An audit of perioperative care for proximal femoral fractures
Residual anaesthesia drugs in intravenous lines
M. Adlam, G. Mathew, B. O. Rose and M. Lowings
S. Bowman1, M. Bosenberg2 and I. Walker2 1. University College Hospital NHS Foundation Trust, London, UK, 2. Great Ormond Street Hospital NHS Foundation Trust, London, UK Corresponding author: [email protected]
University Hospital Lewisham, London, UK, [email protected]
Methods A random sample of 102 patients who had undergone operative repair of proximal femoral fracture during 2011 was taken. A retrospective review of notes compared patients’ perioperative care against the 2012 AAGBI guidelines for management of proximal femoral fractures . Results Preoperatively 63 (62%) were pre assessed by a core trainee, and only 3 patients (3%) received regional analgesia. No patients had a DNACPR form completed pre operatively. Intraoperatively 51 received spinal anaesthesia and 49 general anaesthesia. However only 9/51 (18%) under spinal anaesthesia had additional regional anaesthesia, compared to 44/49 (90%) under general anaesthesia. Minimum AAGBI monitoring was present in all patients, additional monitoring was used in 45/102 (44%). Additional monitoring was largely urine and temperature, with 6/102 (5%) having cardiac Doppler monitoring, and 1/102 (1%) an arterial line. Postoperatively, 97/12 (96%) went to a ward bed, and 11/102 (10%) prescribed oxygen. Regarding blood loss, only 25/102 (24%) had it documented and only 7/102 (6%) had their haemoglobin checked in recovery. Discussion This audit clearly showed that prior to the AAGBI guidance patients were not receiving the gold standard of care. Locally this can and will be addressed by education, discussion and re-audit. However it also shows some findings that are likely to be national, and require larger scale change and improvement. A key finding was an almost complete lack of preoperative regional analgesia. This may be due to misunderstood responsibility, and also lack of training. Ultrasound and landmark techniques for fascia iliaca compartment blocks provide analgesia for femoral fractures , are regularly used by anaesthetists and can be performed in monitored areas such as the resuscitation room and recovery. Timely delivery of adequate and long acting analgesia would reduce the need for systemic analgesia such as opioids with the associated complications. Another area of interest is the use of further regional blockade under spinal anaesthesia, the AAGBI guidelines are clear that all patients should have a longer acting peripheral block to ensure good post-operative pain relief. This is again likely due to education, but also misunderstanding of duration of analgesia and the level of post-operative pain, which is often related to the incision. Finally these patients are high risk patients, 70% ASA 3-4  and their postoperative care is as important as pre and intraoperative. There is a national shortage of level 2 and 3 beds, and thus few of these patients are managed there. However ward care rarely fulfils the guidance of 1 to 4 nurse patient ratio. It is also important to maximised these patients oxygen delivery, which can simply be improved by ensuring a post-operative haemoglobin of >8g/dl and using goal directed oxygen prescribing. References 1. Association of Anaesthetists of Great Britain and Ireland. Management of proximal femoral fractures 2011. Anaesthesia 2012; 67: 85-98. 2. Foss NB, Kristensen BB, Bundgaard M, et al. Fascia iliaca compartment blockade for acute pain control in hip fracture patients: a randomized, placebo-controlled trial. Anesthesiology 2007; 106: 773–8. 3. White SM, Griffiths R, Holloway J, Shannon A. Anaesthesia for proximal femoral fracture in the UK: first report from the NHS Hip Fracture Anaesthesia Network (HIPFAN). Anaesthesia 2010; 65: 243–8.
Abstracts of AAGBI WSM LONDON 2014
Residual anaesthesia drugs in intravenous (IV) lines may be a cause of patient harm that is under-reported and under-recognised . Neuromuscular blocking agents are most commonly involved, particularly suxamethonium. The ED 95 of suxamethonium is only 0.30.5 mg.kg-1, a dose easily contained in the priming volume of a cannula and IV extension . IV extensions are increasingly used to reduce catheter-related bloodstream infection, practice that may inadvertently increase risk relating to residual drugs if the extension is not flushed . Following a number of near misses in our department, we introduced guidance for new starters to flush all lines, a standard tick box on our anaesthetic charts to record this, with a verbal handover in recovery that the IV line had been flushed. We have conducted a series of audits to assess practice relating to flushing of IV lines after anaesthesia.
