National Hip Fracture Anaesthesia Network

1
National Hip Fracture Anaesthesia Network

• The First Year
• Richard Griffiths (Peterborough)
• Kirsty Forrest (Leeds)
• John Holloway (Poole)

2
HIPFA

• Brief run through the activities since last year
• Update on some important new evidence
• Reports from two network members on varied
  experience of dealing with problems
• A look at a minimum dataset
• Results of first national audit

3
National Hip Fracture Anaesthesia Network

• Japanese meta-analysis
• Is Operative Delay Associated with Increased
  Mortality of hip fracture patients?
• Shiga et al Toho University Tokyo Japan
• ASA San Francisco September 2007

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National Hip Fracture Anaesthesia Network

• Surgical repair within 24 hours recommended
• (try within 48 hours)
• Royal College of Physicians London
• However, a 25 of patients have significant
  co-morbidity

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National Hip Fracture Anaesthesia Network

• Shiga et al Toho University Tokyo Japan
• ASA San Francisco September 2007
• 15 studies , observational, 252,336 patients
• Mean age 81 yrs
• Female 77.4
• Cut off of 24-72 hrs (mean 48) to define delay

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National Hip Fracture Anaesthesia Network

• Shiga et al continued
• Delayed surgery increased 30 day all cause
  mortality significantly by,
• 44
• 1 year all cause mortality increased by 33

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National Hip Fracture Anaesthesia Network

• Shiga et al
• For every 1,000 patients who undergo delayed
  surgery instead of early surgery there would be
  29 more deaths after 30 days
• And 52 more deaths after a year

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National Hip Fracture Anaesthesia Network

• Preoperative hematocrit levels and postoperative
  outcomes in older patients undergoing noncardiac
  surgery
• JAMA 2007 297 pages 2481-2488

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National Hip Fracture Anaesthesia Network

• Retrospective study
• 310,311 aged over 65, non-cardiac surgery
• 1.6 increase in 30 day postoperative mortality
  with every 1 increase or decrease in Hct value
  from normal
• lt 39 and gt 51
• WHO definition of anaemia 1968

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HIPFA

• Age Anaesthesia Manchester May 2007
• Article in RCOA Bulletin
• Aim to promote best practice in the anaesthesia
  community for hip fracture patients
• In the future to co-ordinate audit and research
  efforts

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HIPFA

• How many acute Trusts in the UK are in the
  network?
• To date there are 53 represented
• This includes Northern Ireland, Scotland and Wales

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Have I got news for you
13
HIPFA

• Network is owned by every member
• Experience across UK is very different
• Presentations on the Leeds Experience
• Followed by Life on the South Coast

14
Leeds experience

• Leeds Teaching Hospitals NHS Trust is the largest
  in the UK
• There has been a recent reorganization of service
  provision, all Orthopaedic and Trauma surgery for
  the City of Leeds
• Catchment population 720,000
• All centralized to Leeds General Infirmary
• Approx 800 NOFs/year

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What have we got?

• Trauma coordinators x 3
• 4/5 wards (scattered)
• Orthogeritricians
• Guidance for echo/anticoagualtion
• Weekly operational meeting
• 30 lists a week in 2/3 theatres with dedicated
  evening trauma and weekend lists

