The 2004 Report of the National Confidential Enquiry into Patient Outcome and Death

1. Scoping our Practice The 2004 Report of the National Confidential Enquiry into Patient Outcome and Death

2. Elements of the study • Deaths within 30 days of a therapeutic endoscopy • Complications (incl. death) following upper GI dilation and tubal prosthesis insertion (includes denominator data) • Organisational questionnaire

3. GI therapeutic endoscopy - method • All deaths April 2002 - March 2003 reported to NCEPOD • Sample cases identified by OPCS codes and included if death occurred within 30 days of procedure • Retrospective data - questionnaires and case note extracts

4. Data overview

5. Patient assessment

6. Patient assessment • 91% admitted as emergencies • 76% had 2 or more comorbidities • 74% of deaths were either a ‘definite risk’ or ‘expected’

7. Patient assessment • 86% of procedures were appropriate • 83% of procedures were timely • 9% of procedures were either futile or too late to be of any benefit

8. Recommendation Patients must be assessed by the referring clinician and the endoscopist to justify that the procedure is in the patient’s interest. (Professional specialist associations)

9. Training and education

10. Training and education Experience • 74% of procedures performed by consultants, some doing less than 20/ year • 94% appropriate grade • 91% appropriate experience

11. Training and education Supervision • 88% - senior endoscopist in hospital • 18% - direct supervision Audit • 78% of procedures in hospitals that held audit meetings • 26% of cases reviewed

12. Recommendations There should be national guidelines for assuring continuing competency in endoscopy. (Professional specialist associations) All endoscopy units should perform regular audit and all deaths during, or within 30 days of, therapeutic endoscopy should be reviewed. (Local hospitals; Professional specialist associations)

13. Recommendations (cont.) All those responsible for the administration of sedation should have received formal training and assessment. (Local hospitals)

14. Patient consent

15. Consent

16. Consent

17. Recommendation The risks and benefits of therapeutic endoscopy should be explained to the patient, and this should be documented on the consent forms as laid down in the Department of Health guidelines. (Local hospitals)

18. Consent 16% of patients studied had dementia or acute confusion

19. Recommendation The ability of those with dementia or acute confusion to provide consent should be tested and clearly documented. (Local hospitals)

20. Sedation and monitoring

21. Sedation and monitoring

22. Sedation and monitoring • 14% of patients received inappropriate sedation • 14% of those that received sedation required a reversal agent afterwards

23. A patient with severe alcoholic liver disease, Childs-Pugh C, and bacterial peritonitis had undergone previous gastroscopies for bleeding. Bleeding continued and an endoscopist who had received training in sedation, performed what was the patient’s second gastroscopy in two days. Sedation comprised IV midazolam 5mg and further IV midazolam 2mg. Pulse oximetry was recorded as 87-91% during the whole of the procedure and flumazenil was used to reverse the effects of midazolam following it.

24. Sedation and monitoring

25. A patient was admitted with an acute inferior myocardial infarction. Four weeks later the patient suffered a large haematemesis, became hypotensive and their haemoglobin decreased by 2.5 gm/dl. A CVP line was inserted to monitor resuscitation. The next day an endoscopy was performed and adrenaline was injected into two large gastric ulcers. Pulse oximetry and automatic blood pressure were monitored, but ECG was not.

26. Sedation and monitoring

27. Recommendations Sedation and monitoring practices within endoscopy units should be audited and reviewed. (Local hospitals; Professional specialist associations) There should be national guidelines on the frequency and method of the recording of vital signs during the endoscopy. (NPSA; Professional specialist associations)

28. Recommendations (cont.) Clear protocols for the administration of sedation should be available and implemented. (Local hospitals)

29. Percutaneous endoscopic gastrostomy (PEG)

30. PEG Indication • Neurological disorders of swallowing • Cognitive impairment/depressed consciousness • Mechanical obstruction to swallowing • Long-term partial failure of intestinal function requiring supplemental intake

31. PEG Profile • In 59% of cases the indication included acute neurological disease (stroke/trauma) • 82% were  70 years of age • 84% were ASA 3 or poorer • 95% were elective/scheduled procedures

32. PEG Patient selection and timing • 19% of PEG procedures were thought to be futile • 40% had a co-existing diagnosis of chest infection • 18% had dementia • 43% died within 7 days

33. In one case where a patient was over 90 years-of-age an advisor commented: “The PEG placement was technically OK - but the timing was wrong. The patient was very ill, dehydrated and had pneumonia. They should not have had a PEG at this time and died six days later. There is no information about the last few days of life.”

34. Recommendations The decision to use a PEG feeding tube requires an in-depth assessment of the potential benefits to the individual. All patients in whom PEG feeding is proposed should be reviewed by a multidisciplinary team. (NICE) There is a need for more comprehensive national guidelines for the use of PEG feeding, including issues of patient selection. (NICE)

35. Endoscopic retrograde cholangiopancreatography (ERCP)

36. ERCP Profile • 82%  70 years of age • 77% were ASA 3 or poorer • 87% received prophylactic antibiotics • 68% were considered futile

37. ERCP Procedure • 97% performed by consultants • 11% of cases by endoscopist who performed < 50 ERCPs/year • 92% involved the biliary tract

38. ERCP Complications • In 9% of cases during the procedure • 64% of patients had one or more complications in the 30 days following ERCP

39. Recommendation Patients should be reviewed by the consultant endoscopist before therapeutic ERCP to ensure that the procedure is appropriate and the patient’s condition has been optimised. (Local hospitals)

40. Oesophagogastroduodenoscopy (OGD)

41. OGD Profile • 44% of sample cases • 61%  70 years of age • 44% bleeding varices • 35% stricturing disease in oesophagus • 20% ulcer disease

42. OGD Treatment • sclerotherapy, coagulation, banding Complications • haemorrhage, respiratory and cardiac

43. Upper GI haemorrhage

44. Upper GI haemorrhage • 86% needed emergency/urgent endoscopy • In 89% of cases there was a definite or expected risk of death • 94% of endoscopists were GI specialists • 25% had both topical anaesthesia and intravenous sedation

45. Upper GI haemorrhage • 92% of cases were appropriate and timely and in the correct location for both procedure and recovery • 73% had good ‘overall’ care • clinical factors • organisational factors

46. An elderly patient with cirrhosis (no cause stated) and ischaemia related biventricular failure presented with a haematemesis that was not considered to be severe by the admitting clinician as the “urea is only 6.5”. The patient was tachypnoeic, tachycardic and hypotensive. Before endoscopy, the patient did not receive either supplemental oxygen or intravenous fluids - which in view of the cardiac condition should have been governed by central venous monitoring.

47. Recommendations Only experienced endoscopists should treat patients with upper GI haemorrhage. Experience will vary by grade but competence should be assessed by the supervising consultant. (Local hospitals)

48. Recommendations (cont.) Optimising the patient’s pre-endoscopy condition will reduce both morbidity and mortality. Early involvement of an anaesthetist/intensivist if necessary will assist this. (Local hospitals)

49. Pathology

50. Reporting deaths to the coroner and autopsy rates Total autopsies - 144 (8% of all deaths)