A similar function is performed by the Scottish Audit of Surgical Mortality.

Functioning as a team? The role of NCEPOD reports in clinical risk management

Since 1990, the National Confidential Enquiry into Perioperative Deaths (NCEPOD) has published a total of 14 reports. These are intended to assist clinical staff in applying the lessons learned from the analysis of post‐operative deaths to help prevent future incidents. However, anecdotal evidence suggests that the dissemination of this information does not always take place. Access to these reports should be encouraged and perhaps considered more formally during surgical training. Their use is also advocated in the multidisciplinary setting and as part of clinical audit. Unacceptable standards of medical record keeping are frequently highlighted in the NCEPOD reports. All health‐care professionals have a responsibility to raise these standards such that clinical documentation conforms with a basic acceptable standard that does not compromise patient care. Risk managers should also make use of the NCEPOD reports in meeting the requirements of Clinical Negligence Scheme for Trusts (CNST) standards.

Advanced upper airway obstruction in ENT surgery

134 The anaesthetic management of patients with critical upper airway obstruction from tumours involving the area around the larynx can be a challenging problem. A key message from the chapter on head and neck surgery in the 1998 Report of the National Confidential Enquiry into Perioperative Deaths (NCEPOD) was that ‘the management of the obstructed airway gave cause for concern’. The purpose of this review is to discuss the management of patients with advanced obstruction from tumours involving the proximal part of the airway. The sites of obstruction can be divided into supraglottic, laryngeal and subglottic. Pathologies include tumours of the supraglottis, pharynx, pyriform fossa, epiglottis, vocal cords and subglottis. Patients considered in this article will, by definition, have significant stridor at rest. However, it is estimated that only 5% of laryngeal cancers will present with severe dyspnoea and stridor. Therefore, these patients are encountered rarely. Although many anaesthetists have strong views about how such patients should be managed, few will have had ‘hands-on’ experience, apart from those regularly working in major ENT or head and neck surgery. Since these patients may present outside regular hours, experienced anaesthetic staff may not always be on-call. Although only proximal airway obstruction will be considered in detail, reference will be made to the important differences in management between proximal lesions and those causing obstruction at more distal levels of the trachea. Stridor at rest

The autopsy: lessons from the National Confidential Enquiry into Perioperative Deaths

Not long ago, the place of the autopsy in medical practice seemed to be primarily the concern of the medical profession. Then the issue of organ retention came to public attention in the UK following the Bristol Royal Infirmary and Alder Hey Inquiries1,2, and the whole question of keeping organs and other samples from autopsies suddenly became the focus of intense media attention, generally negative, in which the British government was involved3,4. In consequence, there is debate about the future role of the autopsy. Several government-sponsored reviews of the conduct of the medical profession in regard to autopsies have been proposed. Some of these are currently out to consultation and include national standardized autopsy consent forms, a code of practice for bereavement services4, a review of the removal and retention of human organs (including a code of practice for museums, archives and collections of human organs and tissue)5 and a Home Office-led review of death certification and the coronial system in England and Wales6. A comprehensive review of the Human Tissue Act (1961) is planned. These measures will undoubtedly regulate all aspects of autopsy practice and its contribution to research, education and audit. The National Confidential Enquiry into Perioperative Deaths (NCEPOD) stands to be much affected by such changes but must continue to play a part in informing the debate.

The lessons of the National Confidential Enquiry into Perioperative Deaths

The National Confidential Enquiry into Perioperative Deaths (NCEPOD) uses an annual sample of deaths occurring within 30 days of a surgical operation in England, Wales and Northern Ireland to identify remedial factors in the practice of anaesthesia and surgery. In its reports, through a process of peer review, it makes recommendations for improvement. Inevitably in a sample based on deaths, the majority of patients are old and sick and have a low expectation of survival in the longer term. They are therefore very much at high risk for their surgery and anaesthesia. Many have coexisting medical conditions, particularly cardiac, and these are not always well managed pre-operatively. If these high-risk patients are to benefit from the advances in modern anaesthetic, surgical and medical practice, then better organization and provision of services will be required. Information collected by NCEPOD suggests that current arrangements spread acute services too thinly resulting in an unsatisfactory dependence on trainees to sustain emergency care. There are also inadequacies in the provision of intensive treatment unit and high-dependence unit beds.

A plan for the NHS for the 21st century.

A plan for the NHS for the 21st century.

The effect of the National Confidential Enquiry into Perioperative Deaths on clinical practice. Report of a postal survey of a sample of consultant anaesthetists.

A postal survey was performed to investigate whether the National Confidential Enquiry into Perioperative Deaths (NCEPOD) had influenced clinical practice. A short questionnaire was sent to 100 consultant anaesthetists from England, Wales and Northern Ireland. There was a 72% response rate. NCEPOI) had influenced personal clinical practice in 74% of respondents, the inception of guidelines and protocols in 75% and had helped in the improvement of essential services, staff or equipment in 80%. Some individuals had tried and failed to establish improvements. Nearly 80% perceived current threats to standards of care that NCEPOD might investigate in the future. The replies indicated that NCEPOD is perceived by clinicians as influencing clinical practice and standards of care.

Prevention of postoperative venous thromboembolism

The publication of the 1991–1992 report of the National Confidential Enquiry into Perioperative Deaths (NCEPOD) [10] drew attention to prophylaxis against venous thromboembolism in surgical patients as an area of clinical practice that requires attention. The report found that pulmonary embolism is an important cause of mortality in postoperative surgical patients and was responsible for 7 % of all deaths. The role of prophylaxis against venous thromboembolism was not investigated in great detail but the findings suggested that it is not being given to all patients in whom it could be considered appropriate. In high-risk hip replacement patients, for example, 33 % did not receive any prophylaxis against venous thromboembolism. The recommendations made in the NCEPOD report were that every hospital should have an agreed policy for prophylaxis against venous thromboembolism, all surgeons should be made aware of the problem and implementation of the policy should be audited regularly. The aim of this review of the prevention of venous thromboembolism is to identify patients who benefit, discuss the merits of different methods, investigate areas of controversy and explore the role of anaesthetists.

Effective audit: reporting to the National Confidential Enquiry into Perioperative Deaths.

To investigate the effectiveness of computer based and manual district and unit information systems for identifying hospital deaths eligible for reporting to the National Confidential Enquiry into Perioperative Deaths (NCEPOD). Prospective six to 10 week study of hospital (death register, immediate coding of medical records) and district information systems followed by six month assessment after modification to entry of data. Acute units within Lewisham and North Southwark Health District. All 290 patients dying in hospital during the six weeks, for whom the medical records were obtainable in 231. Sensitivity and specificity of the information systems in ascertaining eligible surgical deaths (patients dying in hospital who had during 30 days previously had a surgical procedure while under the care of a consultant in a surgical specialty) tested against validated list of screened medical records. Of 231 medical records, 30 (12 from Lewisham, 18 from North Southwark) met the national inquiry's criteria. The computer based systems of both units detected less than 60% of eligible deaths (sensitivity 53%, specificity 83%); the death register detected about 60% (sensitivity 61%, specificity 89%); manual systems detected all eligible deaths. Subsequent modification to ensure immediate coding of records into the computerised systems during follow up failed to show any improvement. Routine hospital information systems may miss up to half the deaths eligible for NCEPOD.