How to conduct second line assessments Barry Beiles-Clinical Director VASM
ASM receives notification of death Surgical case form sent to surgeon for completion by paper or Fellows Interface Completed paper or electronic surgical case form returned to ASM and de-identified Surgical case form sent for first-line assessment by paper or Fellows Interface Yes Is a second-line assessment required? No Case closed Second-line assessment Feedback to surgeon Has an appeal been lodged on the second-line assessment? Yes No Case closed
Principles of a SLA Summarize history and course of treatment Comment on quality of record keeping Provide constructive comments on how the outcome might have been improved, specifically responding to the FLA comments and adverse events/areas of concern- ACONS Suggest changes in future practice Not too brief
Management issues classification An area for CONSIDERATION is where the clinician believes areas of care COULD have been IMPROVED or DIFFERENT, but recognizes that it may be an area of debate. An area of CONCERN is where the clinician believes that areas of care SHOULD have been better. An ADVERSE EVENT is an unintended injury caused by medical management rather than by disease process, which is sufficiently serious to lead to prolonged hospitalization or to temporary or permanent impairment or disability of the patient at the time of discharge, or which contributes to or causes death.
Substandard SLA report
Suitable SLA report Summary This is the case of an 82 year old, multi morbid patient, admitted on 16 October after a delay at home, with a 7-10 day history of increasing abdominal pain, and lethargy with nausea and anorexia. Her co-morbidities included Congestive heart failure, cardiomyopathy, respiratory disease on CPAP, Chronic Kidney disease, on Warfarin, digoxin and other medications. She had an INR of 10 on 16 Oct and a serum digoxin in the toxic range at 1.3. A diagnosis of acute pancreatitis and sepsis was made on biochemistry and clinical grounds. This was supported by CT. She deteriorated in the emergency department, and sepsis was considered after a MET call. She was moved to the ICU where a central line was considered, but the Right carotid artery inadvertently cannulated. She was then operated upon the morning after admission- 17 October - with removal of the catheter, thrombectomy and vein patch without problem. She rallied and then deteriorated again, with both clinical and biochemical worsening. She was considered for ERCP with stunting and this and US were performed on 18 Oct. She improved biochemically but continued to deteriorate and after discussion with the family active treatment was withdrawn and she was declared dead at 1800 on 20 Oct. The cause of death was felt to be multiorgan failure secondary to ascending cholangitis. A post mortem examination was not performed. Surgical Case Form This was completed by the consultant, who stated concern at the ICU complication, but felt the outcome to be not preventable. First Line Assessment The first line assessor felt there were issues with the pre op investigations and treatment of sepsis, the nature of the carotid artery injury and its treatment, the procedure details and the timing and date of surgery. Also the definitive causes of sepsis and death.
Suitable SLA report part 2 Case Notes These were adequate for the report but in general poor with illegibility, missed timings, incompletely completed forms, especially with dates. There was also no apparent decision making notes re the ERCP, indeed the US report indicated a normal calibre bile duct, no obstruction and no calculi in the gallbladder, making the decision for this difficult to understand, though improvement in the LFTs afterwards was dramatic. There is only a brief note that US was used for the attempted CV cannulation and it is not apparent the grade of doctor performing it. The notes of the operations on the carotid and ERCP are adequate. The timing of the US and the time of theatre for ERCP are not apparent, though it appears to me the US report was not seen prior to theatre, certainly there is no comment in the record. There was no record of blood cultures taken in the record. Medication charts are (as seems universal) not completed as per standards. The concern of timings by the First Line Assessor was due to error by reporting surgeon. The concern re diagnosis of ascending cholangitis is that it was apparently made by inference and there is no record of specimens. This is probably of little importance in outcome but is in clinical completeness. It is noted that the clinical coding sheets have multiple alterations. Comments 1. The complication of IJV cannulation of arterial injury is well recognised though with the use of US should be considered unusual, and may represent lack of experience or supervision. 2. The initial surgery was proper, adequate and timely. 3. The decision for ERCP was not well documented. 4. The diagnosis of ascending cholangitis was not verified, in the absence of obstruction. 5. The pancreatitis aetiology not documented or explained, and not mentioned as part of cause of death. 6. The letter to the GP failed to mention the arterial injury and its management. 7. Attention to detail in completion of documents poor. 8. De-identification process makes it difficult to assess grade of the note maker. 9. Given the serious nature of the presentation, and the significant co-morbidities, the pancreatitis/sepsis would most likely have resulted in death. Recommendations 1. The need for full completion of documentation be emphasised to Fellows and Trainees. 2. De-identification to leave status of the person making of notes. 3. That notes of the decision making process be emphasised as part of a complete clinical record.
Concordance between the treating surgeon and the first-line assessor (4,905) Clinical management issues Postoperative care Timing of operation Grade/experience of surgeon operating Grade/experience of surgeon deciding Choice of operation Decision to operate at all Intraoperative/technical management Preoperative management/preparation Fluid balance HDU care benefit if not received ICU care benefit if not received Risk of death 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Concordance between the treating surgeon and the second-line assessor (1,200) Clinical management issues Postoperative care Timing of operation Grade/experience of surgeon operating Grade/experience of surgeon deciding Choice of operation Decision to operate at all Intraoperative/technical management Preoperative management/preparation Fluid balance HDU care benefit if not received ICU care benefit if not received Risk of death 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Concordance between the first-line assessor and the second-line assessor (1,200) Clinical management issues Postoperative care Timing of operation Grade/experience of surgeon operating Grade/experience of surgeon deciding Choice of operation Decision to operate at all Intraoperative/technical management Preoperative management/preparation Fluid balance HDU care benefit if not received ICU care benefit if not received Risk of death 0% 10% 20% 30% 40% 50% 60% 70% 80% 90%
Validation study 16 (5%) of 329 SLA randomly selected for validation Speciality Second-line cases available for review Cases selected n (%) Cardiothoracic 41 2 (5%) General Surgery 167 3 (2%) Neurosurgery 32 2 (6%) Obs & Gynae 1 1 (100%) Ophthalmology 1 1 (100%) Orthopaedics 40 2 (5%) Otolaryngology 5 1 (20%) Plastic Surgery 1 1 (100%) Urology 18 1 (6%) Vascular 23 2 (9%) Total 329 16 (5%)
Similarities by field
Validation Conclusions Good agreement between surgeon and FLA Moderate agreement between surgeon and SLA Poor agreement between FLA and SLA 85% agreement between SLA assessors The process is robust Will repeat this exercise every 2 years
Trends in clinical management issues over time 80% 60% Issues (%) 40% 20% 0% None Consideration Concern Adverse event Clinical management issues 2007-2011 2011-2012 2012-2013 2013-2014
Frequency of clinical management issues across the audit series (2007-2014) Clinical management issues Current audit period Frequency (%) Operation inappropriate 1,025 (27%) Delay in definitive treatment 970 (26%) Preoperative care issues 500 (13%) Management or protocol issues 478 (13%) Postoperative care issues 370 (10%) General complications after surgery 83 (2%) Communication or poor documentation 177 (5%) Adverse events 91 (2%) Critical care issues 48 (1%) Septicaemia and wound 28 (1%) Transfer problems 19 (<1%)
Conclusion Assessors should realize the importance of their contribution to ASM Their assessment is vital to the educational process and should be comprehensive and focused on lessons and not be overly harshly judgmental Total anonymity is assured This is a unique audit-independent and peerreviewed.