Annual Report Department of Anaesthesia, Intensive Care & Pain Medicine

Transcription

1 Annual Report 2008 Department of Anaesthesia, Intensive Care & Pain Medicine 2008 brought with it a number of significant changes for the Department. Dr Tom Owens took over as Chairman of the Department from Dr Declan O Keeffe in January. The biggest challenge facing the Department was a shortage of staff and this coupled with the need to move to the new operating theatres proved to be difficult challenges for the Department and this is evidenced by the ongoing needs for a significant number of locum appointments in order to maintain a service. The completion of negotiations for the new contract has meant that the Department could progress any proposed new posts. The external review has neared completion at the time of writing also saw the setting up of the Acute Pain Service which is now up and running, albeit at a basic level. This is seen as being a significant development in perioperative care provided for patients. The move to the new theatre block has meant that there has been an increase in the workload with the opening up of an additional theatre to facilitate the cancer strategy. The operating theatres now operate at two different locations within St Vincent s Hospital. In the old block we have retained four theatres and in the new block up to eight theatres can be open at the one time. This poses significant staffing problems for us and is a constant source of difficulty. In addition to this the appointment of another interventional radiologist has meant that the activity in the areas outside of theatre outside of theatre has also expanded in addition to ECT. The Pre-Assessment Clinic has also been up and running. We have new premises adjacent to St Mark s Ward which is a significant development. In addition to that we have secured the services of Olga Treacy three days a week in order to staff the Pre-Assessment Clinic. Again this has been a significant development for our Department. The Pre- Assessment Clinic is being supervised by both Dr Alan McShane and Dr Tom Owens. It is hoped that the proper and efficient use of the Pre-Assessment Clinic will result in better and more efficient use the beds in the hospital along with reduced cancellation rates and complications for surgery. I would like to congratulate Dr Niamh Conlon and Dr Crina Burlacu who were appointed as permanent members of staff in the Spring of Also I would like to congratulate Dr Richard Assaf who retired in October Dr Assaf has provided our Department with many years of outstanding professional service in addition to a commitment to teaching and training. In many ways the success of our candidates in the Part 1 exam is in no small way due to the efforts of Dr Assaf. I would like to thank him for the many years of effort he has put into the training programme and would like to wish him and his wife, Mary Rose, many happy years together in their retirement. March 2009 was marked by the death of Dr Dennis Molyneaux. His passing was quite unexpected and brought great sadness to all the members of staff who had known him over the years. Again I would like to acknowledge the many years of professionalism and dedication that Denis brought to his post and we extend our sympathies to Frouk and his children. On a brighter note the move to the new hospital has been a huge success and the new theatres are much brighter and more spacious than the old theatres. In addition to this the recovery room and holding area are much more suitable for the numbers of patients using these areas. Additionally, Intensive Care, which has been open a longer period of time than theatres are once again in close proximity to the theatres and we greatly

2 appreciate the significant upgrading in facilities and infrastructure that the move has brought with it. Service Development /Activities Activity Report Operating Statistics 2008 During 2008 the throughput of surgical cases was HOSP PNH TOTAL DENTAL E.N.T GENERAL GU ENDO GU OPEN GYNAECOLOGICAL OPHTHALMIC ORTHOPAEDIC PAIN PLASTIC THORACIC VASCULAR Fifty-nine liver transplant operations were performed during the year, with 75 donor retrievals. Resident Merit Awards The following residents received medals as follows: Dr Enda Connolly Dr Gerry Dorrian Award for best SpR in Anaesthesia Dr Gavin Weekes Dr Dick Nolan Award for best BST in Anaesthesia Dr Stephen Frohlich Dr Seamus O Donnell Award for best SpR in ICU Intensive Care Unit

