Joint Meeting of The Liverpool Society of Anaesthetics and the Section of Anaesthesia of the Manchester Medical Society The Park Royal Hotel, Warrington
The meeting was opened by the President of the Manchester Medical Society, Dr Philip Steller who introduced the first lecture.
1) "An Age Old Problem"
Dr Cathy Wilkinson, Norwich
Dr Wilkinson spoke about the NCEPOD report which had been published in November 2010 for which she had been a clinical co-ordinator. It represented two years of work and review of approximately 800 cases of patients over the age of 80 years who had died within 30 days of surgery. Within the next five years the population of people aged over 85 years will double, and a previous report in 1999, had looked at this problem before.
Dr Wilkinson firstly looked at the data. She demonstrated a breakdown of age and gender, urgency of admission (of which 83.4% were emergencies), and the surgery undertaken (most commonly repair of fractured neck of femur). The overall assessment of care was deemed as good practice in only 37.5% of cases. There was room for improvement in clinical care in 36% and in organisational care in 7.6%.
Dr Wilkinson then looked at the co-morbidities of this group of patients which is extremely common with cardiovascular disease, respiratory and renal problems, being the commonest. Over 40% of patients were on more than 5 different medications, and a fifth were on more than 10. Two thirds of these patients were identified as being frail. In contrast to the previous report, pre-operative fluid resuscitation was deemed as adequate or appropriate in 85% of cases. Dementia and memory loss was also common and made consent procedures more complex. Mental capacity was often poorly documented.
Recommendations included co-morbidity, disability and frailty as needing to be recognised as independent markers of risk in the elderly. The assessment of mental capacity and the appropriate use of a consent process should be clearly understood and documented by clinicians. Malnutrition is also common in these elderly surgical admissions, and the assessment of appropriate nutritional management was also extremely poor. Multiple medications have a serious risk of drug interactions and medical review from geriatricians and an experienced ward pharmacist would greatly assist this process.
Dr Wilkinson then looked at pre-operative care. Although consultant review seemed to be common, it was not always clearly documented. There were also delays in the patient receiving surgery, principally related to poor decision making, pre-operative stabilisation and access to operating theatres.
Dr Wilkinson demonstrated the variation in formal input from MCOP or geriatric physicians. Some hospitals had regular ward rounds, whereas others only had input from guidelines and policies, or an on-call service. Less than a quarter of these patients were reviewed by an MCOP physician at any time during their admission. The principal recommendations were that senior clinicians in surgery, anaesthesia and medicine, need to be more involved in the decision to operate on the elderly, and far more routine daily input from medicine for the care for older people is required and should be integral to inpatient care pathways.
Dr Wilkinson then looked at surgery and anaesthesia. Assessors thought that surgery had been performed in a timely manner in three quarters of patients, although a third reached theatre more than 24 hours after being declared ready for surgery. 95% of surgery was performed by the appropriate grade of surgeon and anaesthetist. Intra-operative hypotension was very common, although monitoring was adequate in over 90% of patients. The principal recommendations were that delays in surgery should be avoided as they are often associated with poor outcome in the elderly, temperature monitoring is often inadequate, and hypotension is likely to contribute to a poor outcome.
Dr Wilkinson then looked at postoperative care which was deemed as appropriate in 87% of cases, although the lack of use of level 2 and 3 care facilities needs to be improved. Dr Wilkinson concluded that although things had improved since the last report, there was still further room for improvement for better care in this population of patients.
2) 'National Register of Hip Fractures'
Richard Griffiths, Peterborough and Stamford Hospitals.
Dr Griffiths started his talk by highlighting the recent report into the poor care of elderly patients in NHS hospitals. He then looked at the recommendations of the 1990 NCEPOD report and commented that little had changed in 10 years. The NHS has certainly become good at providing elective surgery for low risk patients. However, it was still poor at providing good care for high risk patients. In this bracket comes patients with fractured neck of femurs which number approximately 70,000 per year and cost the NHS about £1.46 billion. A database of hip fractures had first been started in Sweden and the UK has followed suit in recent years. The reason for having a database is that by gaining a lot more information on this condition, it may change attitudes of healthcare professionals who look after this population of patients. Secondly, it may wake up commissioners who pay for healthcare to start demanding higher standards. Hip fractures are common, the care is complex and costly and outcomes appear to vary widely. Numbers of patients with this condition are rising as the population age.
Dr Griffiths then looked at the UK database which had been started in the late 1980’s and had principally looked at surgical data. This had recently been changed to include anaesthetic data because in order to determine best practice, a large number of patients need to be treated because of all the confounding variables.
Dr Griffiths then commented on the Darcy review and the changes in tariff in the last 12 months which will reward hospitals by up to 3% on the basis of achieving quality thresholds. Hip fractures are one of the parameters with a target of surgery within 36 hours of admission.
