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

4. 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

5. 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

6. 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%

7. 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

8. National Hip Fracture Anaesthesia Network �Preoperative hematocrit levels and postoperative outcomes in older patients undergoing noncardiac surgery� JAMA 2007 297 pages 2481-2488

9. 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 < 39% and > 51% WHO definition of anaemia 1968

10. 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

11. 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

12. 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

15. 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

19. Delayed Surgery 75 out of 138 patients > 48 hours for surgery. 8 patients < 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.

21. Why still a problem? Surgical specialties Too many With too much work to do - Compared with other centres � low number of surgeons

22. 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

23. 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!!

26. Dr John Holloway Consultant Anaesthetist Poole Hospital Trauma ExperiencesA New Beginning I became involved in trauma anaesthesia on a regular basis at the start of 2007. I had previously had an interest in obstetrics. Poole has been forward thinking in certain aspects of its trauma service. The main facet of this proaction was the formation of the Trauma Assessment and Co-ordination Team in 1999. NEXT SLIDEI became involved in trauma anaesthesia on a regular basis at the start of 2007. I had previously had an interest in obstetrics. Poole has been forward thinking in certain aspects of its trauma service. The main facet of this proaction was the formation of the Trauma Assessment and Co-ordination Team in 1999. NEXT SLIDE

27. 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 This team now comprises 2 nurse practitioners and 2 nurses all with a background in trauma nursing. They are involved with the whole throughput process of a patient admitted with a fracture from A & E, listing for theatre, liaising with surgeons at their trauma meeting, anaesthetists, healthcare of the elderly physicians and theatre staff. They are not involved in the clinical management of the patients � that is left to the junior medical staff � orthopaedic and C of E. Helen, their lead nurse also lectures at the local university. They are also involved in the collection of data for the Director of Operations of the Trust. NEXT SLIDE This team now comprises 2 nurse practitioners and 2 nurses all with a background in trauma nursing. They are involved with the whole throughput process of a patient admitted with a fracture from A & E, listing for theatre, liaising with surgeons at their trauma meeting, anaesthetists, healthcare of the elderly physicians and theatre staff. They are not involved in the clinical management of the patients � that is left to the junior medical staff � orthopaedic and C of E. Helen, their lead nurse also lectures at the local university. They are also involved in the collection of data for the Director of Operations of the Trust. NEXT SLIDE

28. # NOF workload One of five busiest units Circa 830 patients per year Peak 10 per day Poole Hospital has one of the largest caseloads of fractured neck of femur in the UK due to population demographics, retired population holidays and a combined catchment population that includes the Royal Bournemouth Hospital Poole Hospital has one of the largest caseloads of fractured neck of femur in the UK due to population demographics, retired population holidays and a combined catchment population that includes the Royal Bournemouth Hospital

29. Trauma lists Two trauma theatres Theatre 5 - am / pm / twilight lists Theatre 4 - am / pm Average 2.35 patients per list Although the formation of the TACT was visionary, the formation of trauma operating lists needs to be improved. This situation still exists on all weekdays except Friday where I have become involved. The efficiency has slipped over the years for a few reasons � change of technique e.g bipolar cf AMP, less experienced surgeons, more regional anaesthesia and a cancellation culture.Although the formation of the TACT was visionary, the formation of trauma operating lists needs to be improved. This situation still exists on all weekdays except Friday where I have become involved. The efficiency has slipped over the years for a few reasons � change of technique e.g bipolar cf AMP, less experienced surgeons, more regional anaesthesia and a cancellation culture.

30. 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 As list efficiency had steadily fallen I was asked to become involved. This was our simple plan to form a team of experienced trauma surgeon an experienced anaesthetist.As list efficiency had steadily fallen I was asked to become involved. This was our simple plan to form a team of experienced trauma surgeon an experienced anaesthetist.

31. A Slow Start! This shows with the right team how even a sick patient can be anaesthetised, positioned, prepared and procedure commenced by 08.30am not pm. Normally KTS is by 08.15This shows with the right team how even a sick patient can be anaesthetised, positioned, prepared and procedure commenced by 08.30am not pm. Normally KTS is by 08.15

32. 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 These are our results for the 1st year. We now have staff asking to work this list although it is heavy going. Reasons cited-good atmosphere, no overruns. The latest a staff member has left is 19.15These are our results for the 1st year. We now have staff asking to work this list although it is heavy going. Reasons cited-good atmosphere, no overruns. The latest a staff member has left is 19.15

33. 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) My #NOF caseload in 1 year. All GAs received a nerve block, 2 FI had to be rescued with LP and 3 in 1, 2 more required opiates. Since then increased the volume. All have iv paracetamol. No more rescues in last 3 monthsMy #NOF caseload in 1 year. All GAs received a nerve block, 2 FI had to be rescued with LP and 3 in 1, 2 more required opiates. Since then increased the volume. All have iv paracetamol. No more rescues in last 3 months

34. Medical cancellations Fast AF Chest infection! INR Na+ / K+ Clopidogrel I am often asked to anaesthetise patients that have been delayed for medical reasons. I am sure you have all seen these before. Delaying multiple co-morbidity #NOFs is deleterious to their outcome in many cases.I am often asked to anaesthetise patients that have been delayed for medical reasons. I am sure you have all seen these before. Delaying multiple co-morbidity #NOFs is deleterious to their outcome in many cases.

35. Delays and deaths = 48 hours � 59 (2 RIP) = 49 hours � 72 (11 RIP) 10 RIP delay = 81 hours I am often asked to anaesthetise patients because they are too ill. I have C of E consultants ringing me. Our discussion goes along the lines of do you think the patient will die imminently with or without operation. If the answer is yes, they receive palliative care. We have only refused 4 patients on this basis and they were all dead within 5 days.I am often asked to anaesthetise patients because they are too ill. I have C of E consultants ringing me. Our discussion goes along the lines of do you think the patient will die imminently with or without operation. If the answer is yes, they receive palliative care. We have only refused 4 patients on this basis and they were all dead within 5 days.

36. 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

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

39. 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

40. 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

41. HIPFA 58 % ASA 3 11 % ASA 4

43. 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

44. HIPFA First Data Information is limited Don�t know when anaesthesia gets involved? Do know that grade of anaesthetist probably influences time of surgery

45. 64% of all cases done by consultants Only 0.5% cases ST 1&2 primary anaesthetist

46. 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?

48. 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!

52. 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

53. 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

54. 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

55. 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?

56. 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?