3 Medial Director Consultants Clinical Nurse Manager III Dr. Kieran Crowley Dr. Pat Benson Dr. Caroline Hickey Ms Geraldine Carey Service workload 649 patients were admitted to the ICU in 2008, another record number. 41% of patients stayed 1 day, while 44% stayed 3 days or more, similar to recent years. Average length of stay was 4 days. Average occupancy for the year was 89%. The ICU continued to provide the critical care component of the liver transplant programme. Organ failure rates and organ support rates were similar to recent years: 60% of patients received mechanical ventilation. Overall ICU survival was 76%, with hospital survival of 68%. St. Vincent s supplied an ICU nurse and registrar to staff the transfer of critically ill patients by MICAS (mobile intensive care ambulance service) on a 1:4 roster. The ICU contributed to a national HSE study on organ procurement. The ICU collected data for the HSE (through Prospectus) for a nationwide report on ICU services. Staff The ICU ran a Foundation Course with 6 nurses graduating in March 08, and a Higher Diploma Course, with 6 nurses graduating in May 08. These courses greatly assist in providing adequate numbers of suitably trained nursing staff, which remains an issue. Maureen Darcy continued in a temporary capacity in the position of ADON. Dr Caroline Hickey was appointed to a permanent consultant position, having worked a locum for the previous two years. For the second half of the year Dr Oleg Ilyinsky worked in a locum consultant capacity, filling in for sick leave. There are two attendants, one shared orderly, one shared technician and a three secretaries. The ICU is staffed by a registrar or specialist registrar rotating from the department of anaesthesia. The aim of achieving out-of-hours cover by consultant intensivist staff has not yet been met. Service developments Of the total of 16 beds in the ICU 10 are open, with overflows to 13 beds at times. Efforts are being made to open further beds. The Clinical Information System, which went live in August; in December it was temporarily suspended to iron out teething problems. In conjunction with the Emergency Department, Therapeutic Hypothermia for survivors of out-of-hospital cardiac arrest was introduced. S/N Dennis Wedgeworth submitted his report to the Director of Nursing on the needs of patients after discharge from ICU having completed his outreach follow-up of these patients for 12 months.

4 ICU ACTIVITY Admissions Average length of stay (days) Average occupancy 89%91% 91% 92% 93% 90% 85% 89% 85% Elective surgical 25%29% 34% 38% 36% 27% 30% 32% 35% Emergency surgical 31%25% 25% 30% 30% 39% 31% 31% 35% Medical 43% 46% 43% 32% 34% 34% 39% 37% 30% Mechanical ventilation 60% 71% 80% 82% 69% 70% 75% 68% 67% Central venous access 72% 77% 73% 77% 64% 73% 81% 69% 78% Vasoactive infusions 33%31% 19% 24% 20% 18% 25% 33% 33% Acute renal failure 23%18% 14% 10% 10% 17% 25% 23% 24% Continuous renal replacement therapy 22%18% 14% 10% 10% 16% 21% 16% 14% Tracheostomy 10% 10% 7% 6% 6% 13% 11% 13% 6% Unplanned ICU discharge 6% - 17% 21% 21% 25% 1.5% 11.4% 6% Readmissions 9.3% 9.7% 8.1% 12% 8.3% 2.9% 0.9% Brainstem deaths Organ donors ICU survival 76% 78% 78% 80% 79% 82% 75% 73% 75% Hospital survival 68% 77% 76% 78% 75% 78% 70% 68% 70%