Methods The audit standard was that 100% of lines should be flushed at the end of anaesthesia, the ‘IV line flushed’ tick box should be checked on the anaesthetic chart, and there should be a verbal handover to the recovery nurse that the line had been flushed. The recovery nurses completed an audit form for 100 patients over a period of a week. Two audits have been completed, one in October 2012, the second in June 2013. A third will be completed in October 2013. The nurses recorded whether the tick box had been checked, whether there had been a verbal handover about the IV line flush, and if neither of the above, the recovery nurse asked the anaesthetist directly if the line had been flushed, prompting them to do so if not. Following the first audit, a recovery handover checklist that included the IV line flush was introduced. The results of the second audit were presented at a multidisciplinary theatre meeting to highlight the importance of the IV flush and recovery handover, and barriers to the use of the checklist were discussed. Results ‘IV line flushed’ box checked on the anaesthetic chart Information verbally handed over in recovery Anaesthetist needed to be prompted to flush the IV line Recovery handover checklist used
Audit 1 n=96
Audit 2 n=100
Discussion The NPSA published guidance in 2009 stating it was the responsibility of the anaesthetist to ensure that all IV lines are flushed at the end of surgery . Despite existing guidance and knowledge of adverse events, anaesthetists still failed to flush the IV cannula before handover to recovery (audit 1). Use of a recovery handover checklist improved communication and reduced the number of anaesthetists who required prompting to flush the IV line (audit 2). Compliance with the checklist was not 100%, and further training will be undertaken to see if compliance can be improved, thus eliminating the risk from retained anaesthesia drugs in IV lines. Reference. 1. Bowman S, Raghavan K, Walker IA. Residual anaesthesia drugs in intravenous lines – a silent threat? Anaesthesia 2013; 68: 557-6
3 An audit of post-operative epidural analgesia monitoring F. Catling, M. Stockman and N. Chauhan
University of Bristol, Bristol, UK, Bristol Royal Infirmary, Bristol, UK, and Bristol Royal Infirmary, Bristol, UK [email protected]
Epidural analgesia provides excellent post-operative pain relief, but must be closely monitored due to the serious complications it produces in some patients . We audited post-operative epidural monitoring in a large UK teaching hospital. A mixed-methods root cause analysis was performed in response to the results obtained and numerous changes were later proposed to improve practice. Methods We measured the frequency of monitoring in patients receiving postoperative epidural analgesia on two surgical wards, a HDU and an ICU. The results from HDU and ICU were combined as they shared nursing staff. A time period over which a minimum of 3176 observations were expected was audited across 19 patients (976 and 928 expected observations on the surgical wards, and 1272 on HDU and ICU). We compared our results with local standards derived from national guidelines . The performance of the different wards was compared using chi-squared tests. To explain the results obtained, we measured uptake of an epidural training course on the wards involved, and conducted a series of semi-structured interviews with nursing staff. The project was approved by the Trust Audit Department. Results
Percentage compliance with standards for monitoring different parameters in Surgical Ward A (white), Surgical Ward B (lines) and HDU and ITU (dots). P values of ≤0.05, ≤0.01, ≤0.001 and ≤0.0001 are represented as *, **, *** and **** respectively. At the beginning of the audit, 61% of Surgical Ward A nurses, 8% of Surgical Ward B nurses and 16% of HDU and ICU nurses had attended the epidural training course. Staff cited lack of time as a barrier to all monitoring. Lack of training and equipment, patient concordance and limited access to monitoring protocols were all cited as particular barriers to motor and sensory block monitoring. Discussion The audit was presented at a local meeting. Strategies for improving staffing, training uptake, protocol accessibility and equipment provision were discussed and are now being investigated to ensure feasibility. A timetable for re-audit has been established. References 1. The Faculty of Pain Medicine. Best practice in the management of epidural analgesia in the hospital setting, 2010. http://www.rcoa.ac.uk/document-store/best-practice-themanagement-of-epidural-analgesia-the-hospital-setting (accessed 23/04/2013).
Abstracts of AAGBI WSM LONDON 2014
6 Comparison of four early warning scores for detection of maternal sepsis
S. Clark, J. Collins and G. Jackson Royal Berkshire Hospital, Reading, UK [email protected]
Sepsis is the most common cause of direct maternal death in the UK . Early warning scores, based on the measurement and assessment of simple physiological parameters, have been developed with the aim of detecting acute illness. We compared four early warning scores in a cohort of pregnant patients with microbiologically proven sepsis.
