Golden Jubilee National Hospital Follow-up Report ~ June 2010 Anaesthesia - Care Before, During and After Anaesthesia
NHS Quality Improvement Scotland (NHS QIS) is committed to equality and diversity. We have assessed the performance assessment function for likely impact on the six equality groups defined by age, disability, gender, race, religion/belief and sexual orientation. For this equality and diversity impact assessment, please see our website (www.nhshealthquality.org). The full report in electronic or paper form is available on request from the NHS QIS Equality and Diversity Officer. NHS Quality Improvement Scotland 2010 First published June 2010 You can copy or reproduce the information in this document for use within NHSScotland and for educational purposes. You must not make a profit using information in this document. Commercial organisations must get our written permission before reproducing this document. Information contained in this report has been supplied by NHS boards/nhs organisations, or taken from current NHS board/nhs organisation sources, unless otherwise stated, and is believed to be reliable on publication. www.nhshealthquality.org 2
Contents 1 Setting the scene 4 2 Summary of findings 6 3 Detailed findings against the standards 8 Appendix 1 Glossary of abbreviations 29 Appendix 2 Details of review panel 30 Appendix 3 Review process 31 Appendix 4 Core and additional criteria 32 3
1 Setting the scene About this report This report presents the findings from the anaesthesia follow-up review exercise for Golden Jubilee National Hospital which took place on 3 March 2010. Membership of the review panel can be found in Appendix 2. Background In July 2003, NHS QIS published the Clinical Standards for Anaesthesia - Care Before, During and After Anaesthesia. Peer review visits to all territorial NHS boards and one special health board (Golden Jubilee National Hospital, Clydebank) were conducted between June 2004 and March. Local reports for each NHS board and the national overview of the key findings and recommendations were subsequently published in September. A similar round of peer review visits was then undertaken to the independent healthcare sector between September 2006 and September 2007. Local reports for each independent hospital were published following each visit. Follow-up review programme The anaesthesia project group was reconvened in February 2009 to provide advice and support to NHS QIS on an appropriate follow-up review methodology and process (see Appendix 3), and agreed on the following areas for review: 1 core criteria: based on the recommendations and challenges in the anaesthesia national overview (2005). These 31 criteria will be applicable to all NHS boards and the independent healthcare sector, whether previously met or not. Although the national overview report related to the NHS board reviews, most of the recommendations and challenges are equally relevant to the independent healthcare sector. 2 additional criteria: ten additional criteria have been identified and, if any of these were not met by an NHS board or independent hospital in the previous review, NHS QIS requires reassurance that action has been taken to address performance in these areas. Additional criteria reviewed will, therefore, be specific to each individual NHS board and independent hospital. A list of the core and additional criteria can be found at Appendix 4. 4
Assessment categories The follow-up review programme is being conducted as a table-top exercise using panels of key representational professionals and public partners. Each review panel assesses performance using the categories met, not met and not met (insufficient evidence), as detailed below: Met applies where the evidence demonstrates the standard and/or criterion is being attained. Not met applies where the evidence demonstrates the standard and/or criterion is not being attained. Not met (insufficient evidence) applies where no evidence is available for the review panel, or where the evidence available is insufficient to allow an assessment to be made. A final category not applicable is used where a standard and/or criterion does not apply to the NHS board/independent hospital under review. 5
2 Summary of findings 2.1 Overview of local service provision The Golden Jubilee National Hospital is Scotland s first wholly elective NHS facility, providing services in key specialties to patients throughout Scotland, in order to assist in reducing waiting times and is run by the National Waiting Times (Scotland) Centre Board, which has responsibility for the efficient, effective and accountable performance of the hospital. The NHS National Waiting Times Centre is a special health board made up of two distinct parts the Golden Jubilee National Hospital and the Beardmore Hotel and Conference Centre, both situated in Clydebank, just west of Glasgow. Further information can be accessed via the website of the NHS National Waiting Times Centre (www.nhsgoldenjubilee.co.uk/home/). All anaesthesia services provided by Golden Jubilee National Hospital are provided within the main theatre suite and cardiac catheterisation laboratory. During 2008, a total of 6,836 patients were anaesthetised at Golden Jubilee National Hospital. 6
