1. 2 Method Hannah Shotton 3 Background Many changes in the last 20 years NCEPOD reports 1989/1999...
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Transcript of 1. 2 Method Hannah Shotton 3 Background Many changes in the last 20 years NCEPOD reports 1989/1999...
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Method
Hannah Shotton
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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
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Background
Less surgery in DGH
Concern regarding deskilling
Networks
Timing of study
Expert group
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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
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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
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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
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Recovery staff
Specialised staffing
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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
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Diagnostic group
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Admission urgency
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ASA status
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Assessment of care
53
Timing of admission and surgery
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Pre-operative
care
55
Transfers
56
Transfer for surgery
57
Care during transfer
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Delays in transfer
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How long did transfer take?
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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?
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Should risk of death have been documented?
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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
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Grade of operating surgeon
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Anaesthetic seniority
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Postoperative
care
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Initial level of care
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Days between surgery and death
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End of life care
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Discussions after death
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Morbidity and mortality meetings
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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
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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
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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
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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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