Methods In our hospital we employ a maternal sepsis care bundle, which directs the clinical management of patients with suspected sepsis, and facilitates audit. Over a 12-month period, this bundle was commenced in 65 pregnant women. In 17 patients, there was concurrent microbiological evidence of infection. We analysed the medical notes and laboratory data of these patients and after auditing completion of the care bundle, calculated four early warning scores for each set of physiological observations documented: our currently-in-use Modified Obstetric Warning Score (MOWS), the Modified Early Obstetric Warning Score (MEOWS), the VitalPAC Early Warning Score (ViEWS) and the National Early Warning Score (NEWS). When a physiological measurement was not documented, it was assigned a score equivalent to zero. Results Data sets were analysed for 17 patients. One set was not included for analysis because the infective episode was some time post-partum and there were significant confounding medical complications. No single patient had a complete set of observations documented at any given time (the most commonly omitted parameters being consciousness level, urine output and haemoglobin oxygen saturations). 12.5% of sepsis care bundles were fully and accurately completed, the remainder being on average 62.5% complete. Of the four early warning scores compared, MEOWS would have triggered clinical review earliest (see table below). Notably, ViEWS would not have triggered for any patient. Table: comparison of time to triggering clinical review prior to activation of sepsis bundle Early Warning Score Mean (range) time to triggering clinical review prior to sepsis bundle activation (hrs) MEOWS 15.1 (0-44.5) MOWS 1.9 (0-14.8) NEWS 0.5 (0-8.4) ViEWS 0 (0) Discussion There was microbiological evidence of infection in 26% of patients triggering our sepsis care bundle. The EWS with the earliest tendency to trigger clinical review in our cohort of such patients was MEOWS. Indeed, other than MOWS, MEOWS is the only scoring system designed for use in gravid patients. However, in three patients even this score would not have triggered, and it remains unclear how many ‘false-negative’ clinical reviews would be generated were this scoring system employed. Nonetheless, in our small and heterogeneous sample, no patient required intensive care and there were no deaths. Accordingly, we recommend the use of the Modified Early Obstetric Warning Score and the employment of a maternal sepsis care bundle. References 1. Cantwell R, Clutton-Brock T, Cooper G et al. Saving Mothers' Lives: Reviewing maternal deaths to make motherhood safer: 2006-2008. The Eighth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom. British Journal of Obstetrics and Gynaecology 2011; 118 Suppl 1: 1-203.
Abstracts of AAGBI WSM LONDON 2014
The iPad as a distraction device to aid induction of anaesthesia A. Dalton, J. Hardy
J. Davies, E. Djabatey
Ninewells Hospital, Dundee, UK [email protected]
Liverpool Women’s Hospital, Liverpool, UK [email protected]
Induction of anaesthesia in children can be stressful and upsetting for the child. The use of local anaesthetic cream reduces the response to intravenous (IV) cannulation . However children still react to the process, despite best efforts to distract them with a combination of pictures/books and verbal reassurance. This is also true with gaseous induction where some children find the application of a facemask distressing. We have recently changed from using books/pictures as the default distraction device to games/videos on an iPad. We audited the response of the children to induction of anaesthesia by this new distraction method. Methods We aimed to compare the response to IV cannulation and gaseous induction of the traditional method of distraction with our newer iPad technique. This was performed in two parts. We had previous data that had been collected in October 2008 when the distraction device in use was solely books/pictures. This data described both the conduct of anaesthesia (IV vs gaseous) the ease of IV access, and the behaviour of the child in the anaesthetic room. We repeated the data collection in April 2012, this time using our now standard iPad distraction device. Results The patient demographics were similar in each group (book group n=116 patients, age 0-5yrs 59 [51%], 5-10yrs 34 [29%], >10yrs 23 [20%] vs iPad group n=127 patients, age 0-5yrs 67 [53%], 5-10yrs 32 [25%], >10yrs 28[22%]). The mode of induction was also comparable (book group 73% IV vs iPad group 67% IV). The ease of IV access (in awake patients), response to IV cannulation and response to inhalational induction (as applicable) are shown in Table 1 along with the p value for the difference (calculated by Fishers exact test). Table 1: Response to anaesthesia induction Book group IV access ‘easy’ 62/105 (59%) No response to IV 68/88 insertion (77%) Smooth inhalational 22/32 induction (69%)
iPad group 77/91 (85%) 82/91 (90%) 37/42 (88%)
