Unwarranted variation and the goal of net zero for the NHS in England: exploring the link between efficiency working, patient outcomes and carbon footprint.

In 2020 the NHS in England set a target of reaching net zero carbon emissions by 2040. Progress has already been made towards this goal, with substantial reductions in the use of environmentally harmful anaesthetic gases, such as desflurane, in recent years. Where an effective replacement already exists, changing practice to use low carbon alternatives is relatively easy to achieve, but much greater challenges lie ahead. The Getting It Right First Time (GIRFT) programme is a clinically-led, data-driven clinical improvement initiative with a focus on reducing unwarranted variation in clinical practice and patient outcomes. Reducing unwarranted variation can improve patient care and service efficiency, and can also support the drive to net zero. In this article we set out what the GIRFT programme is doing to support sustainable healthcare in England, why it is uniquely positioned to support this goal and what the future challenges, barriers, enablers and opportunities are likely to be in the drive to net zero.

Efficacy of surgeon-performed, intra-operative ultrasound scan for localisation of parathyroid adenomas in patients with primary hyperparathyroidism.

BACKGROUND: In the UK, guidance recommends ultrasound scanning alone or in combination with sestamibi scintigraphy to guide surgery in patients with primary hyperparathyroidism. If an adenoma is localised on imaging, this can facilitate targeted or minimally invasive surgery. Surgeon-performed ultrasound scan on the operating table benefits from being performed on an anaesthetised patient with optimal positioning. The aim of this study was to investigate the efficacy of intra-operative, blinded, surgeon-performed ultrasound scan in localisation of parathyroid adenomas. METHODS: Prospective data were collected on consecutive patients undergoing surgery for primary hyperparathyroidism at a single tertiary centre from November 2019 to June 2021. Patients underwent blinded, surgeon-performed ultrasound scan under general anaesthesia immediately prior to surgery. Localisation results from pre-operative imaging and surgeon-performed ultrasound scan were then compared with the intra-operative findings. RESULTS: Forty-nine patients underwent surgery and were found to have single-gland disease. Sestamibi scintigraphy, radiologist-performed ultrasound scan and surgeon-performed ultrasound scan had sensitivities of 59.4, 43.75 and 73.8 per cent, respectively. Surgeon-performed ultrasound scan had a statistically significantly increased sensitivity compared with radiologist-performed ultrasound (p < 0.05). CONCLUSION: Intra-operative, surgeon-performed ultrasound scan is effective in localising parathyroid adenomas and may be a useful adjunct to facilitate minimally invasive parathyroid surgery.

Safety of day-case paediatric tonsillectomy in England: an analysis of administrative data for the Getting It Right First Time programme.

We used the Hospital Episodes Statistics database to investigate unwarranted variation in the rates Trusts discharged children the same day after scheduled tonsillectomy and associations with adverse postoperative outcomes. We included children aged 2-18 years who underwent tonsillectomy between 1 April 2014 and 31 March 2019. We stratified analyses by category of Trust, non-specialist or specialist, defined as without or with paediatric critical care facilities, respectively. We adjusted analyses for age, sex, year of surgery and aspects of presentation and procedure type. Of 101,180 children who underwent tonsillectomy at non-specialist Trusts, 62,926 (62%) were discharged the same day, compared with 24,138/48,755 (50%) at specialist Trusts. The adjusted proportion of children discharged the same day as tonsillectomy ranged from 5% to 100% at non-specialist Trusts and 9% to 88% at specialist Trusts. Same-day discharge was not independently associated with an increased rate of 30-day emergency re-admission at non-specialist Trusts but was associated with a modest rate increase at specialist Trusts; adjusted probability 8.0% vs 7.7%, odds ratio (95%CI) 1.14 (1.05-1.24). Rates of adverse postoperative outcomes were similar for Trusts that discharged >70% children the same day as tonsillectomy compared with Trusts that discharged <50% children the same day, for both non-specialist and specialist Trust categories. We found no consistent evidence that day-case tonsillectomy is associated with poorer outcomes. All Trusts, but particularly specialist centres, should explore reasons for low day-case rates and should aim for rates >70%.

Pre-operative optimisation for chronic obstructive pulmonary disease: a narrative review.

