Findings from the Vascular Surgical Services and Clinical Endarterectomy (Round 2) Audits now available

Background

Carotid Endarterectomy (CEA) is an operation performed in order to prevent stroke. It is carried out on people with narrowing of the neck arteries to remove a diseased area of the main blood vessel supplying the brain. Removing this diseased area helps to prevent small particles breaking off and passing up into the brain, one of the major causes of stroke. To maximise benefit, CEA should be performed as soon as possible after the patient experiences relevant symptoms, for example facial or arm weakness, speech problems, or loss or blurring of vision.

In the UK, CEAs are almost exclusively carried out by vascular surgeons. Vascular surgery is currently undergoing a period of major change. It has historically formed a subspecialty of general surgery, with vascular surgeons undertaking both general surgery and vascular work. Recent rapid advances in technology have driven changes in the treatment of vascular disease and it is now possible to treat conditions which have previously been considered too high risk for intervention. As a result, it has been necessary for vascular surgeons to become more specialised and to form partnerships with different specialties to provide the best treatment for patients.

An independent vascular specialty has emerged but regions are at very different stages of development. The organisational audit was planned to assess the organisation of services related to CEA for patients at risk of stroke or Transient Ischaemic Attack (TIA). At the same time, however, the Vascular Society was planning a quality improvement programme that required information about other organisational aspects of vascular services, and some vascular services were reorganising to fulfil the requirements for participation in the NHS Abdominal Aortic Aneurysm Screening Programme.

The remit of the audit was therefore expanded to examine all aspects of the organisation of vascular surgical services, not just those confined to carotid intervention. Because many of the issues which affect the delivery of a timely carotid service are common to other vascular interventions the decision was taken to present the results of the two audits simultaneously.

The audits aim to evaluate the current structure of vascular services within the UK in order to simulate improvement in the provision of such services. It provides a benchmark around the provision of vascular services regionally and nationally, identifies areas of vascular service which would benefit from further evaluation and guidance and provides baseline data for a quality improvement programme in vascular surgery.

This project was supported with central funding from the Healthcare Quality Improvement Partnership (HQIP). The project was carried out in conjunction with the Vascular Society of Great Britain and Ireland (VSGBI) and was supported by a multidisciplinary Steering Group.

Key findings from the Vascular Surgical Services 2009 Audit:

• At trust level, there were discrepancies between data self-reported to the audit and HES.
• A significant number of trusts undertook fewer than the recommended minimum number of complex cases each year.
• Over 80% of trusts had the recommended products for managing abdominal aortic aneurysm.
• 82% of trusts reported they perform endovascular aneurysm repair in a sterile environment.
• 78% of trusts reported that they were part of a vascular network, but there was a lack of clarity about what this involved. 53% reported the network had some audit or governance function.
• 98% of trusts have multi-disciplinary team meetings to discuss the appropriateness of surgical intervention but only 8% involve an anaesthetist regularly.
• 87% of trusts reported cancellation of elective vascular surgery within the last 12 months due to a lack of critical care beds. An estimated median of 6 cases per trust were cancelled.
• 86% of trusts admit patients to wards with experienced vascular nurses providing care

Key findings from the UK Carotid Endarterectomy Audit (Round 2)

• the median number of days from symptom to surgery 28 (IQR 12-64)
• the median number of days from symptom to referral was was 8 (IQR 3-26)
• the median number of days from referral to operation was 19 (IQR 7-47)
• when delay between symptom and surgery was more than 14 days, the main causes of delay included delay in referral (40%), lack of staff or operating time (18.2%), delay in patient presentation (18%) and operation cancellation as unfit or patient choice (15%), amongst others.