2.2 Summary of findings against the standards A summary of the findings from the follow-up review is illustrated in this section. A detailed description of performance is included in Section 3. The table below summarises Golden Jubilee National Hospital s performance against the 31 core criteria and the identified additional two criteria. Core criteria 2005 Review 2010 Follow-up review 18 met 26 met 10 not met 3 not met 1 not met (insufficient evidence) 1 not met (insufficient evidence) 2 not applicable 1 not applicable Additional criteria 2005 Review 2010 Follow-up review 3.1.1 met not covered in this review 3.1.2 not met not met 3.1.3 met not covered in this review 3.1.4 not met met 3.2.1 met not covered in this review 3.2.2 met not covered in this review 3.2.3 met not covered in this review 3.2.4 met not covered in this review 3.3.3 met not covered in this review 3.4.2 met not covered in this review 7
3 Detailed findings against the standards Standard 1: Organisation of anaesthesia services Standard statement 1.1 Induction of staff: All new members of the anaesthesia team undergo an induction process. Core criterion 1.1.1: A formal and documented induction process is compulsory for all members of the anaesthesia team, which covers the information recommended in the Association of Anaesthetists of Great Britain and Ireland Risk Management and Clinical Negligence and Other Risks Indemnity Scheme Human Resources, Initial/Continuing Staff Competence documents. STATUS: Not met In 2005, this criterion was graded as not met as the induction process for trainee medical staff and consultant anaesthetists was not formal and documented. However, at the time of the review, no new consultant anaesthetists had been appointed within the last 7 years. At the time of the follow-up review, the local induction to anaesthesia and theatres for nursing and operating department practitioner (ODP) staff remains formal and documented and there is now a robust induction process for trainee medical staff. However, no evidence was provided to confirm that the induction process is formal and documented for consultant and career-grade staff. The hospital confirmed that the full training package was in the process of being redesigned at the time of the follow-up review. It should be noted that following publication of the anaesthesia national overview (2005), the Clinical Negligence and Other Risks Indemnity Scheme (CNORIS) risk management standards have been replaced by the NHS QIS clinical governance and risk management standards (2005). 8
Standard 1: Organisation of anaesthesia services Standard statement 1.2 Audit and education: There is a programme of audit and educational activity. Core criteria 1.2.1: There is dedicated time for audit and education meetings. 1.2.2: There are regular anaesthesia morbidity and mortality reviews. The review panel encouraged the hospital to record the names of morbidity and mortality meeting attendees, the outcome of discussions and ensure that the lessons learned are cascaded to the wider anaesthesia team. 9
Standard 1: Organisation of anaesthesia services Standard statement 1.3 Matching anaesthetists skills to patient needs: Each patient receives care from an anaesthetist of the appropriate training and grade for the intended procedure. Core criteria 1.3.1: There is a local protocol to define when non-consultant anaesthetists should request consultant advice and help. 1.3.2: There is an explicit mechanism to identify and contact the supervising consultant for each patient. 10
Standard 1: Organisation of anaesthesia services Standard statement 1.4 Anaesthetic assistance: The presence of a trained and dedicated anaesthetic assistant for the anaesthetist is available at all times. Core criteria 1.4.1: All nurses and operating department practitioners assisting the anaesthetist are trained to a level at least equivalent to the Scottish Vocational Qualification Level III in Operating Department Practice. STATUS: Not met In 2005, this criterion was graded as not met as not all staff assisting the anaesthetist were trained to a level at least equivalent to the Scottish Vocational Qualification (SVQ) Level III in Operating Department Practice. Following publication of the anaesthesia national overview (2005), NHS Education for Scotland (NES) produced the Core Competencies for Anaesthetic Assistants (2006) which states the competencies to be achieved by nursing staff assisting the anaesthetist. ODPs are considered to be trained at an appropriate level if they have at least one of the following: (a) a registered ODP qualification; (b) are registered with the Health Professions Council; (c) have completed the core competencies 1 10 laid out in the NES document. At the time of the follow-up review, anaesthesia assistance is provided by a team of nurses and two ODPs. Two nurses have achieved the NES core competencies and the remainder are working towards completing them by December 2010. 