GIRFT March 2018
- Examination of the 31 units providing cardiothoracic surgery in England suggests that smarter bed management and using designated specialist teams for key cardiothoracic surgery procedures will deliver better outcomes.
- The report found variation across the units in patient flow, clinical outcomes and risk management, lung cancer, video-assisted thoracoscopic surgery (VATS), aortovascular surgery and mitral valve repair.
- Appendix 2 highlights some of the processes, practices and measures that have led to positive patient outcomes matched with greater cost efficiencies at University Hospitals Bristol and University Hospital Southampton.
The report makes 20 recommendations and identify owners and a timeline for each one -
Patient pathways and bed management
1 Make day of surgery admission routine practice.
2 Ring-fence beds on ward and ITU for elective cardiothoracic surgery.
3 Establish regional work-up protocols for non-elective referrals.
4 Pool non-elective cases ready for next available theatre session and next available appropriate surgeon.
5 Ensure that every patient is reviewed by a consultant pre- and post-operatively – and that this happens seven days a week.
The role of risk management in clinical outcomes
6 Establish a formal Standard Operating Procedure on cardiothoracic data validation,risk adjustment, outlier identification, escalation plans and reporting for GIRFT metrics.
7a Use uniform draping technique in theatre
7b Use chlorhexidene skin preparation
7c Ensure that individual cases of deep sternal wound infection (DSWI) are reviewed by a multidisciplinary team, led by a consultant microbiologist.
8a Establish a national formal policy for complex and very high-risk cases.
8b Establish collective responsibility for clinical outcomes.
9 Attribute outcomes for complex and very high-risk cases to units rather than to individuals.
10 Record blood product transfusion rates for cardiac surgery.
Cancer pathway
11a Centralise and reduce the number of lung cancer multidisciplinary teams (MDTs).
11b Ensure that a thoracic surgeon is present at every lung cancer MDT.
12 Ensure that patients being treated with surgery for Stage 1 lung cancerreceive VATS orrobotic-assisted lobectomy as the treatment of choice.
Other pathways and treatment
13a Ensure that patients who do notrecoverfrom medical treatment of empyema within 5-7 days are assessed by a thoracic surgeon.
13b When possible, routinely use VATS rather than open operation to manage empyema.
Aortovascular surgery
14 Ensure that acute aortic syndrome patients are only operated on by rotas of acute aortic syndrome specialist teams.
Mitral valve surgery
15 Ensure that patients with degenerative mitral valve disease are only operated on by specialist mitral valve surgeons.
Trauma
16 Ensure that major trauma centres are covered by published rotas for both thoracic and cardiac trauma. Providers should end of the practice of using full-time, cardiac-dedicated surgeons to provide emergency thoracic surgery cover.
Coding
17 Review the list of complications and comorbidities for cardiothoracic surgery, so that only codes that are genuinely relevan tto the cost of treatment trigger a cc score in pricing, and thatthe HRG splits reflect an authentic variation in cost.
18 Increase collaboration between clinical cardiothoracic teams and coders by including coders in multidisciplinary team meetings (MDTMs) and morbidity and mortality meetings.
NICOR data quality
19 NICOR should work with providers to improve the quality of data submitted and stored, specifically for
• return to theatre
• deep sternal wound infection
• new CVA
• post-operative renal replacement therapy.
Litigation
20 Implement GIRFT 5 point plan for reducing litigation costs.
