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2

Method

Hannah Shotton

3

Background

Many changes in the last 20 years NCEPOD reports 1989/1999 Kennedy Report NSF for children

Clinical and organisational change to healthcare provision for children

Specialisation and centralisation of children’s services

4

Background

Less surgery in DGH

Concern regarding deskilling

Networks

Timing of study

Expert group

5

Aims

To explore remediable factors in processes of care of children 17 years and younger, including neonates, who died prior to discharge and within 30 days of emergency or elective surgery

1) Organisational structure of services

2) Quality of care received by individuals

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Objectives: Organisational

Facilities Networks Transfer Management of the “older child” Skills and competencies of staff Policies & procedures Team working Theatre scheduling Audit

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Objectives: Case Review

Pre-operative care and admission Intra-hospital transfer The seniority of clinicians Multidisciplinary team working

(involvement of paediatric medicine) Delays in surgery Anaesthetic and surgical techniques Acute pain management Critical care Comorbidities Consent

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Method

Hospital participation

Organisational questionnaire

Case ascertainment

Population

Exclusions

Data collection for 2 years

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Method

Surgical/Anaesthetic questionnaire

Case notes

Peer review

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Data returns - organisational

77% return rate

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Data returns – peer review

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Overview data - organisational

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Overview data – peer review

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Organisational Data

David Mason

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Workload

16

Workload

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Networks

‘Clinical network for children’s surgery’ Informal / formal

49% (96/194) of NHS hospitals included in a network

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Networks

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Structure and Function

51/107 were in informal networks without specific accountability or clinical governance arrangements

50/107 clinical leads and 46/107 undertook educational meetings

64/107 agreed policies for clinical care few of these included specific surgical conditions

28/107 hospitals held network based multidisciplinary team meetings

21/107 hospitals held network based audit morbidity and mortality meetings

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Recommendations

Clinical networks for children’s surgery

There is a need for a national Department of Health review of children’s surgical services in the UK to ensure that there is comprehensive and integrated delivery of care which is effective, safe and provides a high quality patient experience.

National NHS commissioning organisations including the devolved administrations need to adopt existing recommendations for the creation of formal clinical networks for children’s surgical services. These need to provide a high quality child focused experience which is safe and effective and meets the needs of the child.

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Transfer of children

93.3% (266/285) of hospitals had a policy No policy in 10 DGHs, 4 UTHs and 1 STPC

Elements included in policy (259) 130 staffing arrangements 127 family support 188 communication procedures 74 equipment provision 95 transport arrangements

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Team working

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Recommendation

Transfer of children

All hospitals that admit children should have a comprehensive transfer policy that is compliant with Department of Health and Paediatric Intensive Care Society guidance and should include; elective and emergency transfers, staffing levels for the transfer, communication procedures, family support, equipment provision and transport arrangements.

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Recommendation

Team working

All hospitals that provide surgery for children should have clear operational policies regarding who can operate on and anaesthetise children for elective and emergency surgery, taking into account on-going clinical experience, the age of the child, the complexity of surgery and any co-morbidities. These policies may differ between surgical specialities.

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Clinical governance

53% of hospitals held audit and M&M meetings for children

4/26 hospitals with a >4000 operations/year did not undertake meetings

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Pre-admission assessment

80% (228/284) of hospitals had pre-admission clinics

Written information 90% (240/267) for surgery 56% (149/267) for anaesthesia

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Recommendations

Clinical governance and audit

All hospitals that undertake surgery in children must hold regular multidisciplinary audit and morbidity and mortality meetings that include children and should collect information on clinical outcomes related to the surgical care of children.

Pre-operative assessment of elective paediatric surgical patients

Hospitals in which surgery in children is undertaken should provide written information for children and parents about anaesthesia. Good examples are available from the Royal College of Anaesthetists website.

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Children’s operating theatres

9 hospitals of all categories that reported >4000 operations/year did not have dedicated children’s operating theatres

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Theatre scheduling

30

Non-elective operating

“Out of Hours” 14/27 of STPCs children only emergency lists. Of note five of the remaining STPCs undertook between

4,000 and 10,000 cases per annum

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Recovery

35% (99/277) children recovered not separately from adults

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Recommendations

Theatre scheduling for children

Hospitals that have a large case load for children’s surgery

should consider using dedicated children’s operating

theatres.

Hospitals in which a substantial number of emergency

children’s surgical cases are undertaken should consider

creating a dedicated daytime emergency operating list for

children or ensure they take priority on mixed aged

emergency operating list.

