M&M

Analysis of the unit’s morbidity and mortality is a very important quality improvement process. There is a database on the shared (S Drive) to record this information. The consultants/registrars will tell you which patients need to be added to this database which will be presented in regular audit meetings throughout the year.

TCI (To Come In) Patients

The Ward Clerk will usually warn the juniors if there are any TCI patients that day. These are elective patients who require:

· Full clerking including examination (incl. peripheral pulses)- the ward has a new clerking proforma in circulation

· Bloods including a coagulation screen and 2x G&S (If pt has a blood bank history at COCH only one pink bottle is needed) and a cannula

NB. Be cautious when cannulating/bleeding bypass patients as, if their saphenous veins are unsuitable, they will often have their cephalic/basilic veins harvested. Check with seniors before proceeding.

· ECG

· Ensure they are consented by a senior

· Cross-match any units of blood they may require

· Prescribe regular meds

· VTE- fill out green form

NB. Please prescribe the appropriate dose of Tinzaparin as per weight. TEDs are often not appropriate for vascular patients as PVD is a contraindication.

If Pt. is usually Warfarinised e.g. for multiple PEs/DVTs, check the patient doesn’t need to be on Tx dose Tinz (i.e. 175 unit/Kg) as they will need bridging Tinz when you re-load them on warfarin between post-op and discharge.

If on warfarin for AF, prophylactic dose Tinz is adequate.

NB. Enoxaparin for renal Pts.

· Analgesia is important for vascular patients as they are often in a lot of rest pain- don’t be afraid to use regular zomorph (e.g. 20mg BD) and prn oramorph (10mg 1-2 hrly) alongside the usual paracetamol, codeine/tramadol etc. (Follow amputation pathway for patients coming in for elective amputation)

NB. If pain control is troublesome, the Pain nurse is happy to advise. Ask nurses to refer to pain team.

· PRN anti-emetics

NB. IR at COCH do not do angioplasties/CTAs on patients on Clopidogrel (should be stopped 7 days before- they should have been told this at pre-op)

NB. Emergency admissions from Chester, the Wirral or Warrington are admitted via the Registrar of the week from A&E or GPs and go under the VCOW unless already known to one of the surgeons. If admitted during normal working hours, the juniors will usually perform all of the above as though they are a TCI.

Discharge Summaries

Every in-patient requires a detailed discharge summary. This is particularly important for a tertiary centre when the discharge summary may be the only information the consultant has about that patient’s stay.

All discharge summaries should be checked by the Registrar/Consultant of the week and ask if you are unsure about any aspects of their management.

e.g. 75 YO male admitted with Left critical limb ischaemia. Background of IHD, AF on warfarin etc.

Include the results of any investigations they have had, typically CT peripheral angiogram (CTA), potentially an echo, CT head etc.

Any medications that have been stopped e.g. ramipril stopped due to AKI should be included and in the recommendations/comments put a note to the GP i.e. consider re-starting with regular U&E checks.

Any additional tasks should go in the recommendations/comments e.g. vein mapping to be arranged as an OP, Dual anti-platelets to continue for 6 weeks etc.

When it comes to follow-up, it is useful to ask the patient where they are from i.e. COCH, Arrowe park (APH) or Warrington (WGH) and if they are known to any consultant. Also any other professionals who have seen the patient may want to follow them up e.g. osteomyelitis sometimes have vascular and orthopaedic follow-up. Equally, a post-op stroke may be followed up by the stroke team or poorly controlled diabetes may need to be followed up at the appropriate local diabetes clinic.

NB. The patient is not automatically followed up by the VCOW. Sometimes if they are an emergency patient (known to no one) and the VCOW doesn’t work in their area, you may have to write “F/U with any Warrington consultant in 6-8 weeks”.

Discharging patients on warfarin

· Before discharging a patient on warfarin you need to ensure they have an appointment to get their INR checked

· It is usual procedure to get them an appointment at a hospital anti-coagulation clinic as some GPs are not happy to dose patients

· Referral to the COCH clinic is on the back of the yellow warfarin chart- fill it out and run it down to the clinic to get an appointment time

· Warrington and Arrowe park have referral forms that need to be faxed across to them, you can then ring and chase an appointment prior to discharge

· Very rarely, a patient goes to the GP/a district nurse who will do their bloods and the GP will dose them. You can ring the practice directly to ensure this is the case.

Regardless of how it happens all patients discharged on warfarin need to have arrangements made for them to have their INR checked.

Important protocols

Diabetes and surgery

A summary of the guidance available on the intranet (search under “Diabetes and Surgery”) Please check this information is the latest clinical guidance

There is little evidence that strict glycaemic control is necessary and therefore bloods glucose should be kept between 4 and 12mmol/l.

