Search

Summary: We collected blank non‐specialist anaesthetic records from 71 National Health Service Trusts in England. A data set was established by collating all data items found in an initial tranche of 28 records. All 71 records were subsequently analysed for each data item in this data set. We found significant variation: the most populated record included 216 data items and the least included 38 data items: a greater than five‐fold variation. There was significant variation in the inclusion of data items commonly considered important to patient safety; 42% of records omitted documentation of fasting status, 72% omitted documentation of a discussion around the risk of accidental awareness during general anaesthesia, 92% omitted documentation of quantitative neuromuscular blockade monitoring and 63% omitted documentation for 'Stop Before You Block' when performing regional anaesthesia. The study highlights significant variability in the composition of anaesthetic records across England which may impact on its value as a data repository, an action trigger, a medicolegal account, and a tool to facilitate safe handover. Standardisation of the anaesthetic record or the establishment of standards of recording would help to allay potential risks to patient safety and assist in guiding future procurement of electronic solutions for anaesthetic records. [ABSTRACT FROM AUTHOR]

Summary: We reviewed all 1230 claims against anaesthesia notified to NHS Resolution (formerly the NHS Litigation Authority, 1995–2017) in England between 2008 and 2018. Claims were categorised by incident type, severity (whether physical or psychological), and cost, and comparisons were made against a similar published analysis of data from 1995 to 2007. While the annual number of claims against anaesthesia increased by 62% from the earlier period, anaesthesia now accounts for smaller proportions of all claims submitted to NHS Resolution (1.5% vs. 2.5%) and of the total cost of all claims (0.7% vs. 2.4%). The absolute costs related to anaesthesia claims rose over 300%, totalling £145 million between 2008 and 2018, but the mean cost per closed claim (retail price index adjusted) fell by 6% to £74,883. The most common clinical categories were regional anaesthesia (24%), inadequate anaesthesia (20%) and drug administration (20%). Claims related to airway management, central venous catheterisation and cardiac arrest remained infrequent but severe and costly. The proportion of claims relating to regional anaesthesia and obstetric anaesthesia fell significantly, but claims relating to peripheral nerve blockade doubled. Our analysis includes categories relating to organisational and human factors which are present in a substantial proportion of claims; categories with the highest mean cost per claim included delayed care, planning, monitoring and consent. Overall, the specialty of anaesthesia is at low risk of litigation. Our analysis provides important insights into current and changing patterns in claim distributions that may help improve the quality of patient care and reduce future litigation. We recommend the establishment of a structure for national review and learning from all cases of litigation. [ABSTRACT FROM AUTHOR]

Implementation of a quality improvement bundle for peri-operative management of emergency laparotomy (ELPQuIC) improved mortality in a previous study. We used data from one site that participated in that study to examine whether it was associated with the cost of care. We collected data from 396 patients: 144 before, 144 during and 108 after implementation of the bundle. We estimated costs incurred using previously published methodology based on the time the patient spent in hospital, in the operating theatre and in critical care. Duration of stay in hospital and critical care did not differ between time periods, p = 0.14 and p = 0.28, respectively. The costs per patient and per survivor did not differ between the time periods, p = 0.87 and p = 0.17, respectively. Costs were similar for patients aged < 80 years vs. ≥ 80 years. Implementation of a quality improvement bundle for emergency laparotomy has the capacity to save lives without increasing hospital costs. [ABSTRACT FROM AUTHOR]

The article discusses the working of the colorectal multidisciplinary team (MDT) at the Leicester General Hospital in Leicester, England. It presents administrative and medical preparation prior to MDT meetings that take place from 8 to 9.15 am each Tuesday. Further, it states that the MDT members deal with the existing cases first as these require more difficult decisions need to be made, whereas, at the end of the session most of the new cases can be processed with a depleted attendance.