P value 35, BMI >30 and airway abnormalities. A pre operative airway assessment was performed in 75%. Despite 50% of DI and FI occurring out of hours (1700-0800) 75% had a senior rescuer. Anaesthesia was continued for both cases of FI using a LMA, one of the DI commenced the caesarean under facemask anaesthesia then achieved intubation post delivery. Four of the 16 had minor complications including sore throat, hoarse voice and bronchoconstriction and 69% of patients were followed up. Discussion Documentation was good, however there are opportunities to improve on airway assessment and follow up of these patients. Comparison to the 2000-2007 data shows that the number of GA’s has halved and rates of DI and FI have risen. Despite this the number of GA’s administered per trainee remains static at 2.5 per month. DI rates remain within the national figures 1:30-1:100 with FI rates lower than average 1:250-1:300 [1, 2, 3, 4, 5]. There will always be a requirement for certain obstetric cases to preferentially receive a GA over regional anaesthesia. With rising obesity rates nationwide [2, 3, 5], managing the obstetric difficult airway remains a challenge and a skill that needs to be maintained. In response to this audit implementation of the difficult airway society airway alert form was recommended and the incorporation of FI drills with the manikin into the induction programme. References 1. Djabatey EA, Barclay PM. Difficult and failed intubation in 3430 obstetric general anaesthetics. Anaesthesia 2009; 64: 1168-71. 2. McDonnell NJ, Paech MJ, Clavisi OM, Scott KL. Difficult and failed intubation in obstetric anaesthesia: an observational study of airway management and complications associated with general anaesthesia for caesarean section. International Journal of Obstetric Anaesthesia 2008; 17: 292-7. 3. The Royal College of Anaesthetists and the Difficult Airway Society. 4th National audit project. Major complications of airway management in the United Kingdom. 2011. 4. Searle R, Lyons G. Vanishing experience in training for obstetric general anaesthesia: an observational study. International Journal of Obstetric Anaesthesia 2008; 17: 233-7. 5. Quinn AC, Milne D, Columb M, Gorton H, Knight M. Failed tracheal intubation in obstetric anaesthesia: 2 year national case-control study in the UK. British Journal of Anaesthesia 2013; 110 (1): 74-80.
Abstracts of AAGBI WSM LONDON 2014
Pre-operative Pregnancy Testing
Admission to intensive care following surgery – a review of current practice
S. Desai and S. Jameel
S. Desai, K. Sim
Whiston Hospital, Merseyside [email protected]
Preoperative pregnancy testing has been a subject of debate for nearly thirty years. NICE has recommended that all women who could be pregnant are tested preoperatively . However the reliability of patient history alone to exclude pregnancy has been conflicting. The single largest study from 2008 showed that 0.2% of women who denied pregnancy were subsequently pregnant [ 2 ]. This audit aimed to identify which patients did not have their pregnancy status confirmed prior to an anaesthetic, and were subsequently exposed to ionising radiation. Methods This prospective audit carried out in a large district general hospital included all women capable of being pregnant attending for surgery over a one month period. A standardized audit proforma was completed in the anaesthetic room for each patient and the results collated and analysed. Results A total of 79 audit proformas were collected of which 66 women were capable of being pregnant. Seventeen patients (26%) were not asked about pregnancy prior to the anaesthetic room and not confirmed by Urine human chorionic gonadotropin (hCG). Two of these patients (3%) were then exposed to ionizing radiation intraoperatively. Discussion Routine questioning of women who could be pregnant often does not occur prior to the WHO checklist being completed in the anaesthetic room. This increases the chances of women who could be pregnant being subjected to teratogenic medications and radiation or delays in the anaesthetic list with resulting cost implications. With the falling cost of pregnancy testing the total cost to test all women of ages 11 to 50 in our hospitals would be £4400. Based on a figure of 0.2% being pregnant despite maternal history this gives a maximum cost per pregnancy avoided of £571 which would appear to be cost effective. References 1. National Institute for Clinical Excellence. Preoperative tests: The use of routine preoperative tests for elective surgery. Clinical Guideline 3. 2003. 2.
Kahn R , Stanton M, et al One-Year Experience with Day-ofSurgery Pregnancy Testing Before Elective Orthopaedic Procedures Anaesthesia Analgesia 2008;106:1127–31
Whiston Hospital, Merseyside [email protected]
High risk elective surgical patients often do not get the post-operative care they require, with perioperative mortality in the UK significantly higher than for the same surgeries in the USA  This may be due to the lower provision of Critical care beds compared to comparable healthcare systems , but may be due to problems in culture or education amongst modern anaesthetists.
