SASM Annual Report 1997: Conclusions and Recommendations

Conclusions

1. Inadequate pre-operative assessment of pre-existing heart disease remains a significant problem.

2. A shortfall in the number of surgical HDU beds is suggested by the number of patients whose treatment could have been improved by High Dependency Care which was not available or not used. This is also supported by a prospective study within this report. There is an urgent need to investigate and address this problem.

3. Deaths following central venous line insertion, although few in number, raise sufficient concern to suggest the need for a more in-depth audit.

4. Failure of adequate response in deteriorating post-operative clinical situations requires rigorous examination of the causes and urgent remedial action.

5. The interpretation of SASM data is limited by lack of denominator information. There is wide acceptance amongst Consultants of the benefits of data linkage between SASN and national data sets to allow assessment of Trust performance in a number of indicator operations, and to give individual surgeons the ability to compare themselves with the national average.

Recommendations

1. Improved pre-operative assessment could be achieved by increased use of pre-admission clinics and early referral for cardiological opinion. Clinicians should consider cardio protective strategies pen-operatively in patients with coronary artery disease.

2. HDU beds must be available at every hospital where major surgery is carried out or where even minor or moderate surgery is undertaken in high risk patients. Action is OVERDUE at Trust, Health Board and National level.

3. Trusts should be encouraged to undertake a prospective audit of the morbidity and mortality of central venous line insertion in the light of the deaths associated with this procedure and our overall view that central venous pressure monitoring is under-used pen-operatively in high risk patients

4. Clear protocols for the management of post-operative complications must be immediately available at all times with adequate safeguards to confirm their application. Failure of an appropriate response in such situations implies a need for increased education of both nursing and medical staff, an issue involving Nursing Colleges, Royal Colleges and Universities. This is an area where the use of Information Technology should be improved.

5. A collaborative approach to the establishment of a national IT system for surgery should be explored. The Royal Colleges are encouraged to develop data linkage between SASM and national data sets to allow more detailed analysis of Trust and individual Consultant performance, bearing in mind the necessity to maintain strict anonymity and the inherent dangers of misinterpretation of the limited data sets.