Caring to the End Dr Peter Nightingale Royal

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

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

ASA status Health status on admission n % 1 A normal healthy patient 52 1. 7 2 A patient with mild systemic disease 244 8. 0 3 A patient with severe systemic disease 743 24. 2 4 A patient with incapacitating systemic disease 1368 44. 6 5 A moribund patient 657 21. 4 Subtotal 3064 Not answered Grand Total 89 3153 ASA = American Society of Anesthesiologists 2/3 1/5

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

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

Adequate time to see the patient? Documented pre-operative anaesthetic review n % Yes 285 68. 8 No 48 11. 6 Unable to answer 81 19. 6 Subtotal 414 Not answered 60 Grand Total 474 Usually elated to urgency of resuscitation and operation

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

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

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

Intra- and post-operative care § Appropriate anaesthetist (96%) Ø Named consultant v In CCT; further Guidance published 2008 § General factors Ø Ø Ø 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%)

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

Palliative care and the ICU § Usually treatment withdrawal on ICU patient § Admission might be appropriate Ø Ø Ø 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 Ø Ø Ø Staffing ratio and use of cubicles Used to handling relevant drugs Relatives frequently send letters of thanks

Summary § Assessment, investigation and treatment of surgical emergencies remains problematical Ø Hospitals often not able to provide adequate facilities, especially out of hours § Who is responsible for continuity of care? Ø 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