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Scoping our
Practice
The 2004 Report of the National
Confidential Enquiry into Patient
Outcome and Death
Elements of the study
• Deaths within 30 days of a therapeutic
endoscopy
• Complications (incl. death) following
upper GI dilation and tubal prosthesis
insertion (includes denominator data)
• Organisational questionnaire
GI therapeutic endoscopy - method
• All deaths April 2002 - March 2003
reported to NCEPOD
• Sample cases identified by OPCS
codes and included if death occurred
within 30 days of procedure
• Retrospective data - questionnaires
and case note extracts
Data overview
Patient assessment
Patient assessment
• 91% admitted as emergencies
• 76% had 2 or more comorbidities
• 74% of deaths were either a ‘definite
risk’ or ‘expected’
Patient assessment
• 86% of procedures were appropriate
• 83% of procedures were timely
• 9% of procedures were either futile or
too late to be of any benefit
Recommendation
Patients must be assessed by the
referring clinician and the endoscopist
to justify that the procedure is in the
patient’s interest. (Professional specialist
associations)
Training and education
Training and education
Experience
• 74% of procedures performed by
consultants, some doing less than
20/ year
• 94% appropriate grade
• 91% appropriate experience
Training and education
Supervision
• 88% - senior endoscopist in hospital
• 18% - direct supervision
Audit
• 78% of procedures in hospitals that
held audit meetings
• 26% of cases reviewed
Recommendations
There should be national guidelines for
assuring continuing competency in
endoscopy. (Professional specialist
associations)
All endoscopy units should perform
regular audit and all deaths during, or
within 30 days of, therapeutic
endoscopy should be reviewed. (Local
hospitals; Professional specialist associations)
Recommendations (cont.)
All those responsible for the
administration of sedation should have
received formal training and
assessment. (Local hospitals)
Patient consent
Consent
Consent
Recommendation
The risks and benefits of therapeutic
endoscopy should be explained to the
patient, and this should be
documented on the consent forms as
laid down in the Department of Health
guidelines. (Local hospitals)
Consent
16% of patients studied had dementia or acute
confusion
Recommendation
The ability of those with dementia or
acute confusion to provide consent
should be tested and clearly
documented. (Local hospitals)
Sedation and monitoring
Sedation and monitoring
Sedation and monitoring
• 14% of patients received inappropriate
sedation
• 14% of those that received sedation
required a reversal agent afterwards
A patient with severe alcoholic liver disease,
Childs-Pugh C, and bacterial peritonitis had
undergone previous gastroscopies for
bleeding. Bleeding continued and an
endoscopist who had received training in
sedation, performed what was the patient’s
second gastroscopy in two days. Sedation
comprised IV midazolam 5mg and further IV
midazolam 2mg. Pulse oximetry was
recorded as 87-91% during the whole of the
procedure and flumazenil was used to
reverse the effects of midazolam following
it.
Sedation and monitoring
A patient was admitted with an acute
inferior myocardial infarction. Four weeks
later the patient suffered a large
haematemesis, became hypotensive and
their haemoglobin decreased by 2.5 gm/dl. A
CVP line was inserted to monitor
resuscitation. The next day an endoscopy
was performed and adrenaline was injected
into two large gastric ulcers. Pulse oximetry
and automatic blood pressure were
monitored, but ECG was not.
Sedation and monitoring
Recommendations
Sedation and monitoring practices
within endoscopy units should be
audited and reviewed. (Local hospitals;
Professional specialist associations)
There should be national guidelines on
the frequency and method of the
recording of vital signs during the
endoscopy. (NPSA; Professional specialist
associations)
Recommendations (cont.)
Clear protocols for the administration
of sedation should be available and
implemented. (Local hospitals)
Percutaneous endoscopic
gastrostomy (PEG)
PEG
Indication
• Neurological disorders of swallowing
• Cognitive impairment/depressed
consciousness
• Mechanical obstruction to swallowing
• Long-term partial failure of intestinal
function requiring supplemental intake
PEG
Profile
• In 59% of cases the indication included
acute neurological disease
(stroke/trauma)
• 82% were  70 years of age
• 84% were ASA 3 or poorer
• 95% were elective/scheduled
procedures
PEG
Patient selection and timing
• 19% of PEG procedures were thought
to be futile
• 40% had a co-existing diagnosis of
chest infection
• 18% had dementia
• 43% died within 7 days
In one case where a patient was over 90
years-of-age an advisor commented:
“The PEG placement was technically OK - but
the timing was wrong. The patient was very
ill, dehydrated and had pneumonia. They
should not have had a PEG at this time and
died six days later. There is no information
about the last few days of life.”
