Annual Report 2013

General anaesthetics, Neuraxial blocks and Regional blocks administered in public hospitalsin Ireland in 2013 and captured in HIPE

May 2016

HEALTHCARE

PRICING

OFFICEClinical Strategy and Programmes Division

National Clinical Programmefor Anaesthesia

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Contents

Page

Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5

Part 1: Principal Data for 2013 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

Part 2: Supplementary data for 2013 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10

Part 3: Proposed Audit Projects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12

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Foreword

This is the first annual report on anaesthetic activity in Ireland describing the number of generalanaesthetics, neuraxial blocks and regional blocks administered in public hospitals in Ireland during2013 and recorded in the Hospital Inpatient Enquiry (HIPE) system. Procedures carried out under

local anaesthesia or sedation are not included but there are plans to include them in future reports. Thesedata were gathered as part of the much wider and longstanding exercise conducted using HIPE data andcollated and analysed by the Healthcare Pricing office (HPO), and formerly by the Economic and SocialResearch Institute, (ESRI). This annual report follows on from the report of the Audit Work Stream Projectof the National Clinical Programme for Anaesthesia (NCPA) which was published in May 2015.1

This report describes the number and type of anaesthetics administered, and also gives details of the age,gender and ASA status of patients as well as the urgency of the procedure and an overview of the clinicalareas of the surgical procedure as described by the Australian Classification of Health Interventions (ACHI)2.

For HIPE, the primary source of information is the patient’s hospital record and the anaesthetic record sheetis the primary source of information concerning anaesthesia. The importance of accurate completion ofanaesthetic record sheets cannot therefore be over stated.

The workload of anaesthetists is far greater than the anaesthetics they administer. For example IntensiveCare, Pre Admission clinics, ward rounds, teaching and administration and other duties all form part of thework routinely carried out by anaesthetists of all grades. The number and type of anaesthetics administeredis only part of a much larger picture but it is a very important part and one which is currently not beingreported on.

The purpose of this report is therefore to try to establish a regular and reliable account of the number andtype of anaesthetics administered in public hospitals in Ireland each year and to give a simple demographicoverview of the patients to whom these anaesthetics are administered.

Collecting and examining such data also provides an opportunity for carrying out simple audit projectssuch as assessing the accuracy and completeness of anaesthetic record sheets. Two entities, the patient ASAstatus and the elective or emergency nature of the procedure, have already been identified as suitable topicsfor audit.

The authors of this report would like to continue the project into the future but the success of this endeavourdepends to a considerable degree on the support and feedback from clinicians around the Country. Forsuch reports to be meaningful the data should be complete, accurate and up to date. The refined searchcriteria developed by the HIPE team at HPO have identified and corrected many potential errors but thesecriteria need to be continuously tested and updated. For this we need input from individual anaestheticdepartments that are willing and able to produce simple data in an IT format which can be compared withHIPE data for the same time period. The importance and value of future Annual Reports can only be assuredby continuously testing the quality of the data presented and the role of the NCPA Hospital Leads will bevital in this regard.

Conducting audit at a national level can be difficult and time consuming. The data contained in HIPEhowever has the potential to allow simple audits at national level to be carried out and reference has already

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been made to assessing the standard of completion of anaesthetic record sheets. Although HIPE data directlyrelating to anaesthesia are limited, they are of course connected to all the other pieces of patient datarecorded by HIPE so that information on day case admissions, day of surgery admissions, admissions toICU post anaesthesia or hospital readmissions are all areas of clinical practice that could be examined.

Information on sedation and local anaesthesia was specifically omitted in this report because of thedifficulties presented by the fact that many non anaesthetists administer local anaesthesia and sedation.Identifying work done exclusively by anaesthetists is possible but requires the use of consultant anaesthetists’codes contained in HIPE. This information can only be retrieved from individual HIPE offices, with thepermission of the relevant anaesthetic departments. The authors are determined to include this aspect ofanaesthetists’ work in future reports but a considerable amount of ground work needs to be done and thefirst priority is to ensure that data currently being presented are accurate and complete.

The importance of feedback and input from clinicians around the Country has already been alluded to. Thepart played by the College of Anaesthetists of Ireland is equally important. From the outset the College hasbeen hugely supportive and has worked closely with the NCPA and there is every reason to believe thatthis will continue.

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Introduction

The Hospital Inpatient Enquiry has been collecting information on day patients and inpatientsadmitted to public hospitals in Ireland since 19723. Information on anaesthesia, though limited, hasbeen collected since 2005 when Ireland introduced the Australian Classification ICD-10-AM (for

diagnosis) and ACHI (for procedures) for collection of morbidity data. We believe that six simple data fields(type of anaesthetic, ASA status, emergency/elective, patient age, gender, and category of the procedure)can yield useful information for the specialty of anaesthesia. Moreover, even simple data on anaestheticactivity at national level, provided they are complete and accurate, can provide a denominator against whichvarious quality and outcome indicators might be measured in the future.

