Death following a first time, isolated coronary artery bypass graft

1. Death following a first time, isolated coronary artery bypass graft The heart of the matter A report of the National Confidential Enquiry into Patient Outcome and Death (2008)

2. Study aim The aim of the study was to examine whether there are identifiable changes in care processes, including the functioning of cardiac teams, that impact on patient outcome following a first time isolated CABG.

3. Study questions

4. Patient inclusion/identification Three year period 1st April 2004 – 31st March 2007 All units in England, Wales, Scotland and Northern Ireland NHS and Independent sector Cases - patients that died in hospital following surgery Direct from units Controls - patients discharged alive following surgery CCAD or direct from the unit

5. Patient identification Office of Population Census and Surveys (OPCS) codes K40 – Saphenous vein graft replacement of coronary artery K41 – Other autograft replacement of coronary artery K42 – Allograft replacement of coronary artery K43 – Prosthetic replacement of coronary artery K44 – Other replacement of coronary artery K45 – Connection of thoracic artery to coronary artery Or by defining the operation as CABG only as defined in the minimum data set of the SCTS

6. Data collected Questionnaires Surgical Anaesthetic Organisational Casenotes Advisors

7. Data returns (cases)

8. Age and gender • 68% male, 32% female

9. Mode of admission

10. Category of operation

11. Overall care assessment (cases)

12. Overall care assessment (controls)

13. Referral and admission process A report of the National Confidential Enquiry into Patient Outcome and Death (2008)

14. Referral and admission Referrals via a variety of different routes Range of admission processes Use of local networks of cardiac care using a ‘hub and spoke’ model Referral protocols, treatment protocols and quality improvement methods should be in place within these networks NSF Coronary Heart Disease Department of Health 2000

15. Use of protocols for referral • Written protocols were available in 28/58 of CTUs

16. Use of protocols for referral • There were discrepancies in the use of protocols as described by surgeons and those reported to be present in each unit • In 674/910 (75%) patients a standard written protocol was used for referral • even though in 349 patients a standard written protocol did not exist in cardiothoracic unit according to OQ! • Surgeon completing SQ may have interpreted the question differently than person completing OQ. • There was a 8% stated increase in use of written protocols over the three years of the study

17. Patient referral process • 99% of patients referred by a cardiologist

18. Patient referral process • 20% of patients were referred verbally

19. To whom were referrals addressed?

20. Case study 1 An elderly patient with triple vessel CAD with ACS and cardiac failure was transferred from another hospital directly to the cardiac ICU. The referral was made between a cardiology SHO to a senior nurse on the ICU without the knowledge of the CT team. By the time that the consultant CT surgeon was informed the patient had developed renal failure, had an EF of <20% and required the use of an IABP with inotropic support but was conscious. A decision to undertake CABG was made despite a stated mortality of >50%. The patient died five days postoperatively from multi-organ failure. No autopsy was performed.

21. Case study 1 Advisors comments: • Lack of senior level communication between the referring cardiologists and cardiothoracic surgeons for this urgent high risk patient • Inappropriate for a nurse to accept such a patient on to the ICU • Was the surgeon put under undue peer pressure to proceed with surgery in view of the likely outcome? • The advisors wonder whether palliative care would been more appropriate for this patient

22. Pre-admission assessment • 49/58 of CTU had a pre-admission clinic • 44/49 of CTU used a pre-admission proforma • 34/49 of CTU used an ICP • In only 33 % (272/821) of patients were ICPs used • non elective patients in the study sample • Many of the ICPs were not fit for purpose because they did not contribute to the patient care pathway • Lack of standardisation • No minimum data set of information

23. Pre-admission assessment • Personnel performing pre-admission assessment • 23/49 (47%) cardiothoracic surgeon and nurse • 9/49 (18%) nurse only • 9/49 (18%) included an anaesthetist • Variation in personnel involved and function National Good Practice Guidance on Pre-operative Assessment for Inpatient Surgery,Modernisation Agency. 2003

24. Delays to first cardiothoracic review • 41/910 (5%) delay in opinion of surgeons • 57/822 (7%) delay in opinion of advisors • unable to assess in 102 (12.5%) • A delay to the first review affected the diagnosis of the patient in 8/57 cases (advisor opinion) • A delay to first review affected the outcome of the patient in 33/57 cases (advisor opinion)

25. Case study 2 A written referral, regarding an elderly patient, was made by a consultant cardiologist from a DGH, to a consultant CT surgeon. The surgeon was on annual leave. Four weeks after referral the cardiologist contacted the surgeon again by letter. The surgeon denied knowledge of the patient. It subsequently transpired that the referral letter had been misfiled awaiting the return of the surgeon. In the mean time the patient’s condition had deteriorated and they were referred to another CT centre. The patient underwent CABG which was complicated by postoperative cardiac failure and they died after a protracted period on the ICU.