Methods A retrospective audit of all patients referred to the critical care unit preoperatively over one year was carried out. The subsequent admission to intensive care or reason for non-admission was recorded. For those not admitted their p-possum score was calculated. Results Over one year 64 elective surgical patients were referred to critical care. Of those patients three (4.6%) had their operations cancelled, one (1.6%) died before his operation was carried out. Of the postoperative patients 31 (52%) were admitted and 29 (48%) were not admitted. The reason for non-admission was because either it was deemed unnecessary by anaesthetist, seven patients (24%) (average ppossum 8.4%), it was decided to outreach by the critical care consultant, six patients (21%) (average p-possum 4.7%) or there was no documented reason 16 patients (55%) (average p-possum 2.94%) Discussion Almost half of patients who were referred to Critical Care were subsequently not admitted. These patients were often at significant perioperative risk with an average p-possum score of 4.6%. Whilst there may be an insufficient number of critical care beds, several patients were returned to level one care without a critical care opinion. Anaesthetists who initially identified these patients as high risk, appear to decline a critical care bed based on intraoperative stability. Patients who are returned to the ward have worse outcomes if they require critical care later, but some are not escalated at all2. Therefore education or more likely a change in culture is needed to provide adequate care for the rising demands of modern patients. A possible suggestion could be a minimum p-possum score requiring a critical care referral and post-operative review, however the p-possum score is not without limitation. References 1. Bennett-Guerrero E, Hyam JA, Shaefi S et al. Comparison of PPOSSUM risk-adjusted mortality rates after surgery between patients in the United States of America and the United Kingdom. British Journal of Surgery 2003 Dec;90(12):1593-8 2. G P Findlay, A P L Goodwin, Protopapa K et al. Knowing the Risk A review of the peri-operative care of surgical patients. National Confidential Enquiry into Patient Outcome and Death (2011)
Abstracts of AAGBI WSM LONDON 2014
How well do anaesthetists prescribe antibiotics? – An audit of doctors’ knowledge of antibiotic prophylaxis
Reducing inadvertent perioperative hypothermia amongst elective orthopaedic patients; results of a rapid cycle audit.
Dr S Dholakia, Dr J Bramall, Dr S Eckersall
A. Eggleton, J. Brown and S. Mulvany
Lister Hospital, East and North Hertfordshire NHS Trust [email protected]
Belfast City Hospital, Belfast, UK, Craigavon Area Hospital, Craigavon, UK, and The Acute Western Hospital, Enniskillen, UK [email protected]
Correct antibiotic prophylaxis is a key component in the prevention of perioperative infection. It is therefore important that clinicians know the antibiotic protocol in order to administer the correct antibiotic. Methods We conducted an audit of doctors knowledge of antibiotic prophylaxis, using a simple proforma, which was distributed to anaesthetists in a district general hospital. Questions were asked about the prophylaxis for 8 common procedures, the precise dose and the ‘penicillin allergy’ alternative. Grade of doctor and length of time working for the trust was also recorded Results 43 responses were received. The mean score was 18.7 out of 49 (38%). Doctors who had worked at the trust for more than 2 years had slightly worse scores than those who had less than 2 years (17 vs 21 p=0.09). Consultants had slightly worse scores than non-consultants (18 vs 20 p=0.3). Knowledge of antibiotics for Laparascopic Cholecystectomy was particularly poor (4.7% correct) Discussion Knowledge of antibiotic prophylaxis among anaesthetists is poor. Neither length of time working at the hospital, nor grade of doctor was associated with better knowledge of antibiotic prophylaxis. Poor compliance with antibiotic prescribing guidelines has been a recurring theme in the literature over the last 15 years.1,2 A recent Cochrane review suggests that simple targeted interventions can result in significant improvements in inpatient prescribing without the need for complex multifactorial education programmes.3 We propose to instigate a focused, and concise educational programme comprising of visible posters in anaesthetic rooms and business cards summarising the Trust’s Antibiotic Prophylaxis policy. In addition, we will provide regular brief refreshers at teaching sessions in order to triangulate this knowledge acquisition. We aim to re-audit doctors knowledge of antibiotic prophylaxis at one and six months post intervention to establish if this programme is a sustainable, consistent and effective method of improving antibiotic prescribing. References 1. Heineck, Isabela, Maria BC Ferreira, and Eloir Paulo Schenkel. "Prescribing practice for antibiotic prophylaxis for 3 commonly performed surgeries in a teaching hospital in Brazil." American journal of infection control 27.3 (1999): 296-300. 2. Lawson, Keith A., et al. "Assessment of antibiotic prophylaxis prescribing patterns for TURP: A need for Canadian guidelines?." Canadian Urological Association Journal 7.7-8 (2013): E530. 3. Davey, Peter, et al. "Interventions to improve antibiotic prescribing practices for hospital inpatients." Cochrane Database Syst. Rev 19 (2013).