Extracting this information in a consistent and reliable manner is not a simple task. In the first instance,HIPE describes data based on hospital discharge dates, therefore a simple request for general anaesthesiafigures for 2013 is generated from patient discharges for 2013. However, patients discharged in early January2013 may have had their anaesthetic in December 2012 but will appear in the 2013 figures. This “apparent”error, which is in fact a particular characteristic of the HIPE data set, may also occur in reverse at the endof the year.

In preparing this Annual Report for 2013, considerable work and expertise has gone into developing a setof search criteria which will overcome these and other “apparent” errors. These criteria will soon be availableas an IT programme so that individual HIPE offices and anaesthetic departments can retrieve data in amanner that is consistent and comparable for all users.

Even with the use of these refined search criteria, some data may require further examination.

For example, in the course of preparing this report, we discovered 790 anaesthetic procedures with nocorresponding surgical procedure on the same date. These were further examined and the vast majority(85%) proved to be anaesthetic procedures for maternity patients who had received epidural analgesia forpain relief during labour and/or delivery.

Other episodes included courses of treatment such as Electroconvulsive Therapy (ECT) where the courseof ECT is coded once only, regardless of the number of times ECT was administered. The anaesthetichowever, is coded every time it is administered for each ECT treatment. There were also occasions when ananaesthetic and a procedure were both performed but not on the same day. This can happen when theanaesthetic and the procedure are performed at either side of midnight causing the dates to differ, or it mayalso happen if the dates are not entered correctly. New checks and edits are being devised by the HIPE teamin the HPO to flag episodes where the anaesthetic and the surgical procedure do not occur on the samedate.

The information for 2013, based on the six data fields, is set out below in tables and charts along with somebrief comments. The number of anaesthetics administered for each data field heading is described(Anaesthetic Count), but for two data fields, Age and Gender, patient discharge numbers are given(Discharge Count).

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Anaesthetic TypeThe total number of anaesthetics administered is the sum of all three types of anaesthetic (Table 1 & Fig 1).This number (234,441) exceeds the total number of patient discharges who had an anaesthetic (223,175),for two reasons. Firstly, some patients had more than one anaesthetic technique at the same time, e.g. generalanaesthesia plus neuraxial block or general anaesthesia plus regional block, and secondly, some patientshad an anaesthetic on separate days during the same admission. The total number of “multiple” anaesthetics,(11,266), represents the difference between the anaesthetic count and the patient discharge count.

GenderThe predominance of female patients receiving anaesthesia (Table 2 & Fig 2) is explained by the largenumber of obstetrics patients, (see also Table 6). Interestingly, when the overall HIPE discharges for 2013are examined3, and maternity figures are excluded, the male to female ratio is almost exactly 1:1, soanaesthesia encounters a disproportionately higher number of female patients by virtue of our commitmentto obstetrics.

Part 1:

Principal Data for 2013

Table 1

Number of anaesthetics administered in2013 by anaesthetic Type

Anaesthetic Type Anaesthetic Count

General 173,564

Neuraxial Block 53,565

Regional 7,312_________

TOTAL 234,441

Table 2

Number of patient discharges reporting ananaesthetic procedure(s) in 2013 by Gender

Gender Discharge Count

Male 85,953

Female 137,582________

TOTAL 223,175

Fig 2

Percent of Patient discharges reporting ananaesthetic procedure(s) in 2013 by Gender

Fig 1

Percent of anaesthetics administered in2013 by anaesthetic type

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ASA StatusOn 80,086 anaesthetic record sheets, (34.2% of the total) HIPE data reports that no documentation of ASAstatus could be found (Table 3 & Fig 3). This is a serious omission but it can easily be corrected as allanaesthetic record sheets have a facility for recording ASA status. The process of correcting this omissionalso has great potential for a simple national audit project.

ASA 6 is not recorded in HIPE and this is dealt with later in the report.

Table 3

Number of anaesthetics administered in 2013 by patient ASA status

ASA status Anaesthetic Count

1 A normal healthy patient 76,699

2 A patient with mild systemic disease 56,537

3 Patient with severe systemic disease that limits activity 19,561

4 Patient with severe systemic disease that is a constant threat to life 1,433

5 A moribund patient who is not expected to survivelonger than 24 hours without surgical intervention 125

9 No documentation of ASA score 80,086 ________

TOTAL 234,441

Fig 3

Percent of anaesthetics administered in 2013 by patient ASA status

N = 234,441

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Emergency/ElectiveLess than 10% of anaesthetics are recorded as being for emergency procedures (Table 4 & Fig 4). This isclearly an error and is undoubtedly due to lack of information on the anaesthetic record sheet. Where“emergency” is not clearly indicated by the anaesthetist on the anaesthetic record sheet, HIPE coders addthe digit “9” to the anaesthetic code to indicate non-emergency or unknown. Since it is common practiceto describe the ASA status and the urgency of the procedure together, e.g. ASA 3E, errors in recording thesedata have a common origin so that efforts to correct them could form part of the same audit project.

