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Method

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).

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Method

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  1. 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

  2. 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

  3. 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

  4. Data overview – hospital participation

  5. Organisation of vascular services

  6. 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

  7. Size of vascular unit

  8. Availability of imaging during the daytime

  9. Availability of imaging out of hours

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

  11. Numbers of elective open operations 2002/03

  12. Numbers of emergency open operations

  13. Outcome of elective cases by volume of cases

  14. Outcome of emergency cases by volume of cases

  15. 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

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

  17. Vascular surgical on-call rotas

  18. 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?

  19. Interventional radiology on-call rotas

  20. Destination after AAA repair

  21. 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)

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

  23. Outcome of elective open repair Overall mortality was 6.2%

  24. Outcome after emergency admission with ruptured AAA, all patients

  25. Palliative care vs. operation on emergency admission with AAA

  26. Outcome after emergency admission with unruptured AAA, all patients

  27. Patient information • How much information should be given to patients on the organisation of vascular services? • How should this information be provided?

  28. Surgical open repair

  29. Mode of admission

  30. Age

  31. Age and outcome

  32. Waiting times

  33. Cancellations • 1 in 25 patients cancelled because no ward bed • 1 in 6 patients cancelled because no critical care bed

  34. 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.

  35. Recommendation 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.

  36. Preoperative assessment clinic

  37. 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

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

  39. Length of operation

  40. Grade of surgeon

  41. Specialty of surgeon <1% 25% 75%

  42. Membership of Vascular Society and outcome

  43. Surgeons workload

  44. 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

  45. Emergency surgery • Unscheduled admission

  46. Age and outcome

  47. 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

  48. Time to operation

  49. Length of operation

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