Chronic obstructive pulmonary disease is a condition commonly present in older people undergoing surgery and confers an increased risk of postoperative complications and mortality. Although predominantly a respiratory disease, it frequently has extra-pulmonary manifestations and typically occurs in the context of other long-term conditions. Patients experience a range of symptoms that affect their quality of life, functional ability and clinical outcomes. In this review, we discuss the evidence for techniques to optimise the care of people with chronic obstructive pulmonary disease in the peri-operative period, and address potential new interventions to improve outcomes. The article centres on pulmonary rehabilitation, widely available for the treatment of stable chronic obstructive pulmonary disease, but less often used in a peri-operative setting. Current evidence is largely at high risk of bias, however. Before surgery it is important to ensure that what have been called the 'five fundamentals' of chronic obstructive pulmonary disease treatment are achieved: smoking cessation; pulmonary rehabilitation; vaccination; self-management; and identification and optimisation of co-morbidities. Pharmacological treatment should also be optimised, and some patients may benefit from lung volume reduction surgery. Psychological and behavioural factors are important, but are currently poorly understood in the peri-operative period. Considerations of the risk and benefits of delaying surgery to ensure the recommended measures are delivered depends on patient characteristics and the nature and urgency of the planned intervention.

Perioperative cardiopulmonary exercise testing (CPET): consensus clinical guidelines on indications, organization, conduct, and physiological interpretation.

The use of perioperative cardiopulmonary exercise testing (CPET) to evaluate the risk of adverse perioperative events and inform the perioperative management of patients undergoing surgery has increased over the last decade. CPET provides an objective assessment of exercise capacity preoperatively and identifies the causes of exercise limitation. This information may be used to assist clinicians and patients in decisions about the most appropriate surgical and non-surgical management during the perioperative period. Information gained from CPET can be used to estimate the likelihood of perioperative morbidity and mortality, to inform the processes of multidisciplinary collaborative decision making and consent, to triage patients for perioperative care (ward vs critical care), to direct preoperative interventions and optimization, to identify new comorbidities, to evaluate the effects of neoadjuvant cancer therapies, to guide prehabilitation and rehabilitation, and to guide intraoperative anaesthetic practice. With the rapid uptake of CPET, standardization is key to ensure valid, reproducible results that can inform clinical decision making. Recently, an international Perioperative Exercise Testing and Training Society has been established (POETTS www.poetts.co.uk) promoting the highest standards of care for patients undergoing exercise testing, training, or both in the perioperative setting. These clinical cardiopulmonary exercise testing guidelines have been developed by consensus by the Perioperative Exercise Testing and Training Society after systematic literature review. The guidelines have been endorsed by the Association of Respiratory Technology and Physiology (ARTP).

Pre-operative variables including fitness associated with complications after oesophagectomy.

Oesophagectomy is a technically-demanding operation associated with a high level of morbidity. We analysed the association of pre-operative variables, including those from cardiopulmonary exercise testing, with complications (logistic regression) and survival and length of stay (Cox regression) after scheduled transthoracic oesophagectomy in 273 adults, in isolation and on multivariate testing (maximum Akaike information criterion). On multivariate analysis, any postoperative complication was associated with ventilatory equivalents for carbon dioxide, odds ratio (95%CI) 1.088 (1.02-1.17), p = 0.018. Cardiorespiratory complications were associated with FEV1 and pre-operative background survival (in an analogous group without cancer), odds ratios (95%CI) 0.55 (0.37-0.80), p = 0.002 and 0.89 (0.82-0.96), p = 0.004, respectively. Survival was associated with the ratio of expected-to-observed ventilatory equivalents for carbon dioxide and predicted postoperative survival, hazard ratios (95%CI) 0.17 (0.03-0.91), p = 0.039 and 0.96 (0.90-1.01), p = 0.076. Length of hospital stay was associated with FVC, hazard ratio (95%CI) 1.38 (1.17-1.63), p < 0.0001.

A survey of UK peri-operative medicine: pre-operative care.