Note: HIPE coders use the digit 0 to indicate “emergency” was indicated on the anaesthetic record sheetand the digit 9 if “emergency” was not indicated. A patient documented with an ASA status of 3 having anemergency procedure would be recorded in HIPE as 3 0. If neither the ASA status nor emergency wereindicated this would be recorded as 99.

Table 4

Number of anaesthetics administered in 2013 by Urgency of procedure

Emergency/Elective Anaesthetic Count

Emergency 22,188 Elective or not known 212,253

_________TOTAL 234,441

Fig 4

Percent of anaesthetics administered in 2013 by Urgency of procedure

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AgeThe largest age group is 26 to 35 years (Table 5 & Fig 5) with the majority of patients aged between 16 and65 years. The number of patients aged less than 16 is almost identical to the number of patients over sixtyfive with a ratio of 1.1:1. Considering the well documented rise in population age in recent years it will beinteresting to see how this figure changes in future reports.

Table 5

Number of patient discharges reporting an anaesthetic procedure(s) in 2013 by Age

Age categories (yrs) Discharge Count

Less than 1 yr 2,482

01 – 05 yrs 16,905

06 – 15 yrs 20,058

16 – 25 yrs 20,637

26 – 35 yrs 45,421

36 – 45 yrs 35,252

46 – 55 yrs 23,886

56 – 65 yrs 23,266

66 – 75 yrs 20,333

76 – 85 yrs 11,967Over 85 yrs 2,968

________TOTAL 223,175

Fig 5

Percent of patient discharges reporting an anaesthetic procedure(s) in 2013 by Age

N = 223,175

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Australian Classification of Health Interventions (ACHI)Procedures on the Musculoskeletal system, Obstetrics, the Digestive system and Gynaecology (Table 6)account for 62.7% of anaesthetics given.

19. Non-invasive, cognitive and other interventions, not elsewhere classified.*This Chapter includes therapeutic or diagnostic interventions without disruption of an epithelial lining or entry into a body partor cavity (e.g. lithotripsy, cardioversion).Procedures where the anaesthetic date and the procedure date do not coincide have been discussed above in the Introduction.**

Table 6

Number of anaesthetics administered in 2013 catergorised by Australian Classification ofHealth Interventions (ACHI)

Interventions Chapters Anaesthetic Count

1 Procedures on nervous system 5,278

2 Procedures on endocrine system 1,367

3 Procedures on eye and adnexa 7,230

4 Procedures on ear and mastoid process 4,643

5 Procedures on nose, mouth and pharynx 9,302

6 Dental services 5,595

7 Procedures on respiratory system 4,148

8 Procedures on cardiovascular system 8,672

9 Procedures on blood and blood-forming organs 1,294

10 Procedures on digestive system 35,713

11 Procedures on urinary system 9,376

12 Procedures on male genital organs 7,536

13 Gynaecological procedures 24,236

14 Obstetric procedures 40,141

15 Procedures on musculoskeletal system 46,834

16 Dermatological and plastic procedures 12,121

17 Procedures on breast 4,559

18 Radiation oncology procedures 839

19 Non-invasive, cognitive and other interventions, not elsewhere classified* 3,027

20 Imaging services 1,740

No procedure on same date as anaesthetic procedure** 790

TOTAL 234,441

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Part 2:

Supplementary data for 2013

ASA 6 not recorded in HIPE.

ASA 6 denotes a declared brain-dead patient whose organs are being removed for donor purposes. NeitherASA 6 nor the procedure of organ retrieval are recorded in HIPE for the simple reason that death is deemedto have occurred at the time of completion of the second set of brain stem tests.

However, anaesthesia involvement in organ retrieval is significant both in the intensive care unit and intheatre and ASA patient status, including ASA 6, can and should be routinely recorded on the anaestheticrecord sheet.

Since the information cannot be recovered from HIPE, we approached Organ Donation and TransplantIreland, (ODTI), formerly the National Organ Donation and Transplantation Office. The National OrganDonation and Transplantation Office was established in 2011 to provide governance, integration andleadership for organ donation and transplantation in Ireland. The figures below have been reproduced withthe kind permission of ODTI. The full report is available from the Health Services Executive web site,www.odti.ie

Organ Donation and Transplant activity for 2013

Total number of Organ Transplants 256*(excluding living donations)

Total number of Deceased Organ Donors 86*

{Non heart beating 6**

{Heart beating 80

*Ratio of donors to transplants: 3.4 : 182 Adult donors; 4 donors < 19 years old

**Figures from the ODTI Annual Report 2013 and refer to deceased organ donor rates for 2012

The figures from the ODTI Annual Report indicate that there were 80 patients with a diagnosis of brainstem death from whom organs were retrieved.