We analysed 366 claims related to regional anaesthesia and analgesia from the 841 anaesthesia-related claims handled by the National Health Service Litigation Authority between 1995 and 2007. The majority of claims (281/366, 77%) were closed at the time of analysis. The total cost of closed claims was £12 724 017 (34% of the cost of the anaesthesia dataset) with a median (IQR [range]) of £4772 (£0–28 907 [£0–2 070 092]). Approximately half of the claims (186/366; 51%) were related to obstetric anaesthesia and analgesia and of the non-obstetric claims, the majority (148/180; 82%) were related to neuraxial block. The total cost for obstetric closed claims was £5 433 920 (median (IQR [range]) £5678 (£0–27 690 [£0–1 597 565]) while that for non-obstetric closed claims was £7 290 097 (£3337 (£0–31 405 [£0–2 070 062]). Non-obstetric claims were more likely to relate to severe outcomes than obstetric ones. The maximum values of claims were higher for claims related to neuraxial blocks and eye blocks than for peripheral nerve blocks. Despite many limitations, including lack of clinical detail for each case, the dataset provides a useful overview of the extent, patterns and cost associated with the claims. [ABSTRACT FROM AUTHOR]

The distribution of medico-legal claims in English anaesthetic practice is unreported. We studied National Health Service Litigation Authority claims related to anaesthesia since 1995. All claims were reviewed by three clinicians and variously categorised, including by type of incident, claimed outcome and cost. Anaesthesia-related claims account for 2.5% of all claims and 2.4% of the value of all claims. Of 841 relevant claims 366 (44%) were related to regional anaesthesia, 245 (29%) obstetric anaesthesia, 164 (20%) inadequate anaesthesia, 95 (11%) dental damage, 71 (8%) airway (excluding dental damage), 63 (7%) drug related (excluding allergy), 31 (4%) drug allergy related, 31 (4%) positioning, 29 (3%) respiratory, 26 (3%) consent, 21 (2%) central venous cannulation and 18 (2%) peripheral venous cannulation. Defining which cases are, from a medico-legal viewpoint, ‘high risk’ is uncertain, but the clinical categories with the largest number of claims were regional anaesthesia, obstetric anaesthesia, inadequate anaesthesia, dental damage and airway, those with the highest overall cost were regional anaesthesia, obstetric anaesthesia, and airway and those with the highest mean cost per closed claim were respiratory, central venous cannulation and drug error excluding allergy. The data currently available have limitations but offer useful information. A closed claims analysis similar to that in the USA would improve the clinical usefulness of analysis. [ABSTRACT FROM AUTHOR]

Background: Integrated working, as encouraged by UK and international policy, occurs when staff from different professions collaborate and share decision making for the benefit of service users (Pollard et al. 2005). There is minimal evidence related to integrated therapy roles in acute settings. It was important to explore this further to inform the introduction of integrated roles at new sites and future work related to service quality. Aim: To explore the experiences and attitudes of therapy staff working in an acute setting in the UK towards integrated occupational therapy and physiotherapy roles. Methods: A phenomenological approach was taken to this qualitative, exploratory study in order to describe individuals' experiences of integrated working in relation to their contexts (Finlay 2011). Data was collected via elite interviews and focus groups with therapists and support workers at a large acute hospital trust in the UK, and analysed using thematic analysis techniques. Results: Three main themes emerged: Participants' understanding of integrated working their experience of this as a journey and the perceived impacts. Overall participants agreed in their understanding of integrated working. Although opinions differed between staff groups, different sites and according to experience, all were able to identify potential benefits and risks of role integration, with the need to maintain specialist professional roles being emphasised. Conclusion: Implications for practice are presented in the form of potential barriers and facilitators to the introduction of integrated therapy roles. These relate to staff, for example the barrier created by feelings about change or the facilitator of receiving appropriate training, and also relate to patients, like the possibility of overwhelming patients or the benefits for patient flow. This could assist managers considering introducing integrated working and inform methodology for the investigation of quality of integrated interventions. [ABSTRACT FROM AUTHOR]