1.4.2: There is a dedicated trained anaesthetic assistant present for all procedures requiring the presence of an anaesthetist. STATUS: Not met In 2005, this criterion was graded as not met as not all staff assisting the anaesthetist were trained to a level at least equivalent to the SVQ in Operating Department Practice. At the time of the follow-up review, not all the dedicated anaesthetic assistants had achieved the NES core competencies. 11
Standard 1: Organisation of anaesthesia services Standard statement 1.5 Anaesthetic record sheet: The hospital anaesthetic record contains the data listed in the minimum anaesthesia data set. Core criterion 1.5.2: The supervising consultant anaesthetist is recorded on the anaesthetic record sheet. In 2005, this criterion was graded as not applicable as at the time of the review, there was a consultant-only service at Golden Jubilee National Hospital. At the time of the follow-up review, the hospital reported that non-consultant anaesthetists are now employed at Golden Jubilee National Hospital. Evidence was provided to confirm that when a non-consultant anaesthetist is providing anaesthesia services, the supervising consultant is recorded on the electronic record and on the rota. 12
Standard 1: Organisation of anaesthesia services Standard statement 1.6 Access to emergency theatre: There is adequate daytime emergency theatre resource to accommodate the hospital s emergency and urgent workload. Core criterion 1.6.1: There is dedicated provision of adequate daytime theatre resource to accommodate the hospital s emergency and urgent workload. The anaesthesia national overview challenged NHS boards to balance the daytime elective and emergency work within maternity units, and to ensure the availability of sufficient theatre and surgical staff. There is no maternity unit associated with Golden Jubilee National Hospital. However, a number of babies are delivered by caesarean section due to the mother s cardiac history. 13
Standard 1: Organisation of anaesthesia services Standard statement 1.8 Maintenance of anaesthetic equipment: Anaesthetic and monitoring equipment undergo regular maintenance and replacement. Core criterion 1.8.2: There is a planned equipment replacement programme that defines equipment lifespan and disposal procedures. The review panel commended the robust equipment replacement process in place at Golden Jubilee National Hospital. 14
Standard 1: Organisation of anaesthesia services Standard statement 1.9 Use of anaesthetic equipment: All anaesthetic staff receive formal and documented instruction in the use of anaesthetic and monitoring equipment. Core criterion 1.9.1: All anaesthetic staff receive formal and documented instruction on the use of equipment. STATUS: Not met (insufficient evidence) In 2005, this criterion was graded as not met (insufficient evidence) as the review team was unable to clarify that training was both formal and documented for all staff. At the time of the follow-up review, it was unclear if training on new equipment was both formal and documented for all staff. The hospital reported that it is finalising the orientation process for consultants who are new in post. 15
Standard 1: Organisation of anaesthesia services Standard statement 1.10 The acute pain service: Each hospital has a multidisciplinary acute pain service. Core criteria 1.10.1: There is a multidisciplinary acute pain service. At the time of the follow-up review, the hospital reported that nurses and consultant anaesthetists form the core acute pain service team. The acute pain service steering group comprises membership from other disciplines. 1.10.2: There is a named consultant, with a designated sessional commitment, responsible for management of the acute pain service. In 2005, this criterion was graded as not met as the named consultant for the management of the acute pain service had no designated sessional commitment. At the time of the follow-up review, Golden Jubilee National Hospital reported that the lead pain consultant has three dedicated acute pain service sessions: two for ward rounds and one for acute pain service administration. The lead pain consultant is supported by four consultant anaesthetists who also have dedicated sessional commitments to the acute pain service. 1.10.3: The acute pain service provides continuing education of hospital staff and patients. At the time of the follow-up review, the panel commended Golden Jubilee National Hospital for the continuing education the acute pain service provides to hospital staff and patients. 16