The junior doctors largely prescribe the insulin on the wards and responsibility to maintain BMs 4-12 falls on their shoulders. Although the diabetes specialist nurse (DSN) is happy to advise, they should not be relied upon for day-to-day adjustments in insulin. The DSN Bleep is 2796.

Professionals referring patients for surgery should make sure they have a HbA1c <69mmol/mol and if control is worse than this, they should refer to the diabetes specialist team.

The perioperative plan for their diabetes treatment should be discussed with the patient to allay anxieties i.e. what is the anticipated starvation period, changes to their usual insulin and peri-operative treatment i.e. GKI or VRIII.

Ideally diabetics should be first on a theatre list and should not have an overnight stay prior to surgery where possible.

Graft surveillance and graft failure

Post-bypass, patients will have graft surveillance with regular duplex scans as an OP. Failure of the graft is particularly important for autologous vein grafts.

There are 3 major time periods for graft failure:

· Immediately within 30 days- due an unrecognised hypercoagulable state, technical complications, inadequate inflow etc.

· 30 days to 1 year: usually due to myointimal hyperplasia within a vein graft

· Late graft failure usually due to progression of atherosclerotic disease

Typical graft surveillance

· Peri-operative

· 6 weeks post-op

· 3 monthly for 1 years

Prognosis

Patients presenting with critical limb ischaemia, at one year 25% will have an amputation and 25% will have a fatal CV event. Prognosis is worst amongst smokers and diabetics.

Guidance for juniors

· Once the decision to bypass is made, the patient will need the usual pre-op work-up i.e. bloods including a coagulation screen and a G&S, they will also need an ECG. The consultant will also ask you to arrange vein mapping on MEDITECH via CRV Vasc US

· Do not give these patients TEDS stockings

· Avoid cannulating veins that the surgeons will use- ALWAYS ask

· Ensure patients are on a statin and an anti-platelet

· Surveillance will be arranged by the surgeon in OP clinic

Angioplasty

Some of these patients will require re-hydration prior to IV contrast- see the summary of the protocol above or on the intranet.

If any of these patients require an inpatient stay, it is important to check their groin wounds for haematomas/signs of infection.

NB. Check the note from IR, if they have a stent in situ then the patient may require dual antiplatelets. Dual antiplatelets are given only for a specified duration. Following this, usually aspirin is stopped and clopidogrel is continued. Please check with the consultant on the duration of dual- antiplatelets. It is extremely rare that antiplatelets and anticoagulants are prescribed together. Enquire about the need for Lansoprazole.

NB. There is an interaction between omeprazole and clopidogrel so Lansoprazole is favoured on ward 54.

Amputation

As of October 2015, we have an amputation pathway that should be commenced once the decision has been made for the patient to have a major amputation i.e. BKA, TKA, AKA. You should document the notes from the ward round in the booklet and not in the normal notes. Sign the front of the booklet so everyone knows has initialled to say things have been done. Compliance with this booklet is audited so please fill it out accurately. The idea behind the booklet is to enhance communication between medical and allied health professionals with a view of expediting discharge. It also acts as a useful reminder to comply with the analgesia required (as described above).

Abdominal aortic aneurysm repair (AAA)

An AAA is a focal, full-thickness dilation of the aorta >50% greater than its normal diameter. The infra-renal section of the aorta is the most common site, where a diameter of >3cm is considered aneurysmal. An AAA can be repaired as an emergency or as an elective case. Patients can undergo an open or an endovascular repair (EVAR). The goal of aneurysm surveillance and repair is to prevent death from rupture of the aneurysm whilst also minimising the morbidity and mortality associated with repair. An open repair has a higher peri-operative mortality (3-5%, compared with 0.5-2% for EVAR) but provides a more definitive repair. Decision for Open vs EVAR is made on a patient-by-patient basis taking into account patient co-morbidities, age, anatomy, life expectancy etc.

Indications for intervention:

· >5.5cm asymptomatic AAA

· Rapidly expanding >1cm/year or >0.5cm/6months

· Symptomatic AAAs; these usually present with pain and may indicate imminent rupture/ rapid expansion/compression of surrounding structures/inflammation

NB. It is important to optimise CV risk factors in these patients, including smoking cessation.

NB. National AAA screening: a single USS scan is offered to men when they reach their 65^th birthday. Men with an aorta >4cm in diameter are recruited to the AAA surveillance program. Surveillance for AAAs generally involves an USS/CT every 6-12 months for aneurysms 4-5.4cm.

Useful contacts

Countess of Chester Hospital

To bleep someone: dial 82+ bleep + extension

VCOW VoIP 3800

On-Call SpR Bleep 3453

COCH Vascular Secretaries

Nicola Price x5465

Sec to DIMS