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Hip Fractures wait from admission to
operation LGI SJUH (July, August, September
2006) LGI (July, August, September 2007)
Standard of fit patients getting to theatre
within 24 hours of admission 1 CEPOD
www.ncepod.org.uk The extremes of age 1999. 2
Scottish intercollegiate Guidelines Network Jan
2002 www.sign.ac.uk Standard of patient getting
to theatre within 48 hours of admission British
Orthopaedic Association, British Geriatric
Society-BOA Sept 2007
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Woman, 95, had hip op cancelled EIGHT times in
a week
Marjorie Fox 25 September 2007, By KATIE BALDWIN
Health Reporter Hospital bosses have apologised
after a 95-year-old woman's hip operation was
cancelled EIGHT times in a week. Marjorie Fox
went without food for hours as she was prepared
for surgery at Leeds General Infirmary, only for
it to be cancelled later. The pensioner was on
morphine because she was in so much pain after
falling and breaking her hip. Now her family have
hit out at the hospital for the delays which they
say affected other elderly patients too. Mrs
Fox's niece Mary Emsley, above right, said "At
her age to have her wait all that time is wrong.
It's not a one-off it's been going on a long
time." Hospital managers have apologised for the
postponed ops, admitting the delays were
"unacceptable", but said it was a busy week
rather than an ongoing issue."They were fasting
her every day and some days all day. Eight
times she was due to go down for the op and eight
times it was cancelled." Mrs Emsley, from
Horsforth, said she understood several other
elderly patients from that ward were also waiting
for the same operation at the same time but only
one was being seen each day. Mrs Fox, originally
from Otley, eventually had surgery a week after
being admitted. A spokesman for Leeds Teaching
Hospitals NHS Trust said "We're extremely sorry
Mrs Fox's operation was postponed so many times
her treatment clearly fell below our usual high
standards. "Although there was a marked increase
in the number of patients requiring orthopaedic
surgery during the week in question, the number
of delays to Mrs Fox's treatment is
unacceptable." He added there was no increased
risk to Mrs Fox because of the delay. Toby
Branfoot, lead trauma surgeon for the hospitals
trust, added that theatre scheduling could cause
problems, as they could operate on young, healthy
patients late at night but not complex cases.
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Hip Fractures wait from admission to
operation LGI SJUH (July, August, September
2006) LGI (July, August, September 2007) LGI
(Jan, Feb, March 2008)
Standard of fit patients getting to theatre
within 24 hours of admission 1 CEPOD
www.ncepod.org.uk The extremes of age 1999. 2
Scottish intercollegiate Guidelines Network Jan
2002 www.sign.ac.uk Standard of patient getting
to theatre within 48 hours of admission British
Orthopaedic Association, British Geriatric
Society-BOA Sept 2007
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Delayed Surgery

• 75 out of 138 patients gt 48 hours for surgery.
• 8 patients lt 48 hours had documented reasons for
  delay
• total number of delays 83
• There were 32 organisational delays
• 48 medical delays
• 1 anaesthetic delay
• 1 delay due to lost x-rays
• 1 patient declined surgery.
• Of the 48 medical delays,
• 13 were for reasons considered acceptable by the
  Scottish Intercollegiate Guidelines.

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Why still a problem?

• Surgical specialties
• Too many
• With too much work to do
• - Compared with other centres low number of
  surgeons

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Too many specialist surgeons

• AR spines
• PM spines
• RD spines
• PT children
• BS children
• NH - foot ankle
• RM - foot ankle
• DL - upper limb
• RH - upper limb

• Locum - athroplasty
• TS - arthroplasty trauma
• PB -  arthroplasty
• PG - pelvis complex trauma
• TB - complex trauma limb reconstruction
• SB -  complex trauma limb reconstruction
• RV - knees

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Why still a problem?

• Surgical specialties
• Too many/not enough surgeons
• Half day lists surgeons/anaesthetists
• X ray
• Not enough machines or radiographers
• Laminar flow theatres
• Not enough
• HDU facilities
• Not enough
• Sterile services!!

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Operations cancelled due to dirty
equipmentPublished Date 14 April 2008
HOSPITAL bosses have admitted dirty surgical
equipment has caused the last-minute cancellation
of operations. Leeds Teaching Hospitals NHS Trust
is holding emergency meetings with its suppliers
after it emerged contaminated instruments were
returned by angry surgical staff on at least two
occasions just as the operation was about to go
ahead.The trust has admitted there were
problems with its new contractor which was
only taken on last month and has now apologised
to affected patients. The row broke out after
patient Helen Rygate, 46, had her hip operation
cancelled twice. She said she had been told by
her surgeon that the problem of dirty equipment
was widespread. A spokesman for Leeds Teaching
Hospitals NHS Trust said We sincerely apologise
to Helen Rygate about problems with instruments
which have meant that her operation at Chapel
Allerton Hospital has been cancelled on two
occasions. The operating theatres previously had
an in-house decontamination service but moved to
a new, external supplier in March.We acknowledge
there have been some problems since then which we
have been dealing with, the spokesman added.
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Poole Hospital Trauma ExperiencesA New Beginning

• Dr John Holloway
• Consultant Anaesthetist

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Trauma Assessment and Co-ordination (TAC) team

• Started 1999
• 4 nurses
• Responsible for pre and post op co-ordination of
  trauma patients
• Especially NOFs and other elderly trauma

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NOF workload

• One of five busiest units
• Circa 830 patients per year
• Peak 10 per day

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Trauma lists

• Two trauma theatres
• Theatre 5 - am / pm / twilight lists
• Theatre 4 - am / pm
• Average 2.35 patients per list

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My experience

• Attended trauma efficiency meeting!!
• Suggested a seamless trauma day with Associate
  Specialist
• Compress 3 lists to 1
• Start 08.00
• Finish 18.30
• Theatre staff 07.30 19.00

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• A
• Slow
• Start!

