National Audit Projects undertaken by ACTACC.
Audit Status: Active
Audit Start Date: March 2024
Audit End Date: March 2025
Post-operative cardiogenic shock is seen in 2% - 6% of all patients undergoing cardiac surgery, and is associated with increased morbidity and mortality. Temporary mechanical circulatory support (tMCS) is often used in combination with vasoactive drug therapies in the perioperative management of cardiac surgical patients with low cardiac output state, including intra-aortic balloon pump (IABP), veno-arterial extracorporeal membrane oxygenation (V-A ECMO), and Impella® transvalvular microaxial flow catheters. There is a lack of prospective data on use of tMCS in cardiac surgery in the UK. Our survey will be followed by a 12 months audit on MCS in cardiac surgery to investigate prospectively current MCS usage and patient-centred outcomes
Project Lead
Dr Benjamin Milne & Professor Gudrun Kunst, St Thomas’ Hospital & King’s College Hospital, London
Audit Status: Closed
Audit End Date: January 2024
Vasoplegic syndrome (VPS) is a relatively common condition that can occur during or after cardiac surgery. There is currently, a lack of evidence, characterising the epidemiology of vasoplegic syndrome in the UK population and the most commonly used treatment options.
Project Lead
Dr Carlos Corredor
Audit Status: Closed
Audit End Date: 2020
Proposal
The quality of non-specialist hospital care and inter-hospital transfer of patients with acute type A aortic dissection.
- Does the quality of care of patients with acute type A aortic dissection have any impact on outcome?
- Does the inter-hospital transfer of patients with acute type A aortic dissection meet current guidelines on the transfer of critically ill patients?
- What are the barriers to delivering appropriate care to patients with acute type A aortic dissection prior to transfer to a specialist centre?
- Can the care to patients with acute type A aortic dissection be improved?
- What additional resources are required to improve the care of patients with acute type A aortic dissection?
Rationale
A recent report by the Healthcare safety investigation board report – Transfer of Critically Ill Adults (HSIB I2017/002A; 2019 36 pages) – focused on the care of a previously fit 54-year old man who presented to his local hospital with acute severe chest pain.
More than three hours after admission to the Emergency Department, dissimilar upper limb blood pressures prompted a chest CT which revealed type A aortic dissection. It took a further two hours to organise ambulance transfer to a specialist centre. There was no medically qualified escort. Invasive blood pressure monitoring was not used. The ambulance crew mistakenly believed that the patient had an abdominal aortic aneurysm. The patient suffered a cardiorespiratory arrest a short distance into the transfer and could not be resuscitated.
The HSIB found that:
- There was a lack of national guidance to assist clinicians during time-critical transfers of level two and three patients (the most critically ill).
- There are no consistent guidelines for the transfer of critically ill patients for both emergency and planned situations.
- There was variation in how Critical Care Operational Delivery Networks, whose role is to coordinate patient pathways between healthcare providers, are set up and governed, with a lack of consistent oversight.
- Ambulance pre-alerts have evolved from their original intent and become mini-handovers with a lack of consistent structure and guidance.
The HSIB recommended that:
- The Department of Health and Social Care should co-ordinate the development of national guidance, with the arm’s length bodies, for the transfer of critically ill adults, both in planned and emergency situations.
- The Association of Ambulance Chief Executives should work with partners to define best practice standards for the criteria, format, delivery and receipt of ambulance service pre-alerts.
Personal Experience
In the last 20 years, it is my perception that the care of patients with acute type A aortic dissection has not improved. The diagnosis is often made by exclusion and is typically delayed. Documentation suggests that physical examination is often incomplete – i.e. measurement of blood pressure in both arms and auscultation of the heart.
Specialists in resuscitation and advanced monitoring (i.e. anaesthetists and intensivists) are often not involved in decision-making until the point of ambulance transfer. Many hospitals are unable or unwilling to send a suitably trained and competent anaesthetist as an escort during transfer. Invasive arterial blood pressure monitoring, and active blood pressure management are rarely undertaken.
Current practice is effectively a form of triage – trial by transfer.
In 2018, The Royal College of Emergency Medicine in collaboration with Aortic Dissection Awareness UK, Heart Research UK and the Society for Cardiothoracic Surgery in Great Britain and Ireland, launched the “Think Aorta” campaign to highlight the importance of considering aortic dissection in pains with central chest pain maximal at onset.
Project Lead
Dr Joe Arrowsmith
Collaborators
Professor Gudrun Kunst
Links
Audit Status: Closed
Audit End Date: 2017
Complications Related to Perioperative Transoesophageal Echocardiography – A One‐Year Prospective National Audit
Previous studies on the safety of peri‐operative transoesophageal echocardiography seem to suggest a low rate of associated morbidity and mortality. The purpose of this national audit project was to determine the rate and severity of complications associated with perioperative transoesophageal echocardiography in anaesthetised cardiology and cardiac surgical patients.
Preliminary results were presented at the joint EACTA-ACTACC meeting held in Manchester in September 2018.
Final results were published in the journal Anaesthesia in 2019.
Project Lead
Dr Joe Arrowsmith
Collaborators
Professor Gudrun Kunst
Links
Audit Status: Closed
Audit End Date: 2015
Over 8500 lung resections take place in the UK each year. A great deal of research has been carried out examining specific complications e.g. atrial fibrillation or lung injury, but comparatively little work has addressed the need for intensive care following lung resection.
Pilot data from our own institution, in addition to published reports from single and multicenter studies, indicate that 2.4-18% of patients undergoing lung resection require unplanned intensive care post-operatively. This suggests that between 204 and 1530 patients may be admitted (unplanned) to intensive care following lung resection surgery each year in the UK. Intensive care admission carries high mortality in this population and increases the burden on both patients and facilities, lengthening hospital stay and leading to increased healthcare costs.
Little is known about this population:
Who are these patients? How many patients are there? Why do they get admitted to intensive care? What is their prognosis? Crucially, what can we do to reduce the need for post-operative intensive care?
Project Lead
Dr Ben Shelley
Collaborators
Dr Philip McCall
Dr Alistair Macfie