BYDR. CHAMIKA HURUGGAMUWAREGISTRAR IN ANAESTHESIA

National Confidential Enquiry into Patient Outcome and Death

HISTORY… Late 1940s, (AAGBI) developed the idea that it might be possible to assess the factors that influence death associated with anaesthesia on a national basis.

This work was further developed in the 1970s by Dr John Lunn

Professor William Mushin, culminated in the publication of the report ‘Mortality Associated with Anaesthesia’ in 1982 

In 1988 the National Confidential Enquiry into Perioperative Deaths (NCEPOD) was then established

It is supported by government funding.

.

First report was published in 1987

THE EARLY WORK OF NCEPOD CENTERED ON RECOMMENDATIONS TO

Improve hospital clinical information systems,

The development of multidisciplinary team working with closer supervision of trainees, and

The use of multidisciplinary clinical audit

STRENGTHS OF NCEPOD

IT IS AN INDEPENDENT ORGANISATION .

Clinical input on a day-to-day basis is provided by Clinical Coordinators who are practising consultants, seconded from NHS

hospital trusts.

The National Confidential Enquiry into Peri-operative Deaths (NCEPOD) is now established in the United Kingdom (excluding Scotland) as a voluntary,

confidential system designed to review the clinical practice which precedes a death within 30 days of surgery.

The Enquiry is comprehensive, widely representative and authoritative.

The influence of these reports on the practice of anaesthesia and surgery in Britain is undeniable.

NCEPOD'S PURPOSE IS TO

Assist in maintaining and improving standards of care for adults and children for the benefit of the public by reviewing the management of

patients,

By undertaking confidential surveys and research,

By maintaining and improving the quality of patient care and

By publishing and generally making available the results of such activities.

NATIONAL CONFIDENTIAL ENQUIRY INTO

PERIOPERATIVE DEATHS

National Confidential Enquiry into Patient Outcome and Death

Improving the quality of healthcare

How does the method of the Clinical Outcome Review Programmes run by NCEPOD differ from the National

Clinical Audits?

NCEPOD uses case note review in a sample of cases to assess the quality of care provided whereas national audits use quantitative

data collected on sequential cases.

Why do NCEPOD does not need ethics approval?

Ethics Committee approval is not required in accordance with the HRA decision tool, the work programme is not classified as

research.

NCEPOD has moved away from reviewing the care of surgical patients only and

now covers all specialties.

This is reflected in the wide range of studies currently undertaken and the

fact that death is no longer used as the only outcome to identify patients.

@NCEPOD#sepsis

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STUDY OBJECTIVES• Timely identification, escalation and

treatment of sepsis: use of systems, EWS, care bundles

• Multidisciplinary team approach

• Communication:- Primary/secondary care- Healthcare professionals; documentation of

sepsis- Patients, families and carers

• End of life care

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Recommendations

All hospitals should have a formal protocol for the early identification and immediate management of patients with sepsis.

The protocol should be easily available to all clinical staff, who should receive training in its use. Compliance with the protocol should be regularly audited. This protocol should be updated in line with changes to national and international guidelines and local antimicrobial policies.

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Recommendations

An early warning score, such as the National Early Warning Score (NEWS) should be used in both primary care and secondary care for patients where sepsis is suspected. This will aid the recognition of the severity of sepsis and can be used to prioritise urgency of care.

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Recommendations

On arrival in the emergency department a full set of vital signs, as stated in the Royal College of Emergency Medicine standards for sepsis and septic shock should be undertaken.

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Recommendations

In line with previous NCEPOD and other national reports’ recommendations on recognising and caring for the acutely deteriorating patients, hospitals should ensure that their staffing and resources enable:a. All acutely ill patients to be reviewed by a consultantwithin the recommended national timeframes (14 hrs post adm.)

b. Formal arrangements for handover

c. Access to critical care facilities if escalation is required; and

d. Hospitals with critical care facilities to provide a Critical Care Outreach service (or equivalent) 24/7.

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Recommendations

All patients diagnosed with sepsis should benefit frommanagement on a care bundle as part of their care pathway.

The implementation of this bundle should be audited and reported on regularly. Trusts/Health Boards should aim to reach 100% compliance and this should be encouraged by local and national commissioning arrangements.