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Hospital facilities

No separate provision in 1/3 of DGHs, 1/2 STPCs & UTHs

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Specialised staffing

13% (37/278) hospitals surgery undertaken on a site remote from the inpatient paediatric beds 6 hospitals (2 small DGH, 1 UTH, 2 PH, 1 SSH) no

provision for paediatric medical support

10.3% (23/223) hospitals trainees from an adult only surgical specialty provided medical cover for inpatient children

8.4% (23/275) hospitals did not have at least one children’s registered nurse per shift on non critical care wards

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Anaesthetic assistance

Specialised staffing

36

Recovery staff

Specialised staffing

37

Recommendations

Specialised staff for the care of children

Children admitted for surgery whether as an inpatient or an outpatient must have immediate access to paediatric medical support and be cared for on a ward staffed by appropriate numbers of children trained nurses.

There is a need for those professional organisations representing peri-operative nursing and operating department practitioners to create specific standards and competencies for staff that care for children while in the operating theatre department.

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Management of the seriously ill child

18.5% (51/276) no policy for the identification of the sick child

56.4% (155/275) hospitals used track and trigger (paediatric early warning scoring)

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Resuscitation

15/277 hospitals no resuscitation policy that included children 3 DGH, 4 UTH, 5 PH, and 3 SSH

6 hospitals no onsite resuscitation team for any age of patient 3 DGH, 3 PH

16 hospitals no member of resuscitation team had advanced training in paediatric resuscitation 4 small DGH, 3 large DGH, 1 UTH, 2 PH 6 SSH

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Recommendations

Management of the sick child

All hospitals that admit children as an inpatient must have a policy for the identification and management of the seriously ill child. This should include Track & Trigger and a process for escalating care to senior clinicians. The National Institute for Health and Clinical Excellence needs to develop guidance for the recognition of and response to the seriously ill child in hospital.

All hospitals that admit children must have a resuscitation policy that includes children. This should include the presence of onsite paediatric resuscitation teams that includes health care professionals who have advanced training in paediatric resuscitation.

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Acute pain management

69% (137/198) of NHS hospitals had an Acute Pain Service

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Acute pain management

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Acute pain management

1/4 hospitals had APN for children

95% (264/ 277) hospitals routinely assessed pain and sedation

48% (131/273) hospitals provided regular education programmes

14% (38/272) hospitals did not have protocols for the management of postoperative pain

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Recommendation

Paediatric acute pain management

Existing guidelines on the provision of acute pain management for children should be followed by all hospitals that undertake surgery in children.

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Peri-operative care

Kathy Wilkinson

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Comparisons 1989, 1999, and 2011 reports

Publication dateStudy duration

19891 year

19991 year

20112 years

Age (years, inclusive)

0-9 0-15 0-17

Population Cardiac, Non cardiac

Non Cardiac Cardiac, Non cardiac

Deaths reviewed 262/295 112 378

Deaths identified

417 139 597

%reviewed/identified

62.8% anaes70% surg

80% 63%

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Age and gender

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Location of death

49

Diagnostic group

50

Admission urgency

51

ASA status

52

Assessment of care

53

Timing of admission and surgery

54

Pre-operative

care

55

Transfers

56

Transfer for surgery

57

Care during transfer

58

59

Delays in transfer

60

How long did transfer take?

61

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Recommendation

National standards, including documentation for the transfer of all surgical patients, irrespective of whether they require intensive care need to be developed by regional networks.

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Time taken to decide surgery needed

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Who took consent?

65

Should risk of death have been documented?

66

Advisor opinion-risk of death if not documented

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Who took consent if death should have been documented?

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Recommendation

Consent by a senior clinician, ideally the one performing the operation should be normal practice in paediatrics, as in other areas of medicine and surgery. Documentation of grade confirms that this process has occurred.

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Recommendation

In surgery which is high risk due to co-morbidity and/or anticipated surgical or anaesthetic difficulty, there should be clear documentation of discussions with parents and carers in the medical notes. Risk of death should be formally noted even if difficult to quantify.

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Intra-operative

care

71

Grade of operating surgeon

72

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Anaesthetic seniority

74

Postoperative

care

75

Initial level of care

76

Days between surgery and death

77

End of life care

78

Discussions after death

79

Morbidity and mortality meetings

80

Recommendations

National guidance should be developed for children that require end of life care after surgery.

Clinicians must make sure that appropriate records are made in medical notes about discussions after death. In addition it is mandatory that the name and grade of clinicians involved at all stages of are recorded in the medical notes and on anaesthetic and operation records.