26. Case study 2 Advisors comments: • Not possible to determine whether the delay in the referral of this patient affected the clinical course • However concerned that no formal cross cover arrangements had been arranged for new referrals during the surgeon’s absence • Wondered if a generic team system for referrals to cardiothoracic units should be considered using a cardiac network approach

27. Deterioration during transfer • It was difficult to assess whether patients deteriorated during transfer • However of the 405 patients that were inter or intra- hospital transfers to the CTU 27 (6.7%) were judged by the advisors to have deteriorated during the transfer • Majority of these patients had evolving infarcts with recurrent chest pain

28. Case study 4 A middle aged patient was transferred as an emergency from another hospital to the cardiology service with ACS. The patient underwent urgent angiography which showed severe stenosis of the right coronary artery. A verbal message was left by the cardiologists for the cardiothoracic team that this patient required urgent CABG. Although blood for a troponin level had been taken the result was not available prior to surgery. It transpired postoperatively that the patient had an evolving myocardial infarct. They developed a low cardiac output state following surgery and died.

29. Case study 4 Advisors comments: • Communication between the cardiologists and surgeons was very poor • No formal referral process occurred with insufficient information given regarding the potential evolving infarct • If the troponin level had been available would this have changed the decision for surgery? • Should the surgeon have made more effort to check information on the patient’s condition was correct before operating?

30. Initial assessment • 10% (80/820) patients “poor” or “unacceptable”

31. Delays to time to operate • Missing data for 20% of cases for each year of the study 7 patients had intervals ≥ 250 days

32. Key findings • Written protocols for referral of patients were available in 28/58 of CTUs. Discrepancies occurred in the use and presence of protocols. • In 272/821 (33%) ICPs were used; variation in the quality was noted. • 99% of patients were referred by a cardiologist. • In 57/822 (7%) of cases there was a delay from referral to the first CT review and in 33 of these patients outcome was adversely affected. • 27/405 (7%) patients deteriorated during the transfer.

33. Recommendations • Cardiothoracic units need to adhere to the requirement of the National Service Framework for Coronary Artery Disease and use protocols for referrals to their unit. These protocols should be standardised nationally for patients who require coronary artery bypass graft surgery. The degree of urgency of referral should be emphasised within these protocols. (Clinical Directors)

34. Recommendations • Cardiothoracic units need to ensure that monitoring systems are in place to record nationally agreed audit data on referrals and the decision to operate. These systems need to identify patients who are in danger of breaching national agreed waiting times so that surgery can be expedited. (Clinical Directors)

35. Recommendations • Patients who have acute myocardial ischaemia and require CABG need special attention. Many of these patients are intra or inter-hospital transfers. This group of patients should have surgery performed as soon as their clinical condition permits based on appropriate investigation and pre-operative therapeutic optimisation. (Clinical Directors)

36. Scheduling of operations A report of the National Confidential Enquiry into Patient Outcome and Death (2008)

37. Out of hours • Out of hours defined as: between 17:59 and 08:00 and any time at weekends • 68/760 (9%) operated upon out of hours • Approximately equal numbers of elective and non-elective cases out of hours

38. Out of hours • Only one out of hours case not operated upon by a consultant surgeon • Only one out of hours case not induced by a consultant anaesthetist

39. In hours • Normal hours 112/642 (17%) operated upon by SpR or SAS • Normal hours 19/604 (3%) anaesthetised by SpR or SAS

40. Standard of care

41. Key findings • Less than 10% out of hours. • High level of consultant involvement. • Better care overall out of hours. • Scheduling did not appear to have a detrimental effect on quality of care.

42. Multidisciplinary case planning A report of the National Confidential Enquiry into Patient Outcome and Death (2008)

43. Multidisciplinary case planning 4 out of 58 units had protocol for multidisciplinary case planning 21 out of 58 units held pre-operative multidisciplinary meetings 17 of these held weekly meetings

44. Who attended the MDT? • 7 units kept records of attendance

45. Individual case planning • Only 225/905 (25%) discussed • Age <55 – 36% • No influence by gender • EuroSCORE

46. EuroSCORE • Mean 7.4 v 7.6 (discussed v not discussed)

47. Multidisciplinary case planning • Effect on treatment? • No difference in global assessment • More likely to have a written pre-operative plan

48. Key findings • Only 21 of the 58 units held pre-operative MDT meetings. • Only one in four patients in this study were discussed at a pre-operative MDT meeting. • Patients who were discussed at a pre-operative MDT meeting were more likely to have a clear written operative plan.

49. Recommendations • Each unit undertaking coronary artery bypass grafting should hold regular preoperative MDT meetings to discuss appropriate cases. Core membership should be agreed and a regular audit of attendance should be performed. (Clinical Directors)

50. Recommendations • Each unit should have a clear policy for which cases should be discussed at preoperative MDT meetings. (Clinical Directors) • Trusts and consultants should identify time within the agreed job plan to allow participation in MDT meetings. (Clinical Directors)