Caring to the End?

1. Caring to the End? Dr Peter Nightingale Royal College of Anaesthetists

2. Objectives • Referral from admission until seen by consultant; • Handover and multidisciplinary team working; • Levels of supervision; • Appropriateness of surgery and anaesthesia; • General issues: DVT prophylaxis / access to other facilities and services; • Paediatric practice; • Palliative care in an acute setting. Less than half (1364) were admitted under a surgeon Relatively few (466) underwent a surgical procedure

3. ASA status 2/3 1/5 ASA = American Society of Anesthesiologists

4. ASA, age and urgency of operation Many patients were elderly and in the urgent or immediate category (91% were emergency admissions); both of these factors are associated with an increased mortality

5. Overall assessment of care • The ASA classification does not consider: • patient age, weight, sex and pregnancy; • nature of the planned surgery; • the skill of the anaesthetist or surgeon; • the degree of pre-surgical preparation; or • the facilities for postoperative care. 61%

6. Adequate time to see the patient? Usually elated to urgency of resuscitation and operation

7. Adequate preoperative optimisation • Generally, adequately prepared (88%) • Reasons for suboptimal state: • Investigation of cardiovascular status • Fluid balance problems • Insertion of central venous line • Delay in surgery • Lack of an intensive care bed.

8. Problems with access to facilities • Investigations: echocardiography, CT & ultrasound • Interventions: angiography, cardiac pacing & stenting, nephrostomy, variceal injections • Theatres: emergency lists, recovery staff, clean instruments • Assistance: need for second anaesthetist? • Critical care: HDU and ICU beds

9. The need for 24/7 services • Service still not delivered by trained doctors • Less trainees in some hospitals • Specialist training →General Practice • EWTD \ Covering on-call • Commissioning of training • Reconfiguration of acute hospitals? • Residency programmes?

10. Intra- and post-operative care • Appropriate anaesthetist (96%) • Named consultant • In CCT; further Guidance published 2008 • General factors • Anaesthetic charts adequate (96%) • Monitoring adequate (94%) • Patient warming (89%); now embedded in care • Airway problems managed appropriately (8.5%) • Postoperative analgesia appropriate (95.5%)

11. Paediatric care • Anaesthesia and intensive care medicine • Little in this report • Continues to cause problems • Lack of paediatric services in many hospitals • Loss of expertise • Who does the transfer? • Need to review CCT in anaesthesia &ICM?

12. Palliative care and the ICU • Usually treatment withdrawal on ICU patient • Admission might be appropriate • Unable to cope elsewhere in the hospital • Family appreciate that ‘all has been done’ • May give the family, and others, time to come to terms • ICU staff can provide good end-of-life care • Staffing ratio and use of cubicles • Used to handling relevant drugs • Relatives frequently send letters of thanks

13. Summary • Assessment, investigation and treatment of surgical emergencies remains problematical • Hospitals often not able to provide adequate facilities, especially out of hours • Who is responsible for continuity of care? • Training and patient care is affected • 96% anaesthetised by an appropriate grade • Care of sick children remains a problem • The ICU has a role in end-of-life care