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Part 3:

Proposed Audit Projects

Patient ASA status

One of the interesting findings in phase 3 of the Work Stream Audit Project1 was the large number ofpatients, 33%, for whom the ASA status had not been recorded on the anaesthetic record sheet. A similarfinding appears in the data for 2013. Accurate completion of anaesthetic records is extremely importantand would be considered as “best practice”. The fact that such a high proportion of anaesthetic record sheetsfail to reach a best practice standard is disappointing, however, the ease with which this can be rectifiedgives reasonable cause for optimism. To the best of our knowledge all anaesthetic sheets currently in usehave a facility to record patient ASA status so that the simple expedient of ticking the appropriate box orcircling the appropriate number could eliminate this failing.

We are also aware that increasingly anaesthetic departments are moving to electronic anaesthetic recordplatforms. In such circumstances anaesthetic departments should ensure that the system is configured tomaximise compliance with current Anaesthetic Record Keeping Standards.5,6 In particular systems shouldbe configured so that users can easily enter ASA status and the emergent nature of surgery to facilitateNational Audit.

Emergency/elective

HIPE data for 2013 indicates that less than 10% of anaesthetics were recorded as administered in emergencysituations. This is clearly an error and would appear to be due to clinicians’ failure to indicate the urgencyof the procedure on anaesthetic record sheets. The situation is complicated somewhat by the fact that thereis no HIPE data field to capture “unknown” with regard to urgency of procedure (unlike ASA status wherethe digit 9 specifically indicated “unknown”) so that where “emergency” is not indicated on the anaestheticrecord sheet, the HIPE coder records this as “non-urgent/unknown” within the ACHI procedureclassification system. Nevertheless, the same arguments in favour of “best practice” regarding completionof anaesthetic record sheets also apply here and the steps required to correct the error are also simple i.e.ticking the appropriate box or using the format ASA 2E as appropriate.

Initiating and completing the audit cycle

The NCPA through its network of Hospital Leads has already begun the process of pointing out some ofthe deficiencies in anaesthetic record keeping and encouraging all anaesthetists to pay particular attentionto clearly indicating the patient ASA status and the urgency of the procedure on all anaesthetic record sheets.This communication process commenced at the beginning of September 2015 and while it is hoped thatclinicians began to change their practice immediately, the audit cycle proper commenced on October 1st2015 and finished on December 31st 2015. Provisional HIPE data relating to the final quarter of 2015 shouldbecome available by mid 2016 and a comparison with data from the final quarter of 2014 can then be madeand publicised. The same cycle can be repeated in the future

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Acknowledgements

The NCPA acknowledges the support and expertise of the following people and the institutions theyrepresent in preparing this report.

Healthcare Pricing Office Ms Jacqui Curley

Ms Deirdre Murphy

Ms Laura Metcalfe

Mr Shane McDermott

Mr Brian McCarthy

College of Anaesthetists of Ireland Dr Kevin Carson, President

Dr Ellen O’Sullivan, immediate past president

Dr Wouter Jonker, consultant anaesthetist, Sligo Regional Hospital

Organ Donation and Transplant Ireland Prof James Egan

Ms Ciara Norton

NCPA Working Group Members Ms Una Quill, NCPA Programme Manager

Ms Aileen O’Brien, NCPA Nurse Lead

Dr Jeremy Smith, NCPA National Clinical Lead

Dr Margaret Bourke

Dr Larry Crowley

Dr James Shannon

Dr John Cahill

References

1. Can HIPE be used as an audit tool for anaesthesia? National Clinical Programme for Anaesthesia Audit Work Stream ReportMay, 2015. Available at hse.ie/anaesthesia

2. National Centre for Classification in Health (NCCH), 2008: The Australian Classification of Health Interventions (ACHI)Tabular List of Interventions. Sydney: NCCH, Faculty of Health Sciences, The University of Sydney

3. Healthcare Pricing Office (2014) Activity in acute public hospitals in Ireland annual report 2013. Dublin. Health ServiceExecutive, Available at www.hpo.ie

4. Organ Donation and Transplant Ireland. Annual Report 2013. Available at www.odti.ie

5. Good Practice. A guide for departments of anaesthesia, critical care and pain management. RCA & AAGBI, Third edition2006

6. Raising the standard: A compendium of Audit Recipes (3rd edition 2012) RCA