Guidance for the timing of surgery following SARS-CoV-2 infection needed reassessment given widespread vaccination, less virulent variants, contemporary evidence and a need to increase access to safe surgery. We, therefore, updated previous recommendations to assist policymakers, administrative staff, clinicians and, most importantly, patients. Patients who develop symptoms of SARS-CoV-2 infection within 7 weeks of planned surgery, including on the day of surgery, should be screened for SARS-CoV-2. Elective surgery should not usually be undertaken within 2 weeks of diagnosis of SARS-CoV-2 infection. For patients who have recovered from SARS-CoV-2 infection and who are low risk or having low-risk surgery, most elective surgery can proceed 2 weeks following a SARS-CoV-2 positive test. For patients who are not low risk or having anything other than low-risk surgery between 2 and 7 weeks following infection, an individual risk assessment must be performed. This should consider: patient factors (age; comorbid and functional status); infection factors (severity; ongoing symptoms; vaccination); and surgical factors (clinical priority; risk of disease progression; grade of surgery). This assessment should include the use of an objective and validated risk prediction tool and shared decision-making, taking into account the patient's own attitude to risk. In most circumstances, surgery should proceed unless risk assessment indicates that the risk of proceeding exceeds the risk of delay. There is currently no evidence to support delaying surgery beyond 7 weeks for patients who have fully recovered from or have had mild SARS-CoV-2 infection., (© 2023 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists.)

The scale of the COVID-19 pandemic means that a significant number of patients who have previously been infected with SARS-CoV-2 will require surgery. Given the potential for multisystem involvement, timing of surgery needs to be carefully considered to plan for safe surgery. This consensus statement uses evidence from a systematic review and expert opinion to highlight key principles in the timing of surgery. Shared decision-making regarding timing of surgery after SARS-CoV-2 infection must account for severity of the initial infection; ongoing symptoms of COVID-19; comorbid and functional status; clinical priority and risk of disease progression; and complexity of surgery. For the protection of staff, other patients and the public, planned surgery should not be considered during the period that a patient may be infectious. Precautions should be undertaken to prevent pre- and peri-operative infection, especially in higher risk patients. Elective surgery should not be scheduled within 7 weeks of a diagnosis of SARS-CoV-2 infection unless the risks of deferring surgery outweigh the risk of postoperative morbidity or mortality associated with COVID-19. SARS-CoV-2 causes either transient or asymptomatic disease for most patients, who require no additional precautions beyond a 7-week delay, but those who have persistent symptoms or have been hospitalised require special attention. Patients with persistent symptoms of COVID-19 are at increased risk of postoperative morbidity and mortality even after 7 weeks. The time before surgery should be used for functional assessment, prehabilitation and multidisciplinary optimisation. Vaccination several weeks before surgery will reduce risk to patients and might lessen the risk of nosocomial SARS-CoV-2 infection of other patients and staff. National vaccine committees should consider whether such patients can be prioritised for vaccination. As further data emerge, these recommendations may need to be revised, but the principles presented should be considered to ensure safety of patients, the public and staff., (© 2021 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists.)