1.10.4: There is cover for the acute pain service on a 24-hour basis. 1.10.5: There is liaison between the acute and chronic pain services. STATUS: Not applicable In 2005, this criterion was graded as not applicable as there was no chronic pain service at the hospital. At the time of the follow-up review, the situation had not changed and there is no chronic pain service at the hospital. 1.10.6: There is audit of the safety and efficacy of analgesic therapies to promote continuous quality improvement. At the time of the follow-up review, the hospital reported that data are collected for every patient using the acute pain service. These data are reviewed regularly with findings reported to both the acute pain service steering group and the clinical governance group. Findings help to inform future practice and specific findings are reported back to relevant staff groups both formally and informally. 17
Standard 2: Preoperative care Standard statement 2.1 Preoperative information: All patients are provided with easily understood information on anaesthesia and perioperative care before admission to hospital. Core criterion 2.1.1: All patients undergoing elective procedures are provided with jargon-free, easily understood information materials (covering anaesthesia and postoperative pain relief) before admission to hospital. In 2005, this criterion was graded as not met, as not all patient information leaflets included information on anaesthesia and postoperative pain relief. There were also inconsistencies in the information that was available preoperatively and across specialties. At the time of the follow-up review, Golden Jubilee National Hospital reported that a comprehensive range of information is now provided. All new patient information is approved by the patient information group prior to its introduction, whilst existing documentation is reviewed at least once per year. 18
Standard 2: Preoperative care Standard statement 2.2 Consent to anaesthesia: All patients have an entitlement to receive information regarding medical treatment, and a right to give or withhold consent to treatment. Core criterion 2.2.1: The anaesthetic techniques to be used and material risks associated with the procedure are discussed with the patient and recorded on the anaesthetic record. In 2005, this criterion was graded as not met as although the anaesthetic techniques to be used and material risks associated with the procedure were discussed with the patient, there was no anaesthetic chart in use, nor was the discussion documented. At the time of the follow-up review, the hospital reported that an anaesthetic form is completed preoperatively by the anaesthetists and the forms have recently been updated. There is one format for cardiothoracic use and another for all other specialties. 19
Standard 2: Preoperative care Standard statement 2.3 Preoperative anaesthetic assessment: All patients are assessed by an anaesthetist before an operation requiring the services of an anaesthetist. Core criterion 2.3.2: Opportunity for preoperative assessment by the anaesthetist is provided in the patient care pathway. 20
Standard 3: Intraoperative care Standard statement 3.1 Preparation for anaesthesia: All patients receive care in a safe environment. The patient s identity and all anaesthetic equipment are checked before the procedure commences. Additional criteria 3.1.2: There is a record kept that anaesthetic machines are checked following servicing. STATUS: Not met In 2005, this criterion was graded as not met as although the medical physics department recorded when anaesthetic machines had been serviced, documentation did not state that the machines had been checked following servicing. At the time of the follow-up review, the hospital reported that the medical physics department continues to service the anaesthetic machines. A sticker recording the date and the engineer s initials is placed on the machine and is not removed until the next service. An A4 sheet alerts the anaesthesia department that the machine has just been serviced. However, this sheet does not record the date or machine serial number and is not retained. The hospital provided evidence of the daily anaesthetic machine check but was unable to provide evidence of the first user check following servicing by the medical physics department. For this reason, the criterion remains not met. 3.1.4: The anaesthetist confirms the identity of the patient and the consent to anaesthesia and surgery before inducing anaesthesia. In 2005, this criterion was graded as not met as the consent to surgery was not routinely checked by the anaesthetist. At the time of the follow-up review, the hospital reported that patient consent and identity are checked preoperatively and as part of the hospital s surgical pause routine. 21