Inadvertent perioperative hypothermia (IPH) is associated with increased incidence of wound infection, cardiac morbidity, blood transfusion, pressure ulceration and prolonged hospital stay. In 2008 the National Institute of Clinical Excellence (NICE) published guidance on the subject. The objective of this series of audits was to assess compliance with NICE reccommendations and to reduce incidence of IPH. Methods A series of prospective audits of patients undergoing lower limb joint replacement was performed. In Audit one patients’ tympanic temperature was recorded on arrival to theatre and recovery using a Genius™2 infrared tympanic thermometer (Covidien, Mansfield, USA). In Audits two and three a urinary catheter incorporating a thermometer (Covidien, Mansfield, USA) was used to record bladder temperature, as a surrogate for core temperature, at the start of the case and on arrival in recovery. Following Audit two pre-operative forced air warming was instituted on the ward and in the anaesthetic room and warm drinks for patients were encouraged in the recovery ward. Through all audit cycles it was routine practice to use forced air warming and warmed intravenous fluids in theatre. Perioperative hypothermia was taken as a core temperature of below 36oC as per the NICE guidance. Results Table 1 Rates of inadvertent perioperative hypothermia in each audit cycle. Values are numbers of hypothermic patients. Tympanic temperature recorded in Audit one. Bladder temperature monitoring introduced after Audit one. Pre-operative forced air warming introduced after Audit two. Audit one Audit two Audit three n = 30 n = 46 n = 31 Pre-op 13 (43%) 25 (54%) 7 (23%) Recovery 23 (77%) 23 (50%) 4 (13%) Discussion Audit one identified apparent high levels of IPH but it was noted that the standard was core temperature and tympanic temperature was being recorded. Subsequently urinary catheters incorporating a thermometer were introduced and Audit two undertaken confirming high rates of IPH. Following Audit two interventions included a minimum of 10 minutes pre-operative forced air warming on the ward, continued in the anaesthetic room where possible and warm drinks in recovery. This led to the reduction in incidence of IPH seen in Audit three. Short periods of pre-operative forced air warming have been shown to dramatically reduce rates of IPH and this is supported by the results of this audit. Utilisation of the same warming blanket pre-operatively and post-operatively with warm drinks in recovery provide a cost effective and minimally disruptive solution to the problem of IPH and its costly complications. References 1. Ratan A, Andrzejowski J, Akunne A et al. The management of inadvertent perioperative hypothermia in adults. NICE Clinical practice guideline 65 2008. 2. Horn EP, Bein B, Bohm R, Steinfath M, Sahili M, Hocker J. The effect of short time periods of pre-operative warming in the prevention of peri-operative hypothermia. Anaesthesia 2012; 67(6): 612-617.
Abstracts of AAGBI WSM LONDON 2014
Cost analysis audit comparing allogeneic blood transfusion and cell salvage autologous blood transfusion.