Background: The intensive care unit (ICU) is a high-cost high-risk area in which analysis of previous litigation cases may help to improve future practice., Methods: Claims received by the National Health Service Litigation Authority (NHSLA) relating to ICU, from 1995 to 2012, were analysed according to clinical categories. The severity of outcome was classified as none, low, moderate, severe and death. The cost of the claims were corrected to 2013 values using the retail prices index., Results: Of the 523 claims in the NHSLA dataset, 210 were excluded (as the claims did not relate to ICU care) and 313 were included in the analysis. The commonest claim categories were [number (% of all claims)]: positioning/nursing standards/skin care (mostly relating to pressure sores)- 86 (28%), infection- 79 (26%), respiratory/airway- 63 (20%). The commonest claims relating to patient death were: respiratory/airway (30%), missed/delayed diagnosis (20%) and paediatrics (17%). The claims categories with the highest proportion of severe outcomes were: positioning/nursing standards/skin care (52%) and infection (33%). The total cost of closed claims was £19,973,339. The categories incurring the highest costs were: infection (£6.6 million), positioning/skin care/nursing standards (£4.5 million), delayed/inadequate treatment (£4.3 million)., Conclusions: Litigation arising from care in the ICU is common, costly, and is likely to follow a poor outcome. Whilst the importance of airway/respiratory care and infection control measures are highlighted, the clear prominence of pressure sores in ICU-related litigation is worrisome and represents one particular area for practice improvement., (© The Author 2015. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Claims notified to the NHS Litigation Authority in England between 1995 and 2007 and filed under anaesthesia were analysed to explore patterns of injury and cost related to airway or respiratory events. Of 841 interpretable claims the final dataset contained 96 claims of dental damage, 67 airway-related claims and 24 respiratory claims. Claims of dental damage contributed a numerically important (11%), but financially modest (0.5%) proportion of claims. These claims predominantly described injury during tracheal intubation or extubation; a minority associated with electroconvulsive therapy led to substantial cost per claim. The total cost of (non-dental) airway claims was 4.9 million pounds (84% closed, median cost 30,000 pounds) and that of respiratory claims was 3.3 million pounds (81% closed, median 27,000 pounds). Airway and respiratory claims account for 12% of anaesthesia-related claims, 53% of deaths, 27% of cost and ten of the 50 most expensive claims in the dataset. Airway claims most frequently described events at induction of anaesthesia, involved airway management with a tracheal tube and typically led to hypoxia and patient death or brain injury. Airway trauma accounted for one third of airway claims and these included deaths from mediastinal injury at intubation. Pulmonary aspiration and tube misplacement, including oesophageal intubation, led to several claims. Among respiratory claims, ventilation problems, combined with hypoxia, were an important source of claims. Although limited clinical details hamper analysis, the data suggest that most airway and respiratory-related claims arise from sentinel events. The absence of clinical detail and denominators limit opportunities to learn from such events; much more could be learnt from a closed claim or sentinel event analysis scheme.

Ninety-three claims (total cost 4,915,450 pounds) filed under 'anaesthesia' in the NHS Litigation Authority database between 1995 and 2007, alleging patient harm directly by drug administration error or by an allergic reaction, were analysed. Alleged errors were categorised using systems employed by the National Coordinating Council for Medication Error Reporting and Prevention, the American Society of Anesthesiologists Closed Claims Project and the UK Health and Safety Executive. The severity of outcome in each claim was categorised using adapted National Patient Safety Agency definitions. Sixty-two claims involved alleged drug administration errors (total cost 4,283,677 pounds) and 15 resulted in severe harm or death. Half alleged the administration of the wrong drug, in most (16) a neuromuscular blocker. Of the claims alleging the wrong dose had been given (25), nine alleged opioid overdose including by neuraxial routes. The most frequently recorded adverse outcomes were awake paralysis (19 claims; total cost 182,347 pounds) and respiratory depression requiring intensive care treatment (13 claims; total cost 2,752,853 pounds). Thirty-one claims involved allergic reactions (total cost 631,773 pounds). In 20 claims, the patient allegedly received a drug to which they were known to be allergic (total cost 130,794 pounds). All claims in which it was possible to categorise the nature of the error involved human error. Fewer than half the claims appeared likely to have been preventable by an 'ideal double checking process'.

Objectives: The TWR system was introduced in July 2000. The purpose of this study was to investigate whether patients below the age of 50 years with colorectal cancer (CRC) are experiencing delays in treatment., Methods: The CRC database was searched for all newly diagnosed colorectal cancers between January 2001 and December 2005 in patients who were aged less than 50 years., Results: There were 911 patients with CRC during the study period. Of these, 41 patients (4.5%) were aged under 50. Thirty-eight case notes were retrieved and reviewed; the median age was 47 years. Fourteen (37%) presented as an emergency, 9 (24%) via the TWR, 8 (21%) were non-TWR referrals to outpatients and the remainder were referred via miscellaneous routes. The median time from referral to initial consultation was 11 days (range 8-14 days) in the TWR group, 24 days (range 14-135 days) in the surgical outpatients group and 44 days (range 11-93 days) in the miscellaneous (direct endoscopy, in-hospital physician's referral) group. The median time from referral to initiation of treatment was 51 days (range 15-116 days) in the TWR group, 103 days (range 43-174 days) in the outpatient group and 96 days (range 27-270 days) in the miscellaneous group. Excluding age as a factor, 73% of the non-TWR referrals met the TWR criteria., Conclusion: Patients with symptoms of CRC below the age of 50 years may face referral and diagnostic delay if not referred via the TWR system; many of these would be eligible if age was not a deciding factor.

