Guidelines for reviewing participation in the National Confidential Enquiry into Patient Outcome and Death and implementing NCEPOD recommendations

Preamble

This tool has been produced to help trusts reviewtheir participation in the National Confidential Enquiry into Patient Outcome and Death, (NCEPOD),and their implementation of NCEPOD recommendations.

This paper describes how NCEPOD works, how trust staff should engage in the Enquiry, and what actions trusts should take when a new NCEPOD report is released.The paper is intended to help trusts:

  • improve the care of patients by ensuring that clinicians and managers are aware of new NCEPOD reports as they are released
  • meet the requirements of the Central Negligence Scheme for Trusts.

Background

The National Confidential Enquiry into Patient Outcome and Death carries out studies into aspects of care in all areas of medicine except obstetrics (covered by the Confidential Enquiry into Maternal and Child Health - CEMACH) and mental health (the national confidential inquiry into suicide and homicide by people with mental illness – NCISH). CEMACH has primary responsibility for studies into child health, but some NCEPOD studies do collect data on the care of children.

The aims of the Enquiry are to review clinical practice, to identify remediable factors in the care ofpatients, and to make recommendations for clinicians and managers to implement. The results of the Enquiry have widespread applicability because NCEPOD collects data from all hospitals in England, Wales, Northern Ireland, the Isle of Man, Jersey, Guernsey, the Defence Secondary Care Agency, and from participating private hospitals.

The GMC states that participation by doctors in the Confidential Enquiries is one of the elements of Good Medical Practice.The Department of Health has stated that all doctors will participate in the work of the Confidential Enquiries.The Clinical Negligence Scheme for Trusts expects the Trust Board or Governance Group to review NCEPOD recommendations as part of their risk managementactivities.

Feeding back data

NCEPOD studies are confidential so NCEPOD will not feed back to a trust data that could be traced to an individual clinician. However NCEPOD is keen to help trusts assess their overall performance,so aggregated unidentifiable data arereturned to trusts along with comparative data from the whole study database whenever possible.

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National Confidential Enquiry into Patient Outcome and Death – June 2008 – “The heart of the matter”