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Recommendation

Confirmation that a death has been discussed at a morbidity and mortality meeting is required. This should comprise a written record of the conclusions of that discussion in the medical notes.

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Specific Care Review

Michael Gough

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Specific care reviews

Specialist Paediatric Surgery Neonatal surgery: gastroschisis,

exomphalos

Necrotising enterocolitis (NEC)

Congenital Cardiac Surgery

Neurosurgery Trauma (including head injury) Non-traumatic illness

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20th century disease 7% of low birth weight (500-1500g) babies 20-30% mortality enteral feeding microbial colonisation

Management: Prevention Early recognition

Responsible for 1/3rd deaths in this study

NEC - Overview

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NEC - Gestational age

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NEC - Management

Medical GI rest, antibiotics, TPN

Surgery Worsening blood tests X Ray signs Perforation

Much uncertainty

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NEC - Referral to paediatric surgeons

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NEC - Inter-hospital transfer

84/103 transferred 5/71 deteriorated during transfer

Transfer delayed in 9

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NEC - Consent

Good practice: senior doctor

90

NEC - Risk of mortalityAdvisors’ opinion

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NEC - Surgery

Operating surgeon:93/103: consultant; 4/97: senior trainee or staff grade; 4/103 NK

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NEC - Quality of care

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Recommendations

This survey and the advice from our specialist Advisors have highlighted the difficulties in decision-making during both medical management and the decision to operate in babies with NEC. A national database of all babies with NEC might facilitate this aspect of care and generate data upon which to base further research.

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Congenital cardiac surgeryOverview

Data difficult to analyse

149 recognised procedures

UK Central Cardiac Audit Database:36 more commonly performed operations

12 interventional procedures2% 30-day mortality

19/54 deaths: hypoplastic left heart syndrome

Safe and Sustainable

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Congenital cardiac surgeryQuality of care

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Neurosurgery - Overview

Trauma and non-trauma: 2nd largest group

Review of Children’s Neurosurgery Services National standards/models of care Local provision versus access to specialist surgery Establish an expert workforce (research, clinical) Specialised support services

Assess centres Agreed standards Sustainable high quality service Networks of local and specialised services

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Neurosurgery - Trauma deaths

Head injury: 19/25 trauma deaths 12/25 ≥ 15 years of age

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Neurosurgery – TraumaQuality of care

99

Neurosurgery - TraumaTransfer delays

Delay in 5/10 cases where this could be assessed

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Neurosurgery: Non-traumaQuality of care

Peaks during infancy and teenage years Majority related to haemorrhage or tumour

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Neurosurgery: Non-traumaGrade of staff

102

Neurosurgery: Non-traumaDelays

Referral 3/34

Transfer 6/33

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Recommendations

Urgent completion of the “Safe and Sustainable Review of Children’s Neurosurgical Services” is required with implementation of the appropriate pathways of care that this is likely to recommend.

This should be followed by a further audit to ensure compliance with national standards and models of care for all children requiring neurosurgery.

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Specific care review

Similarities: transfer, delays, consultant input

Necrotising enterocolitis vulnerable population, increasing numbers, surgery appropriate for few, predetermined mortality collaborative research (prevention)

Cardiac surgerytransferred semi electively

very low mortality (1989: 193/295, 65%)

Neurosurgery emergency surgery, deficiencies very apparentS & S review crucial to improve care pathway

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Autopsies

1999 “Extremes of Age”2011 “Are we there yet?”

Has anything changed?

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Autopsies

1999 22 cases

“generally good”

Coronial cases: Not enough

histopathology Reports “too brief”

Less than half autopsies by paediatric pathologists

2011 49 cases

All except one done by paediatric pathologists or neuropathologists

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What has changed?

Children are now seen as ‘special’

Autopsies are now the remit of specialist paediatric pathologists

Tissue sampling undertaken – despite the Human Tissue Act 2004

Coroners want specialists in this specific area

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What has changed?

Virtually all the autopsy reports were ‘excellent’

Benefit to families, clinicians, coroners & public health

Many reports were perhaps too detailed Cost implications here?

If only adult autopsies were generally done as well

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Summary

NCEPOD has presented a wide ranging review of the organisation and delivery of children’s surgical services

Overall the peer review demonstrated a good standard of care

There is room for improvement both in hospital service provision and clinical care

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Summary

There is a need for children’s surgical services in the UK to be organised in a comprehensive and fully integrated fashion

National leadership is required to ensure networks are fully developed

Existing national standards for children’s surgery and anaesthesia requires rationalisation

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