Metastatic CA Pleural effusions 2 x Cancellations
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All day list

• 1st year 40.5 lists
• Average 8.4 patients per day
• 340 patients treated
• 131 NOFs
• 5 overruns - average 10 minutes
• Max overrun - 30 minutes
• Cancellations for organisational reasons
  eliminated

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Fractured Neck of Femur

• 131 1st year
• GA 124
• Spinal 7
• Fascia iliaca blocks 114
• Lumbar psoas 9 (1 rescue)
• 3 in 1 3 (1 rescue)

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Medical cancellations

• Fast AF
• Chest infection!
• INR
• Na / K
• Clopidogrel

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Delays and deaths

• 48 hours 59 (2 RIP)
• 49 hours 72 (11 RIP)
• 10 RIP delay 81 hours

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HIPFA

• After one year
• 60 enthusiast connected by email with network
  space provided by NHS Networks
• Including one from Australia
• First basic audit of anaesthetic practice
  started in January 2008
• A snap shot of what was happening in the network

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HIPFA

• Enquiries from nurses and managers
• Prompted by an article in the HSJ in January 2008
• Although for anaesthetists, this is
  multi-disciplinary

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HIPFA First Data

• Data is still arriving so have to be patient
  before final report
• Limited mortality data yet
• Basic data
• Some useful information
• I will present the interesting parts

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HIPFA First Data

• 20 hospitals (to 8/5/2008)
• Jan/Feb 2008
• 1,000 patients (double the largest ever RCT on
  hip fracture anaesthesia)
• 27 men
• 73 women
• Average age 81.5 years

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HIPFA

• 58 ASA 3
• 11 ASA 4

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HIPFA First Data

• Average time to operation 49.3 hours
• Range 20 to 106 hours
• 40 patients postponed for surgery
• 56 of these cancellations were for
  organisational reasons
• Only 1.4 of cancellations by anaesthesia

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HIPFA First Data

• Information is limited
• Dont know when anaesthesia gets involved?
• Do know that grade of anaesthetist probably
  influences time of surgery

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• 64 of all cases done by consultants
• Only 0.5 cases ST 12 primary anaesthetist

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HIPFA

• What data do we want collected on a prospective
  basis?
• This would form a minimum dataset and should be
  collected on every patient

47
HIPFA

• Suggestions from network members
• Drug doses, especially for spinal block
• The use of concomitant nerve blocks
• What to do with clopidogrel?
• How quickly can an ECHO be obtained?

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Minimal Data Set for Hip Fracture Anaesthesia

• How can we develop on the success of the first
  HIPFA audit?
• Coordinate national data collection, through the
  development of an appropriate database.
• In its infancy.
• Any further suggestions on pertinent data for
  collection welcome!

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Demographic, Personnel and Timing Data
Anaesthetic Assessment Data
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Reason for delaying operation
Major co morbidity contributing to delay
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Anaesthetic Technique Data Regional
Anaesthesia General Anaesthesia Sedation Invasive
Monitoring Postoperative Analgesia
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HIPFA First Data

• Anaesthesia 2008,63,250-258
• Survey of UK practice
• Spinal preferred in 76 of UK anaesthetists
• 40 used sedation to position
• Regional Anaesthesia in 44 of case

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• Remember, all suggestions regarding suitable
  data to be collected welcome!
• Involve your department and join the Hip
  Fracture Anaesthesia Network.
• www.networks.nhs.uk/hipfa

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NHFD

• Collects a lot of information,
• But nothing about anaesthesia, the assessment or
  the process
• I could not find the grade of anaesthetist or the
  ASA grade

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HIPFA

• Next 12 months
• Organize into regional sub-networks
• Find a home as funding for NHS networks goes by
  October 2008
• Secure funding for national database
• NPSA? NCEPOD? NIAA? RCA?

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HIPFA

• Aim for each patient in UK to be recorded on a
  national anaesthetic database
• Anaesthesia for hip fracture to be benchmark
  procedure for departments
• Could we also achieve the same with emergency
  laparotomy?