NCEPOD Self-assessment checklist

Recommendation / Is it met? Y/N/Partially/Planned / Comments (Examples of good practice or deficiencies identified) / Action required / Timescale / Person responsible
Cardiothoracic units need to adhere to the requirementof the National Service Framework for Coronary ArteryDisease and use protocols for referrals to their unit. Theseprotocols should be standardised nationally for patientswho require coronary artery bypass graft surgery. Thedegree of urgency of referral should be emphasised withinthese protocols.
(Clinical Directors)
Cardiothoracic units need to ensure that monitoringsystems are in place to record nationally agreed audit dataon referrals and the decision to operate. These systemsneed to identify patients who are in danger of breachingnational agreed waiting times so that surgery can beexpedited.
(Clinical Directors)
If cardiothoracic units use integrated care pathways (ICPs)for patients requiring CABG surgery these should be fit forpurpose. A standard minimum data set of information thatshould be included in these ICPs needs to be developed.
(Clinical Directors)
Pre-admission clinics have an important place inassessing and determining patient requirements forsurgery. Cardiothoracic units need to review the functionof these clinics to ensure that they meet nationally agreedrequirements.
(Clinical Directors)
Patients who have acute myocardial ischaemia and requireCABG require special attention. Many of these patientsare intra or inter-hospital transfers. This group of patientsshould have surgery performed as soon as their clinicalcondition permits based on appropriate investigation andpre-operative therapeutic optimization.
(Clinical Directors)
Each unit undertaking coronary artery bypass graftingshould hold regular pre-operative MDT meetings todiscuss appropriate cases. Core membership shouldbe agreed and a regular audit of attendance should beperformed.
(Clinical Directors)
Each unit should have a clear policy for which casesshould be discussed at pre-operative MDT meetings.
(Clinical Directors)
There should be a clear protocol for deciding on besttreatment strategy (surgery v PCI) that involves bothcardiologists and surgeons.
(Clinical Directors)
A clear written plan should be made pre-operatively forall patients (with the exception of salvage cases).
(ClinicalDirectors)
Trusts and consultants should identify time within theagreed job plan to allow participation in MDT meetings.
(Clinical Directors)
There should be a written protocol available for the pre-operativeinvestigation of all patients.
(Clinical Directors)
Pre-operative investigations should be contemporaneous;where delay has occurred between assessment andsurgery consideration should be given to repeatinginvestigations.
(Clinical Directors)
There must be a system in place to ensure that pre-operativeinvestigations are reviewed by a senior clinicianand acted upon.
(Clinical Directors)
Further studies should be undertaken to establishthe risks and benefits of continuing pre-operativemedication. Guidelines should be produced based uponsound evidence.(Society for Cardiothoracic Surgery in
Great Britain and Ireland / NICE)
NCEPOD supports the guidance of the AmericanCollege of Cardiology and the American HeartAssociation that clopidogrel should be stopped priorto surgery wherever practicable.
There should be a protocol to ensure timely andappropriate review of unstable cases that involves bothcardiologists and cardiac surgeons.
(Clinical Directors)
The senior surgeon needs to be aware of any change in clinical status in the pre-operative period to ensure thatsurgery is still appropriate.
(Consultant Cardiothoracic Surgeons)
Given the high mortality when operating soon after anacute infarct more use should be made of strategies tooptimise clinical condition, provide symptom relief andallow surgery to be performed at a later date (IABPand PCI).
(Clinical Directors)
A “track and trigger” system should be used to provideearly recognition of clinical deterioration and earlyinvolvement of consultant staff.
(Clinical Directors)
All patients should have height, weight and a BMIrecorded on admission, unless their clinical conditionprecludes this.
(Medical Directors)
Where pre-operative comorbidity exists, thereshould be a clear written management plan which isfollowed in order to optimise the physical status ofthe patient prior to surgery, and identify the need forspecific postoperative support to be available.
(Clinical Directors)
There should be clear guidance about how to estimateLV function, and at what point in the patient journey thisshould be ascertained and recorded. Units should auditdiscrepancies in recorded LV function from surgeonsand anaesthetists and where there are significantdifferences ensure that systems are in place toaddress this.
(Clinical Directors and Audit Leads)
Patients who have a more complicated postoperativeperiod are difficult to manage. Any interaction betweendifferent medical specialties about patient managementshould be at consultant-to-consultant level, in particularfor patients with suspected intra-abdominal pathology.
(Consultants)
Cardiac recovery areas/critical care units are bestsuited to managing the majority of patients who recoveruneventfully. Patients who are developing critical illnessand additional organ failure should be managed in anenvironment with sufficient throughput of such patients tohave the resources and experience to provide optimumoutcomes. (General Critical Care Units)
Cardiac critical care units should have the facility toprovide renal replacement therapy. (Cardiac CriticalCare Units)
Senior clinicians should be readily available throughout theperi-operative period in order to ensure that complications(which occur commonly) are recognised without delayand managed appropriately.
(Clinical Directors andConsultants)
A clear written operative plan should be available. Thisshould include contingency arrangements where thefindings at surgery dictate an alternative approach (backplanning).
(Clinical Directors and Consultant CardiothoracicSurgeons)
Where unexpected events occur during surgery, surgeonsshould have an adaptable approach, and modifythe operation to suit the circumstances of the case.
(Cardiothoracic Surgeons)
A clear description of the extent of the disease should berecorded.
(Cardiothoracic Surgeons)
Where an operation performed deviates from the operationplanned, the reason for this should be clearly documented.
(Cardiothoracic Surgeons)
Protocols must exist for handover between clinical teamsand patient locations to ensure effective communicationand continuity of care.
(Clinical Directors)
All patients should receive an information sheet describingthe proposed operation.(Consultant CardiothoracicSurgeons)
A consultant should obtain consent for coronary arterybypass grafting.
(Consultant Cardiothoracic Surgeons)
Potential complications must be recorded on the consentform. This should detail the likely complications andthe incidence of these complications based on localdata.
(Clinical Directors and Consultant CardiothoracicSurgeons)
An accurate risk of death must be quoted on the consentform. This should take into account the proposedprocedure and clinical status of the patient.
(ClinicalDirectors and Consultant Cardiothoracic Surgeons)
Morbidity and mortality audit meetings should be heldin all cardiothoracic units. The majority of units shouldhold meetings at least monthly. If the numbers of casesperformed in a unit are small, alternative arrangementsshould be made to incorporate these cases in othersurgical audit meetings.
(Clinical Directors and AuditLeads)
The personnel present at morbidity and mortalityaudit meetings should reflect the composition of themultidisciplinary cardiothoracic team.
(The Cardiac Team and Clinical Directors)
A clear record should be kept of morbidity and mortalityaudit meeting which should comply with national guidelines.
(Audit Leads)
A common system for grading of quality of care ofpatients should be employed for all patients discussedin morbidity and mortality audit meetings. The peerreview scale used by NCEPOD provides such a system.
(Clinical Directors)
There should be robust systems in place to learn fromthe findings of morbidity and mortality meetings. Thecardiothoracic audit leads should be responsible formanaging this process.(Audit Leads)
The decline in the number of autopsies performedfollowing deaths from first time coronary artery bypassgrafting needs to be reversed. To achieve an increasein the autopsy rate will require a substantial changeto both the coronial system and hospital autopsyservice.
(Chief Executives, Medical Directors andClinical Directors)

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