Method

• Two month data collection period (Feb-Mar 2004)

• NHS and independent hospitals in England, Wales, N Ireland, Guernsey, Isle of Man and Defence Secondary Care Agency

• Adults >=16 years of age• Open repair; endovascular repair;

diagnosed but not treated and died in hospital

Method (cont)

• Expected sample size was 1129 operated cases and 106 non-operated cases

• Questionnaire sent to combination of surgeon, anaesthetist and radiologist

• No casenote review• Organisational questionnaire for each

hospital• Risk stratification planned using a

published model• Multidisciplinary advisory group

Data overview – hospital participation

• 226 hospitals identified as possibly undertaking AAA repair

• 188 completed organisational questionnaires

• 181 eligible to take part in study (163 NHS and 18 independent)

• 87% participation rate for clinical questionnaires

Data overview – hospital participation

Organisation of vascular services

Size of vascular unit

• Large• 500,000 patients, 4 surgeons,

potential for vascular surgical on-call rota

• Intermediate• <500,000 patients, fully equipped for

vascular surgery, not enough surgeons for on-call rota

• Remote• Remote, small catchment population

Size of vascular unit

Availability of imaging during the daytime

Availability of imaging out of hours

Recommendation

Trusts should ensure the availability outside normal working hours of radiology services including CT scanners.

Numbers of elective open operations 2002/03

Numbers of emergency open operations

Outcome of elective cases by volume of cases

Outcome of emergency cases by volume of cases

Published evidence

• Improved outcomes for unruptured AAA when higher volumes performed by:• surgeons• hospitals

• US recommendation – hospitals should perform 50 cases/year

• 19/181 hospitals in this study performed 50 or more cases/year

Recommendation

Clinicians, purchasers, Trusts and Strategic Health Authorities should review whether elective aortic aneurysm surgery should be concentrated in fewer hospitals.

Vascular surgical on-call rotas

Vascular anaesthetic on-call rotas

• 3% (5/178) of hospitals reported that they had an anaesthetic on-call rota for vascular surgery

• Should large vascular units implement anaesthetic vascular on-call rotas?

Interventional radiology on-call rotas

Destination after AAA repair

Use of recovery areas after elective surgery

• 4 hospitals reported that the recovery area was the preferred destination

• 9% of elective patients were reported to have been cared for in recovery areas for a substantial period of time (from the anaesthetic questionnaire)

Recommendation

Major elective surgery should not take place unless all essential elements of the care package are available.

Outcome of elective open repair

Overall mortality was 6.2%

Outcome after emergency admission with ruptured AAA, all patients

Palliative care vs. operation on emergency admission with AAA

Outcome after emergency admission with unruptured AAA, all patients

Patient information

• How much information should be given to patients on the organisation of vascular services?

• How should this information be provided?

Surgical open repair

Mode of admission

Age

Age and outcome

Waiting times

Cancellations

• 1 in 25 patients cancelled because no ward bed

• 1 in 6 patients cancelled because no critical care bed

Recommendation

Patients with an aortic aneurysm requiring surgery must have equal priority with all other patients with serious clinical conditions for diagnosis, investigation and treatment.

Trusts should take action to improve access to Level 2 beds for patients undergoing elective aortic aneurysm repair so as to reduce the number of operations cancelled and inappropriate use of Level 3 beds.

Recommendation

Preoperative assessment clinic

Comorbidities

• Cardiac history and signs associated with increased risk of death

• Diabetes carried no additional risk of death in this study

• Increased risk of death among morbidly obese or cachectic patients

Trusts should ensure that clinicians of the appropriate grade are available to staff preoperative assessment clinics for aortic surgery patients.

Recommendation

Length of operation

Grade of surgeon

Specialty of surgeon

75%

25%

<1%

Membership of Vascular Society and outcome

Surgeons workload

Postoperative complications within 30 days of surgery

• 21% had an infective complication, most commonly of the chest and wound

• 7% had a myocardial infarct, nearly half these patients died

Emergency surgery

• Unscheduled admission

Age and outcome

Comorbidities

• Higher risk of death in patients with cardiac disease, diabetes, morbid obesity or cachexia

• Mortality increased among patients not fully conscious, though 2/7 patients with GCS below 9 did survive

Time to operation

Length of operation

Grade of surgeon

Specialty of surgeon

Membership of the Vascular Society and outcome

Surgeons workload

Workload and outcome

• The best results were seen among patients operated on by surgeons who also performed the most elective aneurysm repairs

Postoperative complications within 30 days of surgery

• 1 in 5 patients had a chest infection

• Graft complications were more common than in elective repairs

• 21 of 37 patients who had an MI died

• Renal impairment also carried a high risk of mortality

Recommendation

Strategic Health Authorities and Trusts should co-operate to ensure that only surgeons with vascular expertise operate on emergency aortic aneurysm patients, apart from in exceptional geographic circumstances.

Anaesthesia

Use of beta blockers in AAA patients

Elective open operations

Emergency open operations 26%

Use of statins in AAA patients

Elective open operations

Emergency open operations 31%

Preoperative investigations – large units

Preoperative investigations – intermediate sized units

Most senior anaesthetist at the start – elective open operations

Range 81% - 94%

Most senior anaesthetist at the start – emergency open operations

Range 70% - 88%

In 27 cases a consultant assumed responsibility after the start of anaesthesia – overall 97%

Information about the numbers of cases done by anaesthetists

Recommendation

Trusts should ensure that anaesthetists can identify the major cases that they have managed in order to support audit and appraisal.

Numbers of elective open operations, 2002/03

Outcome and volume, elective operations, in this study

Numbers of emergency open operations, 2002/03

Outcome and volume, emergency operations, in this study

Recommendation

Anaesthetic departments should review the allocation of vascular cases so as to reduce the number of anaesthetists caring for very small numbers of elective and emergency aortic surgery cases.

Epidural analgesia

• 92% (345/377) of open elective operation patients received an epidural catheter

• 168 received aspirin in the 7 days before surgery

• 61 received fractionated heparin within 6 hours of surgery

• In 55 cases the anaesthetist did not know when the catheter was removed

Recommendation

Trusts should ensure that they have robust systems for the postoperative care of epidural catheters with accompanying appropriate documentation.

Destination after elective open surgery

Management of temperature, all open patients

Mechanical ventilation of the lungs after elective open surgery

Recommendation

Anaesthetic departments and critical care units should review together whether vascular surgery patients who routinely receive postoperative mechanical ventilation could be managed in a Level 2 High Dependency facility breathing spontaneously.

Endovascular aneurysm repair

Demographics

Reason for decision to treat with endovascular repair

Status of aneurysm

Length of procedure

Destination after the procedure

Complications

Outcome

• All patients on whom we had data were alive at 30 days (47/53)

The care of patients who did

not undergo surgery

Demographics

Demographics

• 36% were female, vs. 29% of the emergency operated patients

• 43% were known to have an AAA, vs. 26% of the emergency operated patients

Selection of patients

• It was not possible to test the NCEPOD data against the Hardman criteria

• Patients aged 80 years or over• 55% of patients aged 80 or over

received surgery vs. 90% of patients under 80 years

• Of 68 patients who received surgery• 37% discharged alive within 30 days• 9% alive but still in hospital

Effect of size of vascular unit

Other associations with decision to provide operative, not palliative, care• Membership of Vascular Society• Presence of a surgical vascular on-

call rota• NCEPOD has confirmed the difficulty

of drawing robust conclusions about the decision to provide palliative care