5 LIVER TRANSPLANTATION 2008 was a very busy year for the Liver Transplantation Group. 58 Orthotopic Liver transplants took place. The results for 2008 were very good. Transplantation is demanding work for all concerned. All credit to the Anaesthesia Team: Consultant Anaesthetists Liver Fellows Anaesthetic Nurses Dr Neil McDonald Dr Nageswaran Narayanan Sr. Jean McCarthy Dr. John Boylan Dr. Ashit Bardhan Billie Stafford Karl Perocillo Karen Ann Keating The transplant anaesthesia group provided coverage for 58 liver transplants, including 52 primary elective transplants, during The 60-day survival for primary isolated elective transplants was 96%, with median ICU stay and hospital stay of 1 and 21 days, respectively. Outcome for primary elective liver transplantation at SVUH continues to be one of the best in the UK and Ireland. Peer-reviewed papers Dr. Alistair Nichol, a former Conway research fellow, was awarded a PhD for his research project entitled: Investigation of the effects of buffered hypercapnia on the severity of infection-induced lung injury. Peer-reviewed papers Ó Cróinín D. Nichol AD. Hopkins N. Boylan JF. O Brien S. O Connor C. Laffey JG. McLoughlin P. Sustained hypercapnic acidosis during pulmonary infection increases bacterial load and worsens lung injury. Critical Care Medicine 2008; 36: Editorial Boylan JF. Kavanagh BP. Emergency airway management: competence versus expertise? Anesthesiology 2008; 109:945-7 Correspondence Boylan JF. Kavanagh BP. The name of the game: no transfusion (or nontransfusion) by cookbook. Anesthesiology 2008; 109: Abstracts Naughton FM. Nichol AD. Boylan JF. McLoughlin P. Ambient hypoxia and hypercapnia alter lung cytokine kinetics but do not impair lung mechanics. American Thoracic Society 2008; 177: A329 Nichol AD. Naughton FM. Ó Cróinín D. Boylan JF. McLoughlin P. Buffered hypercapnia worsens E coli induced lung injury in vivo. American Thoracic Society 2008; 177: A752

6 VASCULAR ACCESS Director: Consultant: Dr. Alan McShane Dr. Neil McDonald The Vascular Access service continues to work with a variety of healthcare groups. The requests include device placement but consultations are also made to discuss the options for patients with complicated conditions. Again we continued to work with the cystic fibrosis service and the oncology services. Ultrasound usage for line placement has almost become routine and has aided the teaching and the safety of line placement. Formal training in central vascular access is now a training requirement of the College of Anaesthetists. Drs McShane and McDonald again organised the Vascular Access Study Day in the College of Anaesthetists. This course continues to be popular and oversubscribed. It provides didactic lectures, live and cadaveric demonstrations and tuition in the use of ultrasound. South East Dublin Department of Anaesthesia (SEDDA) Chairman: Secretary: Dr. Alan McShane Ms Louise McNicholas Again in 2008 there was a heavy reliance of the services of locums to help provide consultant cover in the constituent hospitals. The service contributed greatly to the ongoing growth of cold elective surgery for patients seen in St. Vincent's University Hospital and carried out in St. Michael s Hospital Annexe. This model is a good one, as it allows planning of elective surgery without the anxiety over bed availability that is a part of life in the University Hospital because of the unpredictable effects caused by events in the Accident & Emergency Department. The SEDDA training scheme retains its popularity, with a constantly increasing number of applications. This reflects on the individual teaching done by consultants and the facilities and varied clinical experience available in the constituent hospitals. Results for trainees taking exams were good and that is due to the many who contributed to this success. PAIN MEDICINE 2007 was another year of immense development in the Pain Service in St. Vincent's University Hospital with the appointment of a new Consultant in Pain Medicine, Dr Paul Murphy. Dr Murphy did his Pain Fellowship training in the world famous North Shore Hospital in Sydney, Australia, under the guidance of Prof Michael Cousins. We also had the project of planning a new pain suite, and the commencement of the transfer of our clinical activities from St Anthony s Rehabilitation Centre to the main SVUH building. Outpatient Activity

