Surgery in Children

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Surgery in Children

• David G. Mason
• Consultant Paediatric Anaesthetist,
• Oxford
• NCEPOD Clinical Co-ordinator

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• What is NCEPOD
• Background to surgery in children
• Aims of study
• Methods
• Impact

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Aims

• Undertake research into the way patients are
  treated, to identify ways of improving the
  quality of care
• NCEOD publishes reports summarising key findings
  and recommendations arising from the information
  they gather
• Aim to identify changes in clinical practice that
  will improve quality of care and ultimately
  improve patients' outcomes

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Status of NCEPOD

• Company limited by guarantee and a registered
  charity
• Operates as an independent entity under the
  umbrella of the NPSA
• Funded by NPSA/HSSE (NI)/Guernsey/Isle of Man/
  Independents

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Structure of NCEPOD

• Steering Group
• Trustees
• Clinical Co-ordinators
• Non-clinical Staff
• Expert Groups
• Advisors

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Why does it work?

• Medicine is a complex system which cannot be
  described by quantitative analysis alone
• NCEPOD unashamedly uses qualitative analysis
• Cases reviewed by those that understand problems
  at coalface
• Interpretation of collected data by practising
  clinicians who understand pressures of clinical
  practice
• Comment by those sympathetic to but not
  uncritical of current working practices

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Confidentiality

• Key part of the Enquiry protocol
• Anonymised cases
• Confidentiality agreement
• Section 251 exemption

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Background

• Childrens surgical services in UK
• Many changes in the last 20 years
• Clinical
• Organisational
• Specialisation and centralisation of childrens
  services
• Modification of staff training
• Not all beneficial to childrens surgical
  services in DGHs
• Events following congenital cardiac surgery at
  the Bristol Royal Infirmary

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Factors for changes

• NCEPOD 1989 1999
• Atwell JD, Spargo PM. The provision of safe
  surgery for children. Arch Dis Child 1992 67
  345-349
• The Audit Commission report Children first a
  study of hospital services. 1993
• Kennedy Inquiry 2001
• Monro Report 2003
• Department of Health, National Service Framework
  for Children. 2004
• Healthcare Commission, Improving Services for
  Children in Hospital. 2007

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NCEPOD reports

• Surgeons and anaesthetists should not undertake
  occasional paediatric practice
• Consultants who have responsibility for children
  need to maintain their competence in the
  management of children
• Concentration of expertise with a Regional
  approach to the organisation of paediatric
  surgical services
• Review of manpower planning for surgical
  anaesthetic services of children
• Better audit review of mortality

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Audit Commission / NSF / HCC

• Provide access to care and treatment of the
  highest quality that is evidence based, effective
  and safe
• Ensure care is provided within an environment
  suited to the needs of children and young people,
  with appropriate facilities to support families
  in caring for their child
• Ensure care and treatment is provided by staff
  that are suitably trained and experienced in
  caring for children and families and that these
  staff are appropriately supported and developed
• Establish clinical networks and improve
  outreach from regional centres, particularly in
  surgical specialities, to maintain local expertise

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Safe surgery for children

• Audit of surgical practice
• Centralisation of paediatric surgery
• Transfer of children lt 5 years of age,
  particularly for acute surgical conditions
• Change in paediatric population
• Longer survivors
• Changes in surgical practice
• Changes in society e.g. obesity

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Congenital cardiac surgery

• Standards were proposed (Monro)
• Development of regional team working
• Systematic clinical accountability
• National audit
• Child centred care
• Clinical assessment
• Consent
• Medical and surgical care.
• National Specialised Commissioning Group (2009)
• Safe and Sustainable Paediatric Cardiac Surgery
  Services

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Interpretation / misinterpretation

• Arbitrary number of paediatric surgical /
  anaesthetic cases per year
• Arbitrary age limits
• Changes in surgical anaesthetic training
• Incomplete networks of care

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Consequences of changes

• Decline in the number of children who have
  surgery performed in DGHs
• Change in paediatric surgical practice
• Increase in referrals to tertiary centres
• Deskilling of surgeons and anaesthetists in DGHs
• Is a tipping point approaching in the care of the
  surgical child in DGHs?
• Is the current organisation of CCD surgical care
  providing the best care?

Cochrane H Tanner S Trends in Childrens
Surgery 1994-2005 statistical report 2007 DH
Pye JK Survey of general paediatric surgery
provision Ann R Coll Surg Engl 2008 90 193-197
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Aims of Study

• Primary aim
• Determine the remediable factors in process of
  care of children 17 years and younger who die
  within 30 days of surgery
• Secondary aim
• What impact have the changes in practice over the
  last 10 years had on the quality of care of
  children who require surgery?

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Aims of Study

• The primary aim would be met by addressing the
  following factors
• Preoperative care and admission
• Intra-hospital transfer
• Networks of care
• The seniority of clinicians
• Multidisciplinary team working (involvement of
  paediatric medicine)
• Delays in surgery
• Anaesthetic and surgical techniques
• Acute Pain Management
• Critical Care
• Co-morbidities
• Consent

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Aims of Study

• Secondary aims would be met by addressing the
  following issues
• To what extent has specialisation /
  centralisation of paediatric surgical services
  occurred?
• How has staff training developed in last 10
  years?
• How do hospital facilities (infrastructure)
  affect care?

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How?

• Organisational Questionnaire
• Clinical Questionnaires
• Surgical
• Anaesthetic
• Peer review
• Survey of practice

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Examples of reasons for not returning data
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Impact

• Add to the body of information on surgical and
  anaesthetic services for children thus guiding
  future service development
• and
• Maybe answer the question
• What is the best organisational model for
  delivering surgical care for children in the UK?

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Questions?
http//www.ncepod.org.uk