Standard 3: Intraoperative care Standard statement 3.4 Anaesthetic emergencies: Adverse reactions and uncommon conditions occurring during anaesthesia are managed appropriately. Core criterion 3.4.3: Training sessions for management of anaesthetic emergencies are undertaken by relevant members of the anaesthesia team. In 2005, this criterion was graded as not met as no training sessions for the management of anaesthetic emergencies had been undertaken by relevant members of the review team. At the time of the follow-up review, the hospital confirmed that there is a half-day training programme for the management of anaesthetic emergencies using a meti-man simulator. Several sessions were carried out to test the training. A junior and a consultant anaesthetist have been involved in each session, along with theatre staff. The nursing and ODP staff are allocated in a way that allows a whole team to attend. This training has now been included in the mandatory training programme. In addition, morning training sessions have been introduced which are dedicated to anaesthetic emergencies. These are predominantly attended by nursing and ODP staff but are open to the multidisciplinary team and often have representation from the anaesthetists. 22
Standard 3: Intraoperative care Standard statement 3.5 Perioperative blood transfusion: Anaesthetists are responsible for intraoperative blood transfusion. Blood transfusion is sometimes required for the safe performance of surgical procedures. The decision to give a patient a blood transfusion balances the risks of transfusing against not transfusing. Core criterion 3.5.1: There is a local transfusion protocol, including transfusion thresholds, in keeping with the SIGN Guideline Perioperative Blood Transfusion for Elective Surgery. In 2005, this criterion was graded as not met as the local transfusion protocol did not include transfusion thresholds in keeping with the Scottish Intercollegiate Guidelines Network (SIGN) guideline 54: perioperative blood transfusion for elective surgery. Staff reported that a draft protocol on transfusion guidelines, including transfusion thresholds, was under review at the time of the visit. At the time of the follow-up review, the hospital provided evidence that demonstrated that transfusion thresholds are included in keeping with SIGN guideline 54. Electronic prescribing is scheduled to be introduced later in 2010 and transfusion policies will be reviewed by the transfusion committee prior to the introduction of electronic blood issue. 23
Standard 3: Intraoperative care Standard statement 3.6 Thromboembolism prophylaxis and spinal and epidural anaesthesia: All patients receive appropriate deep vein thrombosis prophylaxis according to a local protocol. All patients also receiving spinal or epidural anaesthesia have dose and timing of the drug prophylaxis adjusted as appropriate. Core criteria 3.6.1: There is a local protocol for deep vein thrombosis prophylaxis in the perioperative period in keeping with the SIGN Guideline Prophylaxis of Venous Thromboembolism. 3.6.2: Local protocols for deep vein thrombosis prophylaxis include timing of anticoagulant administration, to ensure safe spinal and epidural anaesthesia including insertion and removal of epidural catheters. In 2005, this criterion was graded as not met as the local protocol for deep vein thrombosis (DVT) prophylaxis did not include timings of anticoagulant administration which would ensure safe spinal and epidural anaesthesia. The review team was concerned that the protocol stated that heparin should be given on the morning of surgery, and encouraged Golden Jubilee National Hospital to update the protocol. At the time of the follow-up review, Golden Jubilee National Hospital confirmed that there is an agreed standardised time for anticoagulant administration per specialty. For orthopaedic and thoracic surgery it is 10pm and 6pm for all other specialties. 24
Standard 4: Postoperative care Standard statement 4.1 Recovery area: There is provision of an appropriate recovery area for immediate postoperative care. Core criteria 4.1.1: Whenever elective or emergency procedures are undertaken there is a staffed recovery facility available. 4.1.2: All patients are cared for on a one-to-one basis by qualified and trained staff until fully conscious and able to maintain a clear airway. 4.1.7: There are local protocols for the management of pain, and postoperative nausea and vomiting. 4.1.8: There is an agreed protocol describing discharge criteria from the recovery area. 25