7 Number Of Sessions New Patients Return Patients Total Tues ,244 2,494 Dr O'Keefe Tues Dr Victory Wed Dr O'Keefe Pain Unit Total ,764 4,152 The Wednesday Clinic has been taken over by Dr Paul Murphy as his basic OPD assessment access for new patients, this commences at 3 p.m and finishes at 6 p.m. We have continuted with the initiative which was introduced in 2006, of the Wound Clinic and the Walk In OPD Service for emergencies and urgent referrals. This had a huge impact in accident & emergency admission avoidance and prolonged stay at St. Vincent's University Hospital. Publications and Presentations Presentations National 5 International 4 Publications 2 2 Papers were presented by Dr Zuberi and Dr Hannsman. INSUKI Meeting in York in October There were 5 poster presentations at the Irish Pain Society Meeting in UCD in October 2007, which were jointly authored by Dr O Keeffe and Dr Murphy. With presentations from Dr Zuberi, Dr Hannsman, Dr Idrees, Dr Kamraj on a variety of topics, including Audits of Electronic Neuromodulation Practice, and the use of Pharmacologic Neuromodulation using a novel new drug, Ziconatide. There were also 2 presentations from the Unit at the North American Neuromodulation Society in Acapulco, Mexico, in December 2007, given by Dr Zuberi. One of which was a case report and the second was an audit of our Electronic Neuromodulation Practice. Dr Philip Hu commenced and successfully completed a year in the Dept of Functional MRI and the University of Oxford, under the guidance of Prof Eileen Tracey, where he is investigating the Impact of Subcutaneous Electrical Stimulation on Brain psychophysics. The Pain Programme, under the joint Clinical Directorship of Dr. Rosemary Walsh and Dr Declan O Keeffe, continued with its cognitive behavioural therapy programme, 3 week programme for patients with chronic pain and new innovations including tailored programmes for patients with special needs. Publications: Subcutaneous Electrical Nerve Stimulation for Luterscapular Neuropathic Pain Najede MP, Allajade A, O Keeffe D. Pain Medicine, Volume 9, Issue 1, Page (AAPM Abstracts) January / February 2008.

8 Audit of Neuromodulation: Our Experience of 83 Implanted Systems. Hu P, Majedi Max P, Illynski O, Al Majedi A, O Keeffe D. Neuromodulation Vol 10 Issue 2. Page April Finally the total patient interaction in the department was over 5,200 for 2007 Director: Dr. Declan O Keeffe 11 sessions Consultants: Dr. Paul Murphy 7 sessions Dr. Ray Victory 2 sessions Dr Oleg Illynski 4 sessions Pain Fellows Dr. Michael Hannsman Dr. Aamir Zuberi Dr Kamraj Senior Clinical Psychologist: Dr. Rosemary Walsh 0.5 WTE Physiotherapist: Miss Aoife Caffrey 1.0 wte Occ Therapist Miss Shannon Barr Pain Management Co-ordinator/ PA to Director Niamh Clohessy Neuromodulation Co-ordinator Locum Activity OUTPATIENT CLINICS Day Consultant Total No. of Patients to visit OPD Pain Clinic Tuesday Dr. O Keeffe 2492 Wednesday Dr. Victory 287 Tuesday Dr. O Keeffe 998

9 St. Clare s Pain Unit Procedure Room Wound Clinic 1319 Extramural Theatre Bone&Joint Unit Pain Management Programmes Type Programme No. of Courses in 2007 Total Number of Patients on Course 3 week Day 2 8 Distinguished Guests Dept was honoured by the presence of the world famous Pain Physician / Scientist, Prof Michael Cousins, of the University of Sydney, in October Prof Cousins visited the unit, and delivered the Anaesthesia grand round lecture on Chemotherapy Analgesia. Given Prof Cousins background, this was a view into the future of pain medicine, and he explained to us the new goal of attempting to achieve periods of remission from pain of patients with unrelenting chronic pain. Prof Cousins was also accompanied by Dr Damian Finess, (Chairman of the IASP Group on Placebo), who is attached as a Physiotherapist / Neuroscientist to the famed North Shore Hospital facility in Sydney, Australia. Prof Cousins also gave an address on Pain Relief as a Human Right at the Royal College of Physicians, as part of the Irish Pain Society s Annual Scientific Meeting. It was a great pleasure to have Prof Cousins visit our unit, and I on behalf of the MDT in St Vincents Pain Clinic would like to thank our new colleague Dr Paul Murphy for facilitating this wonderful experience for our group.