The majority of UK hospitals now have a Local Lead for Peri-operative Medicine (n = 115). They were asked to take part in an online survey to identify provision and practice of pre-operative assessment and optimisation in the UK. We received 86 completed questionnaires (response rate 75%). Our results demonstrate strengths in provision of shared decision-making clinics. Fifty-seven (65%, 95%CI 55.8-75.4%) had clinics for high-risk surgical patients. However, 80 (93%, 70.2-87.2%) expressed a desire for support and training in shared decision-making. We asked about management of pre-operative anaemia, and identified that 69 (80%, 71.5-88.1%) had a screening process for anaemia, with 72% and 68% having access to oral and intravenous iron therapy, respectively. A need for peri-operative support in managing frailty and cognitive impairment was identified, as few (24%, 6.5-34.5%) respondents indicated that they had access to specific interventions. Respondents were asked to rank their 'top five' priority topics in Peri-operative Medicine from a list of 22. These were: shared decision-making; peri-operative team development; frailty screening and its management; postoperative morbidity prediction; and primary care collaboration. We found variation in practice across the UK, and propose to further explore this variation by examining barriers and facilitators to improvement, and highlighting examples of good practice.

Parathyroid ectopia: development of a surgical algorithm based on operative findings.

OBJECTIVES: To study the incidence of ectopic parathyroid adenomata from a single surgical series, and to devise a surgical algorithm from the results to follow when an adenoma cannot initially be located. METHODS: A retrospective review was conducted of prospectively collected data. The study comprised all patients who underwent parathyroidectomy between June 2001 and February 2008 under the care of the senior author. A systematic surgical protocol was developed for locating ectopic superior and inferior parathyroid adenomata based on the order of incidence identified from the database. RESULTS: Parathyroid ectopia occurs in approximately 10 per cent of hyperparathyroidism cases. It is more common in superior than inferior parathyroid glands. The most common superior location is the right retroesophageal position and the most common inferior location is within the left thymic remnant. CONCLUSION: Prospective data collection and subsequent analysis can be used to develop a systematic surgical protocol to aid the localisation of ectopic enlarged parathyroid glands in the surgical management of hyperparathyroidism.

Validation of long-term survival prediction for scheduled abdominal aortic aneurysm repair with an independent calculator using only pre-operative variables.

We observed survival after scheduled repair of abdominal aortic aneurysm in 1096 patients for a median (IQR [range]) of 3.0 (1.5-5.8 [0-15]) years: 943 patients had complete data, 250 of whom died. We compared discrimination and calibration of an external model with the Kaplan-Meier model generated from the study data. Integrated Brier misclassification scores for both models at 1-5 postoperative years were 0.04, 0.08, 0.11, 0.13 and 0.16, respectively. Harrel's concordance index at 1-5 postoperative years was 0.73, 0.71, 0.68, 0.67 and 0.66, respectively. Groups with median 5-year predicted mortality of 40% (n = 251), 18% (n = 414) and 8% (n = 164) had lower observed mortality than 114 patients with 70% predicted mortality, hazard ratio (95% CI): 0.58 (0.37-0.76), p = 0.0031; 0.30 (0.19-0.48), p = 1.7 × 10(-12) and 0.19 (0.13-0.27), p = 1.3 × 10(-10) , respectively, test for trend p = 5.6 × 10(-15) . Survival predicted by the external calculator was similar to the Kaplan-Meier estimate.

Cardiopulmonary exercise testing before and after blood transfusion: a prospective clinical study.

BACKGROUND: Cardiopulmonary exercise testing (CPET) is used to risk-stratify patients undergoing major elective surgery, with a poor exercise capacity being associated with an increased risk of complications and death. Patients with anaemia have a decreased exercise capacity and an increased risk of morbidity and mortality after major surgery. Blood transfusion is often used to correct anaemia in the perioperative period but the effect of this intervention on exercise capacity is not well described. We sought to measure the effect of blood transfusion on exercise capacity measured objectively with CPET. METHODS: Patients with stable haematological conditions requiring blood transfusion underwent CPET before and 2-6 days after transfusion. RESULTS: Twenty patients were enrolled and completed both pre- and post-transfusion tests. The mean (sd) haemoglobin (Hb) concentration increased from 8.3 (1.2) to 11.2 (1.4) g dl(-1) after transfusion of a median (range) of 3 (1-4) units of packed red cells. The anaerobic threshold increased from a mean (sd) of 10.4 (2.4) to 11.6 (2.5) ml kg(-1) min(-1) (P=0.018), a mean difference of 1.2 ml kg(-1) min(-1) (95% confidence interval (CI)=0.2-2.2). When corrected for the change in Hb concentration, the anaerobic threshold increased by a mean (sd) of 0.39 (0.74) ml kg(-1) min(-1) per g dl(-1) Hb. CONCLUSIONS: Transfusion of allogeneic packed red cells in anaemic adults led to a significant increase in their capacity to exercise. This increase was seen in the anaerobic threshold, and other CPET variables.