Recommendations
The decision to use a PEG feeding tube
requires an in-depth assessment of the
potential benefits to the individual. All
patients in whom PEG feeding is
proposed should be reviewed by a
multidisciplinary team. (NICE)
There is a need for more
comprehensive national guidelines for
the use of PEG feeding, including
issues of patient selection. (NICE)
Endoscopic retrograde
cholangiopancreatography (ERCP)
ERCP
Profile
• 82%  70 years of age
• 77% were ASA 3 or poorer
• 87% received prophylactic antibiotics
• 68% were considered futile
ERCP
Procedure
• 97% performed by consultants
• 11% of cases by endoscopist who
performed < 50 ERCPs/year
• 92% involved the biliary tract
ERCP
Complications
• In 9% of cases during the procedure
• 64% of patients had one or more
complications in the 30 days following
ERCP
Recommendation
Patients should be reviewed by the
consultant endoscopist before
therapeutic ERCP to ensure that the
procedure is appropriate and the
patient’s condition has been
optimised. (Local hospitals)
Oesophagogastroduodenoscopy
(OGD)
OGD
Profile
• 44% of sample cases
• 61%  70 years of age
• 44% bleeding varices
• 35% stricturing disease in oesophagus
• 20% ulcer disease
OGD
Treatment
• sclerotherapy, coagulation, banding
Complications
• haemorrhage, respiratory and cardiac
Upper GI haemorrhage
Upper GI haemorrhage
• 86% needed emergency/urgent
endoscopy
• In 89% of cases there was a definite or
expected risk of death
• 94% of endoscopists were GI
specialists
• 25% had both topical anaesthesia and
intravenous sedation
Upper GI haemorrhage
• 92% of cases were appropriate and
timely and in the correct location for
both procedure and recovery
• 73% had good ‘overall’ care
• clinical factors
• organisational factors
An elderly patient with cirrhosis (no cause
stated) and ischaemia related biventricular
failure presented with a haematemesis that
was not considered to be severe by the
admitting clinician as the “urea is only 6.5”.
The patient was tachypnoeic, tachycardic
and hypotensive. Before endoscopy, the
patient did not receive either supplemental
oxygen or intravenous fluids - which in view
of the cardiac condition should have been
governed by central venous monitoring.
Recommendations
Only experienced endoscopists should
treat patients with upper GI
haemorrhage. Experience will vary by
grade but competence should be
assessed by the supervising consultant.
(Local hospitals)
Recommendations (cont.)
Optimising the patient’s preendoscopy condition will reduce both
morbidity and mortality. Early
involvement of an
anaesthetist/intensivist if necessary will
assist this. (Local hospitals)
Pathology
Reporting deaths to the coroner and
autopsy rates
Total autopsies - 144 (8% of all deaths)
Autopsy rates comparison
NCEPOD study
England & Wales
national averages - all
deaths
• 38% deaths
• 27% deaths
reported
reported
• 30% accepted for • 58% accepted for
autopsy
autopsy
Evaluable autopsy reports
• Clinical history present in 86% of
cases (increase on previous NCEPOD studies)
• Gross description ‘satisfactory’ or
better in 89% of cases (increase)
• Histology taken in 37% of cases
(increase)
• Clinico-pathological summary absent
or poor in 44% of cases (same)
ONS cause of death formulation
• 1a. Disease, due to
• 1b. Disease, due to
• 1c. Fundamental pathological cause of
death
• 2. Other diseases contributing to
death, but not the main cause
ONS
• Wrong structure = 13%
• Wrong cause of death = 34%
Main deficiencies in cause of death
• Omitting the operative procedure
• Lazy thinking on sequence of events
• Leaving out fundamental pathology (e.g. cancer)
• Attributing death to ‘ischaemic heart disease’
instead - convenient but probably not true
In an otherwise excellent report, including
histology, of a patient who died of
cholangiocarcinoma, and who also had
documented 60-70% stenoses of the
coronary arteries, the cause of death was
stated to be:
1a. Myocardial insult due to anaemia
following ERCP (August 2002)
1b. Ischaemic heart disease
Better would be:
1a. Cholangiocarcinoma (ERCP August 2002)
2. Ischaemic heart disease
Recommendations
The operative procedure should be
included in the cause of death
statement. (Undergraduate and postgraduate deans; ONS)
Post-procedure deaths (i.e. those
occurring during or within 24 hours of
anaesthesia or sedation or those where
it is known that the procedure is
implicated in the death) should be
reported to the coroner. (Local hospitals)
Recommendations (cont.)
Pathologists should think more
carefully about all the clinical
circumstances of a death, to produce
an autopsy report more useful for
clinical governance and audit.
(Professional specialist associations particularly
the Royal College of Pathology)
NCEPOD supports the reforms of the
coronial and death certification
systems, which will result in better
scrutiny of deaths. (Home Office)
Additional recommendations
Organisational issues
Hospitals should ensure that the
appropriate monitoring equipment and
resuscitation equipment is available in
each of their endoscopy rooms and
recovery areas. (Local hospitals; Primary Care
Trusts)
In order to produce optimal care for
what is a large group of severely ill
patients, hospitals should consider
establishing formal on-call
arrangements. (Local hospitals)
Upper GI dilation and tubal
prosthesis insertion
A national audit across all specialties of
specific techniques and equipment
that is used for upper GI dilation and
tubal prosthesis insertion is indicated.
(NPSA)
The future for NCEPOD
Changes
•
•
Responsibility for the confidential
enquiries passed from NICE to the
NPSA -April 2005
Bulletin board
Studies in progress
•
•
•
•
•
Medical admissions into intensive
care - May 11th 2005
Abdominal aortic aneurysms (Oct ‘05)
Emergency admissions (Oct’ 06)
Coronary artery bypass grafts
Sickle cell and thalassaemia
Studies in progress (cont.)
•
•
Severely injured patients
Coronial autopsies