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Dr Neil SmithDr Simon McPhersonMr Derek O’Reilly

#AP

ACUTE PANCREATITIS

Management crosses many specialties

High mortality and morbidity

Recurrent admissions

Complex care and specialist input

Varied implementation of guidelines

Dr Neil SmithDr Simon McPhersonMr Derek O’Reilly

#AP

ACUTE PANCREATITIS

Management crosses many specialties

High mortality and morbidity

Recurrent admissions

Complex care and specialist input

Varied implementation of guidelines

CAUSE & PATIENT CHARACTERISTICS

CAUSE OF AP – STUDY POPULATION

Gallstones 46.5% (322/692)

Alcohol excess 22% (152/692)

Post-ERCP 4% (28/692)

No cause 17.5% (121/692)

EARLY WARNING SCORES

RECOMMENDATION 4 - EARLY WARNING SCORES

An early warning score should be used in the ED and throughout the patient’s hospital stay to aid recognition of deterioration. This should be standardised within and across all hospitals. NCEPOD supports the use of NEWS to facilitate standardisation

RECOMMENDATION 5 - EARLY WARNING SCORES

All acute hospitals should have local arrangements to ensure an agreed response at each NEWS trigger level including:

Speed of responseClear escalation policy which ensures an appropriate response 24/7Seniority and clinical competencies of the responderAppropriate setting for on-going acute care and timely access to high dependency care if requiredFrequency of subsequent monitoring

RECOMMENDATION 9 - GALLSTONES

Gallstones should be excluded in ALL patients, including those thought to have alcohol-related AP, as gallstones are common in the general population.

Abdominal US is the minimum that should be performed.

RECOMMENDATION 17 - AP OF UNKNOWN CAUSE

After excluding the commoner causes of AP those in whom the cause remains unknown should undergo MRCP and/or endoscopic ultrasound to detect micro-lithiasis, neoplasms and chronic pancreatitis as well as rare morphological abnormalities. A CT of the abdomen should also be considered.

ANTIBIOTIC USE & MISUSE

INDICATION FOR ANTIBIOTIC USE

RECOMMENDATION 7 - ANTIBIOTIC PROPHYLAXIS

Antibiotic prophylaxis is not recommended in acute pancreatitis.

All healthcare providers should ensure that antimicrobial policies are in place including prescription, review and the administration of antimicrobials as part of an antimicrobial stewardship process.

These policies must be accessible, adhered to and frequently reviewed with training provided in their use.

NUTRITION

RECOMMENDATION 8 - NUTRITIONAL SUPPORT

All patients admitted to hospital with acute pancreatitis should be assessed for their overall risk of malnutrition.

This could be facilitated by using the Malnutrition Universal Screening Tool (MUST) and provides a basis for appropriate referral to a dietitian or a nutritional support team and subsequent timely and adequate nutrition support.

THE PROBLEM OFRECURRENT ADMISSIONS

RECOMMENDATION 10 - GALLSTONE PANCREATITIS

For those patients with an episode of mild acute pancreatitis, early definitive surgery should be undertaken, either during the index admission, as recommended by IAP, or on a planned list, within two weeks.

For those patients with severe acute pancreatitis, cholecystectomy should be undertaken when clinically appropriate after resolution of pancreatitis.

NATIONAL EARLY WARNING SCORE (NEWS)

Other risk scores, like MEWS and PEWS, have been in widespread use for some years. The introduction of NEWS brought about a significant lowering of the threshold for contacting senior medical input and involvement of critical care teams.

NATIONAL EARLY WARNING SCORE (NEWS)

Six simple physiological parameters form the basis of the scoring system:

1  Respiratory rate2  Oxygen saturations3  Temperature4  Systolic blood pressure5  Pulse rate6  Level of consciousness.

NEWS AS AN EXCELLENT INITIATIVE WHICH SHOULD

Help staff recognize patients whose condition is deteriorating on the wards earlier than at present so they can have the benefit of

being treated in time to prevent their admission to intensive care.

Enable the sickest patients to be identified quickly and admitted to intensive care more promptly than at present and so they can have

a greater chance of a better outcome.

Help identify post operative patients whose condition is deteriorating on the wards earlier than at present so they can have the benefit of being treated in time to prevent

their admission to intensive care.

THANK YOU