Inadequate anaesthesia may cause distress to the patient and lead to medical litigation. All claims made to the NHS Litigation Authority 1995-2007 were obtained and the data was examined independently by all authors and classified. In a dataset of 1067 claims there were 161 cases of inadequate anaesthesia and data were suitable for analysis in 159: intra-operative awareness (79), brief awake paralysis (20) and inadequate regional anaesthesia (60). The total cost of closed claims was pound 3.2 m. Cost was incurred in 100% of claims of brief awake paralysis, 87% of claims of awareness and 80% of claims of inadequate regional blockade. Mean cost of closed claims was pound 32,680 for anaesthetic awareness, pound 29,345 for inadequate regional blockade and pound 24,364 for brief awake paralysis. Inadequate anaesthesia accounts for 19% of anaesthesia-related claims in the NHS in England. Strategies that reduce anaesthetic awareness, drug errors and inadequate regional blockade are known and their improved implementation is likely to reduce such claims.

Background: The population in the UK is growing older and the number of elderly patients cared for on intensive care units (ICU) is increasing. This study was designed to identify risk factors for mortality in critically ill patients of >80 yr of age after surgery., Methods: We identified 275 patients, aged 80 yr or greater, admitted to the ICU after surgery. After exclusions, 255 were selected for further analysis. Multivariate analysis was then performed to determine the covariates associated with hospital mortality., Results: The overall ICU and hospital mortality was 20.4% and 33.3%, respectively. Patients who received i.v. vasoactive drugs on days 1 and 2 had hospital mortality of 54.4% and 60.5%, respectively. Multivariate analysis showed that requirement for i.v. vasoactive drugs within the first 24 h on ICU [odds ratio (OR) 4.29; 95% CI, 2.35-7.84, P<0.001] and requirement for i.v. vasoactive drugs for a further 24 h (OR 3.63; 95% CI, 1.58-8.37, P<0.01) were associated with hospital mortality. The requirement for i.v. vasoactive drugs was also strongly associated with hospital mortality in all the subgroups studied (elective surgery, emergency surgery, and emergency laparotomy)., Conclusions: For patients aged 80 yr and more, admitted to ICU after surgery, the requirement for i.v. vasoactive drugs in the first and second 24 h was the strongest predictor of hospital mortality.

An audit was carried out of 102 patients aged over 75 years undergoing urgent or emergency surgery in a district general hospital. The risk of death in hospital after general surgery (13 deaths in 49 patients) was greater than after orthopaedic surgery (two deaths in 53 patients) (P < 0.05). In particular, laparotomy carried a high in-hospital mortality: 12 of 25 patients undergoing laparotomy died. Risk of death after general surgery increased with increasing preoperative ASA class, increasing medical risk factors and duration of operation. Orthopaedic cases were fitter than the general surgical cases as determined by ASA class and the number of medical risk factors. NCEPOD has recommended increased involvement of senior medical staff in operations, reduced night-time operating and avoidance of futile surgery. A high proportion of cases were operated on and anaesthetised by higher specialist trainees and consultants. Death rate was not affected by the seniority of doctors involved, nor by the time of day the operation took place. General surgical deaths were predictable postoperatively in most cases, but preoperative prediction of outcome was not specific enough to alter management.

Data was reviewed on patients presenting with lower limb-threatening ischaemia to a single vascular unit between September 1984 and December 1990. Three hundred and thirty patients underwent either femoro-popliteal or femoro-infrapopliteal reconstructive surgery and 316 primary amputations were performed on 281 patients. Sixty-three secondary amputations were performed following a femoro-distal bypass failure. The below-knee amputation to above-knee amputation ratio (BKA/AKA) was 1.0 in the primary amputation group to 0.91 in the secondary amputation group. A direct comparison cannot be made as the patients represent two separate clinical groups. The ratio of reconstructive operations to primary amputations more than doubled between the first and second halves of the study. The BKA:AKA ratio in the secondary amputation group and the total number of secondary amputations remained relatively constant. This study supports the view that previous femoro-distal surgery does not adversely affect the overall outcome of amputation.