New carotid endarterectomy audit shows improvement in time to referral and intervention in the UK

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The Vascular Society of Great Britain & Ireland (VSGBI) and the Royal College of Physicians have released the UK Carotid Endarterectomy Audit Round 4. This fourth public report from the Carotid Interventions Audit demonstrates continuing improvement in the service that hospital teams provide to patients.

 

“The median time to intervention is still coming down and indicates a commitment to improving the quality of service within the NHS. There is much to be pleased with, but also much to do. Some hospitals are very good, treating nearly all patients within the NICE target of 14 days from the onset of symptoms. Others are not so good and need to improve their performance. A few are worryingly poor and the clinical teams and the executives of these organisations need to ask themselves if they are providing any benefit to their patients.

Serious consideration should be given to moving the service to adjacent better performing Trusts,” wrote David Mitchell, chair, Audit & Quality Improvement committee, VSGBI.

The audit includes operations performed between 1 August 2010 and 30 September 2011 by 98% of eligible NHS trusts in England, Northern Ireland, Scotland and Wales. It aims to assess the current speed of delivery of carotid endarterectomy in the UK, variations in access and quality of care for patients needing carotid endarterectomy, 30-day mortality and complications rates following carotid endarterectomy, and to stimulate improvements over time in the quality of care provided to patients undergoing carotid endarterectomy.

In the period audited, 5,543 carotid endarterectomy procedures were performed. Of these, 4,818 patients were symptomatic and 4,638 attended a follow-up appointment. In symptomatic patients, the main symptoms that triggered referral were transient ischaemic attack (47%), stroke (34%) and amaurosis fugax (loss of vision in one eye) (18%). The median number of days from symptom onset to carotid surgery was 15 (8–40), which is shorter than in the third report (1 October 2010 – 30 September 2010), when it was 21, and in the second report (January 2008–30 September 2009), when it was 28. The median number of days from symptom onset to referral was five (2–14), against six in the third report and eight in the second report; and the median number of days from referral to carotid surgery was nine (4–23) – this was 12 in the third report and 19 in the second.

In terms of post-operative outcomes, the audit showed that the stroke and death rate at 30 days after surgery was 2%, myocardial infarction post-operatively was 0.6%, bleeding post-operatively was 3% and cranial nerve injury was 4%.

Mitchell also stated that one feature of note is that patients are treated most quickly in London. “The capital has undergone a significant re-organisation of stroke services, with fewer centres seeing more patients. If it can be shown that re-configuration has delivered clear benefit to patients, then other regions will need to look at how their services can be best organised for patient benefit,” he said.

“Despite patients being operated upon more quickly and at higher risk, reassuringly, we are not seeing a sharp rise in stroke and other perioperative complications. Carotid surgery is being performed more effectively than before in the NHS and in doing so preventing more strokes and their associated misery. What is required now is to reduce the variation in clinical performance and for teams to work hard on managing their pathways of care to treat all patients within the NICE target.”

The report notes that the number of stenting procedures entered into the audit has not been sufficient to include with these reports. There were a total of 35 carotid stents submitted to the audit within Round 4, from 11 NHS trusts in the UK, ranging from between one and nine per trust. There were 230 carotid stents identified in medical records for England for the same time period from a total of 29 Trusts.


Recommendations for change


  • All staff involved in organising and delivering care to patients who require carotid surgery need to examine their data and assess their performance against standards within NICE Guideline CG68.
  • Clinicians should ensure that data from patients having carotid surgery are included in national clinical audit. Appropriate time within job plans must be made available for consultants to validate and act upon their data.
  • Systems should be in place to ensure that coding of patients with carotid surgery is accurate. This requires close collaboration between hospital coding departments and clinicians and is likely to require regular (at least monthly) coding review meetings with the vascular team.
  • Every health economy offering carotid surgery must have a clearly documented pathway of care. This should state how the patient accesses services and how they flow through to surgery if required.
  • Clinicians involved in providing care to patients with transient ischaemic attack and minor stroke should ensure that there are agreed referral protocols to minimise delays in the pathway.
  • It is recommended that referrals to vascular surgery or interventional radiology should go to a central point within the department, rather than individual clinicians. There should be someone available to deal with referrals on a daily basis. These processes should work both during the working week and at the weekend.
  • Patients requiring carotid endarterectomy should be allocated to the next available operating list (ideally within three days of referral).
  • Carotid intervention should be prioritised as urgent/emergency in all symptomatic cases.
  • Clinical teams should seek feedback from patients to help improve the quality of care offered.
  • Stroke teams should publicise their services to primary care and the public. Attention should be given to highlighting the importance of amaurosis fugax as this diagnosis is associated with significantly greater delays in the pathway.

 

For more information on the UK Carotid Endarterectomy Audit Round 4 please click here.