Standard 4: Postoperative care Standard statement 4.2 Management of acute pain: All patients receive effective acute pain management. Core criterion 4.2.2: There are local guidelines, which are in routine use, on drug therapy of acute pain. 26
Standard 4: Postoperative care Standard statement 4.3 Postoperative nausea and vomiting: All patients are assessed for postoperative nausea and vomiting, and these are treated promptly. Core criterion 4.3.2: There is a local protocol, which is in routine use, for the prompt management of postoperative nausea and vomiting. 27
Standard 4: Postoperative care Standard statement 4.4 High dependency unit care: All patients requiring high dependency care after a procedure are admitted to a high dependency unit (HDU). Core criterion 4.4.1: A needs assessment has been undertaken, which has demonstrated that there are sufficient staffed and equipped surgical high dependency beds for the clinical activity of the hospital. In 2005, this criterion was graded as not met as Golden Jubilee National Hospital did not have a high dependency unit (HDU) facility and a formal needs assessment had not been undertaken. The review team considered that, at the time of the visit, the hospital had sufficient beds within the intensive care unit (ICU) to care for all HDU patients. At the time of the follow-up review, the hospital reported that there were 21 staffed ICU beds and 18 staffed HDU beds available at the hospital. These are primarily for cardiothoracic use but there is a two-bedded facility for patients from other specialties. Prior to the opening of the West of Scotland Heart and Lung Centre in 2008, a review of critical care bed requirements was carried out. A year following the opening of the centre, an external assessment identified a requirement for 21 ICU beds and 18 HDU beds. There is capacity for 24 HDU beds but, at the time of the review, only 18 are required and staffed. 28
Appendix 1 Glossary of abbreviations Abbreviation CNORIS DVT HDU ICU NES NHS QIS ODP RCA SIGN SVQ Clinical Negligence and Other Risks Indemnity Scheme deep vein thrombosis high dependency unit intensive care unit NHS Education for Scotland NHS Quality Improvement Scotland operating department practitioner Royal College of Anaesthetists Scottish Intercollegiate Guidelines Network Scottish Vocational Qualification 29
Appendix 2 Details of review panel The follow-up panel review for Golden Jubilee National Hospital was conducted on 3 March 2010. Panel members Colin Sinclair (Team leader) Consultant Anaesthetist, NHS Lothian Sam Elijamel Consultant Neurological Surgeon, NHS Tayside Norah Johnston Public Partner, Fife Vimty Muir Consultant Anaesthetist, NHS Lanarkshire Sarah Peach Charge Nurse, Anaesthesia and Recovery, NHS Tayside NHS Quality Improvement Scotland staff Catriona Macmillan Project Officer Fiona Russell Programme Manager 30
Appendix 3 Review process 31
Appendix 4 Core and additional criteria Standard 1: Organisation of anaesthesia services Standard statement Criterion Core Additional 1.1: Induction of staff 1.1.1 1.2: Audit and education 1.2.1 1.2.2 1.3: Matching anaesthetists skills to patient needs 1.3.1 1.3.2 1.4: Anaesthetic assistance 1.4.1 1.4.2 1.5: Anaesthetic record sheet 1.5.2 1.6: Access to emergency theatre 1.6.1 1.8: Maintenance of anaesthetic equipment 1.8.2 1.9: Use of anaesthetic equipment 1.9.1 1.10: The acute pain service 1.10.1 1.10.6 Standard 2: Preoperative care Standard statement Criterion Core Additional 2.1: Preoperative information 2.1.1 2.2: Consent to anaesthesia 2.2.1 2.3: Preoperative anaesthetic assistance 2.3.2 Standard 3: Intraoperative care Standard statement Criterion Core Additional 3.1: Preparation for anaesthesia 3.1.1 3.1.4 3.2: Perioperative monitoring 3.2.1 3.2.4 3.3: Management of the airway 3.3.3 3.4: Anaesthetic emergencies 3.4.2 3.4.3 3.5: Perioperative blood transfusion 3.5.1 3.6: Thromboembolism prophylaxis and spinal and epidural anaesthesia Standard 4: Postoperative care 3.6.1 3.6.2 Standard statement Criterion Core Additional 4.1: Recovery area 4.1.1 4.1.2 4.2: Management of acute pain 4.2.2 4.3: Postoperative nausea and vomiting 4.3.2 4.4: High dependency unit care 4.4.1 4.1.7 4.1.8 32
You can read and download this document from our website. We can also provide this information: by email in large print on audio tape or CD in Braille, and in community languages. NHS Quality Improvement Scotland Edinburgh Office Glasgow Office Elliott House Delta House 8-10 Hillside Crescent 50 West Nile Street Edinburgh EH7 5EA Glasgow G1 2NP Phone: 0131 623 4300 Phone: 0141 225 6999 Textphone: 0131 623 4383 Textphone: 0141 241 6316 Email: comments.qis@nhs.net Website: www.nhshealthquality.org