Dr Griffiths then looked at the national hip fracture database which now contains up to 55,000 cases. It demonstrated mortality at 30 days at being only 7.7%. Dr Griffiths thought this was rather a low figure and it may be higher because 3% of patients did not get an operation. Interestingly the non operation rate varied between 0 and 10% in different hospitals. The ASA grade was 3 or higher in well over half the patients. He then looked at grades of anaesthetists and surgeons performing these operations and demonstrated a greater input from consultant anaesthetists than consultant surgeons.
Finally, Dr Griffiths looked at other aspects such as transfusion triggers and future developments.
3) 'Modern Perspectives and an Ageing Population: Early Discharge.'
Dr Susan Nimmo, Western General Hospital, Edinburgh
Dr Nimmo started her talk by looking at a paper by Basse et al (Ann.surg.2000;232; 51-57) which analysed postoperative hospital stay in 60 patients having elective colonic resection. Over half the patients only had a two day postoperative stay demonstrating a highly accelerated recovery although their re-admission rate was 15%. A more recent paper had demonstrated a 23 hour stay following laparoscopic colorectal resections. Dr Nimmo contrasted this with her own hospital’s data which showed a median length of stay of 8 days, an anastomotic leak rate of 3.6% and a re-admission rate of 5%. This figure could certainly be reduced, however, other aspects such as patient confidence, stoma care etc, often delayed discharge.
Dr Nimmo said there had been certainly major changes in recent years with early nutrition, good quality analgesia helping early mobilisation. She asked what else can we do? This ranged from pre-operative optimisation, laparoscopic surgery, good quality analgesia and early mobilisation. She commented that the better the quality of recovery, the greater the reduction in length of stay. Bowel prep was now a thing of the past for colonic surgery, fasting times had been reduced, carbohydrate loading had been introduced and there was now better goal directed peri-operative fluid management. Carbohydrate loading appeared to reduce insulin resistance by preventing the depletion of energy stores and metabolism, and reducing the incidence of postoperative hyperglycaemia leading to postoperative complications.
Dr Nimmo then looked at goal directed fluid therapy and discussed the evidence showing that too much or too little fluid has a deleterious effect on recovery. A paper by Gann et al 2002 showed that goal directed therapy using the doppler guided cardiac output monitor appeared to reduce postoperative morbidity. This was repeated by Noblett, Snowden, et al, BJS 2006 which indicated that the timing of fluid rather than the volume was more important.
Dr Nimmo also looked at the benefits of epidural analgesia which helped to limit the stress response and reduce the incidence of ileus as well as cardio-pulmonary complications. However, their quality wasn’t always as good as was hoped for, with up to a third of patients experiencing poor quality analgesia. There were however some alternatives from simple paracetamol to adjuvants such as Ketamine and Gabapentin, as well as TAP blocks.
Dr Nimmo concluded that to change practice significantly requires a whole team effort and not just a change in one person’s practice.
4) ‘The Clinical Interface with Health Technology Innovation: Who is in the Driving Seat?’
Dr Paul Dark, University of Manchester.
Dr Dark started his talk by defining health technology. He made the point that it was more than just a new piece of kit or drug. It is more broadly; methods for health promotion, the prevention and treatment of disease and the improvement of rehabilitation and long term care. The assessment of health technology considers the broader impacts and consequences on medical, economic, social, organisation, political, ethical outcomes. The stakeholders of health technology assessment include commissioners, investigators, sponsors and consumers. There is therefore real potential for bias and a conflict of interest.
Dr Dark looked at the key stages in health technology assessment which in some way mirrored development of new drugs. He also pointed out the difference between efficacy and effectiveness; the former asking the question “can it work under ideal trial conditions?” and the latter asking the question “does it work under every day conditions?” Dr Dark then looked at the Department of Health publication in 2005 ‘Best Research for Best Health’. It recommended the formation of the National Institute of Health Research (NIHR) to establish the NHS as an internationally recognised centre for research excellence. The NIHR was certainly challenging the traditional research focus within the NHS. Dr Dark then looked at the challenges of delivering innovation in the NHS. There could be conflicts with institutional priorities and the regulatory frame work. Institutional priorities were usually short term with an emphasis on quality improvements with research and development being not part of the core business. Secondly SPA funding is principally used for management and education with research being a very low priority. Finally, with University departments facing reductions in funding, teaching is becoming a greater priority for lecturers.
Dr Dark concluded that firstly there were significant attempts at developing the NHS as a market place for innovation, and there are also attempts at developing health technology assessment around key NHS service goals. These were not currently realised although funding streams were protected at present. He thought that there were significant competing barriers such as NHS Trust priorities and regulations. The biotechnology industry is crucial for UK growth and financial stability and it was vital for these competing barriers to be eliminated because there was ever great competition from other European countries and other continents.
The meeting concluded at 5 p.m. with a vote of thanks from the President of the Liverpool Society of Anaesthetists, Dr Christine Bell.
28 March 2011