An audit of intravenous fluid administration in day surgery patients in a district general hospital
D Fawkes and C Wright
B Feix1, P Whitney2, V Kushakovsky1
Broomfield Hospital, Chelmsford, UK [email protected]
1 The Ipswich Hospital, Ipswich, UK and, 2 Addenbrooke’s Hospital, Cambridge, UK [email protected]
Intraoperative blood loss is frequently treated with donor blood products which can be associated with complications. With restrictions on donor eligibility, the volunteer donor pool is limited and as testing and processing becomes more sophisticated, the cost increases . Cell salvage is a method of intraoperative blood loss conservation. Blood is collected from the operative field by a suction device, processed and re-infused to the patient. Studies have shown that cell salvage minimises the requirement for allogeneic blood transfusion and increases mean erythrocyte viability which should improve oxygen carrying capacity and delivery . In a time of austerity, we wanted to analyse the cost effectiveness of cell salvage. Methods From November 2011 to April 2012, an audit form was completed documenting the details of the procedure, estimated blood loss and volume of processed blood re-infused when the cell salvage equipment was used. At the time of the audit, it cost £100 to use the cell salvage equipment with no additional staff required to operate it. Mid Essex Hospital NHS trust’s haematology laboratory quoted the cost of one unit of red blood cells as £125 and the volume varied from 250-300mls. Therefore, we used 275mls as our average volume per unit of donor red blood cells. We compared the volume of processed blood against the volume of our standard treatment of donated blood products. The cost of each was then calculated. Results Cell salvage was utilised in 16 cases of which 55% were elective and 44% emergencies. It was most frequently used in vascular and orthopaedic procedures. Estimated blood loss ranged from 500 – 3,096mls. The mean volume of blood re-infused was 459mls with a total of 7,336mls. The cost of using cell salvage for the 16 patients was £1,600. If the equivalent volume of donated blood had been used, we would have required 26.7 units of red blood cells at a cost of £3,334.5. This equates to a saving of £108 per patient by using cell salvage. Discussion Our audit demonstrated significant potential saving by utilising cell salvage techniques to reduce expenditure on allogeneic blood. For autologous transfusion to be cost effective, 220mls or greater of processed blood would need to be re-infused. There are guidelines available for the safe and effective use of cell salvage technology . This audit was used as part of a successful business case that resulted in the department purchasing two cell salvage machines. The number of anaesthetists routinely using cell salvage was very small and presentation at a local meeting stimulated significant interest in increased use. There was confusion over how to prepare the equipment, when its use should be considered and situations where it would be inappropriate. Equipment training sessions have been planned and information regarding national safety guidelines and recommendations distributed. We plan to re-audit cell salvage use to assist in forming local protocol and also to monitor usage of allogeneic blood products to assess whether savings were made. References 1. The Association of Anaesthetists of Great Britain. Blood Transfusion and the Anaesthetist Intraoperative Cell Salvage. AAGBI Safety Guideline September 2009. 2. A Ashworth, A A Klein. Cell salvage as part of a blood conservation strategy in anaesthesia. British Journal of Anaesthesia 2010; 105: 401-16
Abstracts of AAGBI WSM LONDON 2014
The proportion of patients undergoing elective surgical procedures as day cases has expanded considerably over the past decade. The recently re-written AAGBI guidelines  for day case and short stay surgery stress the importance of anaesthetic technique, in particular long-acting analgesia and avoidance of post-operative nausea and vomiting (PONV). Intra-venous fluid administration has been shown to reduce incidence of PONV and is thus included in local day surgery guidelines.
Methods Data on adult patients was collected by day surgery nursing staff in June 2012. Information collected included age, ASA grade, type of surgery, PONV risk factors (sex, smoking status, previous history of PONV or motion sickness, peri-operative morphine use), type of anaesthetic, intra- und post-operative anti-emetic use, and intraoperative IV fluid administration. A 14 question questionnaire, with a maximal score of 28, combining points of the QoR-9 score  and the post-operative gastro-intestinal tract dysfunction score  was given to patients just prior to discharge. Results Data on 45 patients was collected. Seven patients were excluded as the combined anaesthetic and surgical time of their procedure was less than thirty minutes. Questionnaire results were recorded for 34 patients. Twenty-one patients had at least two risk factors for PONV. Thirty patients received at least one antiemetic agent intra-operatively. Twenty-one patients received inhalational maintenance anaesthesia, 14 total intravenous anaesthesia and three a regional technique and TIVA. Fifteen patients received IV fluids, 22 did not. Median score amongst patient who were given IV fluids was 26 (interquartile range 25-27) and 26 (interquartile range 24.5-28) which was confirmed as non-significant using the Whitney Mann U test. There was also no statistically significant difference in the subgroups with low (≤1) or high (>1) PONV risk scores. Only one patient had symptoms