Double bypass for inoperable pancreatic malignancy at laparotomy: postoperative complications and long-term outcome.

INTRODUCTION: Between 4% and 13% of patients with operable pancreatic malignancy are found unresectable at the time of surgery. Double bypass is a good option for fit patients but it is associated with a high risk of postoperative complications. The aim of this study was to identify pre-operatively which patients undergoing double bypass are at high risk of complications and to assess their long-term outcome. METHODS: Of the 576 patients undergoing pancreatic resections between 2006 and 2011, 50 patients who underwent a laparotomy for a planned pancreaticoduodenectomy had a double bypass procedure for inoperable disease. Demographic data, risk factors for postoperative complications and pre-operative anaesthetic assessment data including the Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (P-POSSUM) and cardiopulmonary exercise testing (CPET) were collected. RESULTS: Fifty patients (33 men and 17 women) were included in the study. The median patient age was 64 years (range: 39-79 years). The complication rate was 50% and the in-hospital mortality rate was 4%. The P-POSSUM physiology subscore and low anaerobic threshold at CPET were significantly associated with postoperative complications (p =0.005 and p =0.016 respectively) but they were unable to predict them. Overall long-term survival was significantly shorter in patients with postoperative complications (9 vs 18 months). Postoperative complications were independently associated with poorer long-term survival (p =0.003, odds ratio: 3.261). CONCLUSIONS: P-POSSUM and CPET are associated with postoperative complications but the possibility of using them for risk prediction requires further research. However, postoperative complications following double bypass have a significant impact on long-term survival and this type of surgery should therefore only be performed in specialised centres.

Effects of low cardiopulmonary reserve on pancreatic leak following pancreaticoduodenectomy.

BACKGROUND: Postoperative complications are increased in patients with reduced cardiopulmonary reserve undergoing major surgery. Pancreatic leak is an important contributor to postoperative complications and death following pancreaticoduodenectomy. The aim of this study was to determine whether reduced cardiopulmonary reserve was a risk factor for pancreatic leak. METHODS: All patients who underwent pancreaticoduodenectomy between January 2006 and July 2010 were identified from a prospectively held database. Data analysis was restricted to those who underwent cardiopulmonary exercise testing during preoperative assessment. Pancreatic leak was defined as grade A, B or C according to the International Study Group on Pancreatic Fistula definition. An anaerobic threshold (AT) cut-off value of 10·1 ml per kg per min was used to identify patients with reduced cardiopulmonary reserve. Univariable and multivariable analyses were performed to identify other risk factors for pancreatic leak. RESULTS: Some 67 men and 57 women with a median age of 66 (range 37-82) years were identified. Low AT was significantly associated with pancreatic leak (45 versus 19·2 per cent in patients with greater cardiopulmonary reserve; P = 0·020), postoperative complications (70 versus 38·5 per cent; P = 0·013) and prolonged hospital stay (29·4 versus 17·5 days; P = 0·001). On multivariable analysis, an AT of 10·1 ml per kg per min or less was the only independent factor associated with pancreatic leak. CONCLUSION: Low cardiopulmonary reserve was associated with pancreatic leak following pancreaticoduodenectomy. AT seems a useful tool for stratifying the risk of postoperative complications.

Decreasing delays in urgent and expedited surgery in a university teaching hospital through audit and communication between peri-operative and surgical directorates.

National Confidential Enquiry into Patient Outcome and Death guidelines for urgent surgery recommend a fully staffed emergency operating theatre and restriction of 'after-midnight' operating to immediate life-, limb- or organ-threatening conditions. Audit performed in our institution demonstrated significant decreases in waiting times for urgent surgery and an increased seniority of medical care associated with overnight pre-operative assessment of patients by anaesthetic trainees. Nevertheless, urgent cases continued to be delayed unnecessarily. A classification of delays was developed from existing guidelines and their incidence was audited. The results were disseminated to involved directorates. A repeat of the audit demonstrated a significant decrease in delays (p = 0.001), a significant increase in the availability of surgeons (p = 0.001) and a significant decrease in the median waiting time for urgent surgery compared to the first audit cycle and a previous standard (p < 0.01). We conclude that auditing delays and disseminating the results of the audit significantly decreases delays and median waiting times for urgent surgery because of improved surgical availability.