National Hip Fracture Anaesthesia Network

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National Hip Fracture Anaesthesia Network

• The First Year
• Richard Griffiths (Peterborough)
• Kirsty Forrest (Leeds)
• John Holloway (Poole)

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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
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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

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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

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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
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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
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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

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National Hip Fracture Anaesthesia Network
Preoperative hematocrit levels and
postoperative outcomes in older patients
undergoing noncardiac surgery JAMA 2007 297
pages 2481-2488
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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 lt 39 and gt
51 WHO definition of anaemia 1968
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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
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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
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Have I got news for you
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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
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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

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Woman, 95, had hip op cancelled EIGHT times in
a week
Marjorie Fox 25 September 2007, By KATIE BALDWIN
Health Reporter Hospital bosses have apologised
after a 95-year-old woman's hip operation was
cancelled EIGHT times in a week. Marjorie Fox
went without food for hours as she was prepared
for surgery at Leeds General Infirmary, only for
it to be cancelled later. The pensioner was on
morphine because she was in so much pain after
falling and breaking her hip. Now her family have
hit out at the hospital for the delays which they
say affected other elderly patients too. Mrs
Fox's niece Mary Emsley, above right, said "At
her age to have her wait all that time is wrong.
It's not a one-off it's been going on a long
time." Hospital managers have apologised for the
postponed ops, admitting the delays were
"unacceptable", but said it was a busy week
rather than an ongoing issue."They were fasting
her every day and some days all day. Eight
times she was due to go down for the op and eight
times it was cancelled." Mrs Emsley, from
Horsforth, said she understood several other
elderly patients from that ward were also waiting
for the same operation at the same time but only
one was being seen each day. Mrs Fox, originally
from Otley, eventually had surgery a week after
being admitted. A spokesman for Leeds Teaching
Hospitals NHS Trust said "We're extremely sorry
Mrs Fox's operation was postponed so many times
her treatment clearly fell below our usual high
standards. "Although there was a marked increase
in the number of patients requiring orthopaedic
surgery during the week in question, the number
of delays to Mrs Fox's treatment is
unacceptable." He added there was no increased
risk to Mrs Fox because of the delay. Toby
Branfoot, lead trauma surgeon for the hospitals
trust, added that theatre scheduling could cause
problems, as they could operate on young, healthy
patients late at night but not complex cases.
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Hip Fractures wait from admission to
operation LGI SJUH (July, August, September
2006) LGI (July, August, September 2007)
Total No patients
Average wait (days)
Median wait (days)
Range days)
at 24 hour standard
at 48 hour standard
LGI 06
81
3.26
2
0-16
30.9
56.8
SJUH 06
69
1.46
1
0-10
68.1
91.3
LGI 07
143
3.81
3
0-16
15.4
35.7
Standard of fit patients getting to theatre
within 24 hours of admission 1 CEPOD
www.ncepod.org.uk The extremes of age 1999. 2
Scottish intercollegiate Guidelines Network Jan
2002 www.sign.ac.uk Standard of patient getting
to theatre within 48 hours of admission British
Orthopaedic Association, British Geriatric
Society-BOA Sept 2007
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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

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Hip Fractures wait from admission to
operation LGI SJUH (July, August, September
2006) LGI (July, August, September 2007) LGI
(Jan, Feb, March 2008)
Total No patients
Average wait (days)
Median wait (days)
Range days)
at 24 hour standard
at 48 hour standard
LGI 06
81
3.26
2
0-16
30.9
56.8
SJUH 06
69
1.46
1
0-10
68.1
91.3
LGI 07
143
3.81
3
0-16
15.4
35.7
LGI 08
137
3.22
3
0-42
16.1
45.3
Standard of fit patients getting to theatre
within 24 hours of admission 1 CEPOD
www.ncepod.org.uk The extremes of age 1999. 2
Scottish intercollegiate Guidelines Network Jan
2002 www.sign.ac.uk Standard of patient getting
to theatre within 48 hours of admission British
Orthopaedic Association, British Geriatric
Society-BOA Sept 2007
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Delayed Surgery

• 75 out of 138 patients gt 48 hours for surgery.
• 8 patients lt 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.

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Why still a problem?

• Surgical specialties
• Too many
• With too much work to do
• - Compared with other centres low number of
  surgeons

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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
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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!!

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Operations cancelled due to dirty
equipmentPublished Date 14 April 2008
HOSPITAL bosses have admitted dirty surgical
equipment has caused the last-minute cancellation
of operations. Leeds Teaching Hospitals NHS Trust
is holding emergency meetings with its suppliers
after it emerged contaminated instruments were
returned by angry surgical staff on at least two
occasions just as the operation was about to go
ahead.The trust has admitted there were
problems with its new contractor which was
only taken on last month and has now apologised
to affected patients. The row broke out after
patient Helen Rygate, 46, had her hip operation
cancelled twice. She said she had been told by
her surgeon that the problem of dirty equipment
was widespread. A spokesman for Leeds Teaching
Hospitals NHS Trust said We sincerely apologise
to Helen Rygate about problems with instruments
which have meant that her operation at Chapel
Allerton Hospital has been cancelled on two
occasions. The operating theatres previously had
an in-house decontamination service but moved to
a new, external supplier in March.We acknowledge
there have been some problems since then which we
have been dealing with, the spokesman added.
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Poole Hospital Trauma ExperiencesA New Beginning

• Dr John Holloway
• Consultant Anaesthetist

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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

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TAC Team Office
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NOF workload

• One of five busiest units
• Circa 830 patients per year
• Peak 10 per day

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Trauma lists

• Two trauma theatres
• Theatre 5 - am / pm / twilight lists
• Theatre 4 - am / pm
• Average 2.35 patients per list

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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

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• A
• Slow
• Start!

Metastatic CA Pleural effusions 2 x Cancellations
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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

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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)

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Medical cancellations

• Fast AF
• Chest infection!
• INR
• Na / K
• Clopidogrel

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Delays and deaths

• 48 hours 59 (2 RIP)
• 49 hours 72 (11 RIP)
• 10 RIP delay 81 hours

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

• 58 ASA 3
• 11 ASA 4

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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
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HIPFA First Data
Information is limited Dont know when
anaesthesia gets involved? Do know that grade of
anaesthetist probably influences time of surgery
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• 64 of all cases done by consultants
• Only 0.5 cases ST 12 primary anaesthetist

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HIPFA
What data do we want collected on a prospective
basis? This would form a minimum dataset and
should be collected on every patient
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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?
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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!

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Demographic, Personnel and Timing Data
Anaesthetic Assessment Data
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Reason for delaying operation
Major co morbidity contributing to delay
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Anaesthetic Technique Data Regional
Anaesthesia General Anaesthesia Sedation Invasive
Monitoring Postoperative Analgesia
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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

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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
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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
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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?

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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?