of PONV requiring antiemetics in the recovery room. Discussion Only 39% of patients received intravenous fluids intra-operatively, but there was no significant difference in the incidence of PONV in both groups even though the more sensitive measure of a combined QoR9/PGID score was used rather than the directly reported PONV. The reasons for this could be related to a small sample size but there are also many confounding factors related to anaesthetic technique. Our questionnaire confirms that patients already experience very few postoperative gastro-intestinal symptoms in our hospital. We are planning to repeat the audit with larger sample sizes that allows subgroup analysis with respect to anaesthetic technique, intra-operative antiemetic administration and PONV risk. References 1. Verma R, Alladi R, Jackson I, et al. Day case and short stay surgery: 2, Anaesthesia 2011; 66: 417-34 2. Myles PS, Hunt JO, Nightingale CE, et al, Development and Psychometric Testing of a Quality of Recovery Score After General Anesthesia and Surgery in Adults, Anaesthesia & Analgesia 1999; 88:83–90 3. Kushakovsky V, Wakeling H, Development and evaluation of postoperative gastrointestinal tract dysfunction score in extraabdominal surgery: a prospective study, Anaesthesia, 2009; 64:809-10
15 Group and screen sampling in elective surgery – who has access to group specific blood products at the time of surgery? J. Fortune, J. Green* North Tyneside General Hospital, North Shields, UK. *Sunderland Royal Hospital, Sunderland, UK. [email protected]
Group and Screen (G&S) investigations are required to establish patient ABO/Rhesus status and screen for antibodies in order to issue cross matched blood products. Due to several wrong blood in tube incidents, the British Committee for Standards in Haematology now recommends a patient reference G&S, and a second sample from which to issue blood products . Current guidance on G&S sampling for elective surgery is based on surgical grading and likelihood of blood loss, with grade 3 and 4 necessitating consideration for G&S . In a busy district general hospital with a nurse led preoperative assessment clinic we set out to establish firstly the extent of G&S sampling and its appropriateness, and secondly which patients ultimately had access to group specific blood products at the time of surgery. The standard was that all reference G&S taken in pre assessment should be repeated on attendance for surgery. Methods A random sample of patients in theatre for elective surgery over a three month period was taken and their operation and its classified surgical grade was recorded. We then established whether a G&S sample was taken in pre assessment, and whether it was repeated when the patient attended for surgery. The hospital electronic pathology system was used to confirm investigations undertaken. Results Sixty five patients were sampled. Of these, 36 had grade 1 or 2 operations and 29 had grade 3 or 4 operations. No G&S samples were sent for low risk grade 1 or 2 operations. Twenty two patients undergoing grade 3 or 4 surgery had G&S samples in pre-assessment. Of these only 10 (45.5%) had a G&S repeated, and therefore had access to group specific blood products at the time of surgery. These cases included hip and knee replacement (n=5), vertebral fusion (n=1), hysterectomy (n=3) and laparoscopic cholecystectomy (n=1). In the 12 patients who did not have G&S on attendance for surgery (54.5%), there were 2 cases of neck dissection and 2 laparoscopic cholecystectomies. The rest being non laparoscopic or body cavity surgery such as breast remodelling (n=1), wrist arthrodesis (n=1), rhinoplasty (n=3) and tendon repairs (n=3). Discussion In this cohort 12 patients had G&S samples taken in pre assessment but not repeated at the time of surgery. Some of these omissions were for operations with higher bleeding risk. This indicates that the initial investigation was either later considered unnecessary, or that a second sample was not sent accidentally, potentially compromising patient safety. Emergency transfusion with group O blood carries the risk of transfusion reaction and development of alloantibodies. Eliminating unnecessary preoperative investigations in elective surgery has potential to save cost - each G&S sample in our hospital is estimated to cost £5.06. It is therefore important to target investigations only where required. We suggest more specific local pre- assessment guidance, and where the need for perioperative transfusion is considered high ensuring a second sample is taken as part of the preoperative checklist, with later re-audit following these changes. References 1. C. Milkins, J. Berryman, C. Cantwell. Guidelines for pretransfusion compatibility procedures in blood transfusion laboratories. Transfusion Medicine 2012; 23: 3-35. 2. NICE. The Use of Routine Preoperative Tests for Elective Surgery2003.www.nice.org.uk/nicemedia/pdf/preop_fullguidelin e.pdf (accessed 09/09/2013)
16 Quality Outcomes in Recovery Audit Tool J. Gan, E. Dempsey, C. Lanigan University Hospital Lewisham, London. Corresponding author: [email protected]
It has become very difficult to measure outcomes in anaesthesia as these are closely linked to other confounding patient and surgical factors. Traditional mortality outcomes are unsatisfactory as these events are very rare in anaesthesia. We studied outcomes in recovery which are patient focused to see if these might be used to indicate quality of anaesthesia. Methods Following local discussion, we set standards for recovery outcomes as follows: 2hrs; temperature 36-38C ; needing rescue anti-emetic or analgesia; SpO23 >2.5-2-