## National Hip Fracture Database Anaesthesia Sprint Audit Of Practice (Asap)

In partnership with:

# Falls And Fragility Fracture Audit Programme National Hip Fracture Database Anaesthesia Sprint Audit Of Practice 2014

Prepared on behalf of the Clinical Effectiveness and Evaluation Unit at the Royal College of Physicians by the ASAP collaboration team:
Chris Boulton, NHFD project manager Colin Currie, former NHFD clinical lead, orthogeriatrics Richard Griffiths, consultant anaesthetist, Peterborough and Stamford Hospitals Mike Grocott, director, National Institute of Academic Anaesthesia, Health Services Research Centre Antony Johansen, NHFD clinical lead, orthogeriatrics Amer Majeed, consultant anaesthetist, Central Manchester University Hospitals Iain Moppett, consultant anaesthetist, Nottingham University Hospitals Karin Pappenheim, executive director, Association of Anaesthetists of Great Britain & Ireland Fay Plant, NHFD project coordinator Jonathan Roberts, web developer, Crown Informatics Rob Wakeman, NHFD clinical lead, orthopaedic surgery Stuart White, consultant anaesthetist, Brighton & Sussex University Hospitals Andy Williams, NHFD project coordinator

## Copyright

All rights reserved. Applications for the copyright owner's written permission to reproduce significant parts of this publication (including photocopying or storing it in any medium by electronic means and whether or not transiently or incidentally to some other use of this publication) should be addressed to the publisher. Brief extracts from this publication may be reproduced without the written permission of the copyright owner, provided that the source is fully acknowledged. Copyright © Healthcare Quality Improvement Partnership 2014 Royal College of Physicians 11 St Andrews Place Regent's Park London NW1 4LE www.rcplondon.ac.uk Registered Charity No 210508

## Contents Executive Summary  5

Anaesthetic Sprint Audit of Practice standards  6
Key findings   6 Key recommendations  7

## Introduction   8 Background   9 Methods   11 Key To Participating Hospitals  12

Findings  15
Ascertainment of cases  15
Patient characteristics  16
Comorbidities  17
Standard 1: Patients should be anaesthetised by a consultant or specialist with similar clinical experience.  18
Standard 2: Spinal/epidural anaesthesia should be considered for all patients  20
Standard 3: Spinal anaesthetics should be administered using hyperbaric bupivacaine (< 10mg) with the patient positioned laterally (bad hip down)  22 Standard 4: Co-administration of intrathecal opioids should be restricted to fentanyl  24 Standard 5: If sedation is required this should be midazolam or propofol  26 Standard 6: Supplemental oxygen should always be provided  28 Standard 7: Inhalational agents should be considered for the induction of general anaesthesia  30
Standard 8: Spontaneous ventilation should be used in preference to mechanical ventilation  32
Standard 9: Consider intraoperative nerve blocks for all patients undergoing surgery  34 Standard 10: Neuraxial and general anaesthesia should not be combined  36 Standard 11: Hypotension should be avoided  38 Standard 12: Patients should be routinely assessed for the occurrence of Bone Cement Implantation Syndrome (BCIS)  42
Conclusion  44 Future work  45

## Appendix 1  46 Appendix 2  47 References   59 Executive Summary

Hip fracture is the commonest reason for a frail older person to need an anaesthetic and operation. Its outcome serves as a marker of the quality of hospital care across the many disciplines and departments who will collaborate before, during and after this operation. However, the immediate physiological stress experienced by these patients is the pain and blood loss associated with the fracture. High quality anaesthetic care is crucial to the effective management of both stresses. The aim of this Anaesthetic Sprint Audit of Practice (ASAP) was to profile individual hospitals' compliance with standards for peri-operative care described in the Association of Anaesthetists of Great Britain and Ireland (AAGBI) guideline *The Management of Proximal Femoral Fracture*1. 

We aimed to prospectively collect data on all patients aged over 60 who underwent hip fracture surgery in hospitals across England, Wales and Northern Ireland between 1 May and 31 July 2013. Data for 16,904 patients treated for a hip fracture in 182 hospitals were submitted to the NHFD. Nearly all patients (97.6%) underwent anaesthesia and operation. Data for 80% of these patients were collected by teams including anaesthetists in each hospital, and submitted using the existing online reporting system of the National Hip Fracture Database (NHFD). Twelve hospitals (CHE, CHS, HIN, NOB, NTH, OHM, PET, RFH, SCA, SHH, UCL and WDH) submitted ASAP data on every patient in their NHFD submission, and 95 hospitals submitted data on over 80% 
of their patients. A detailed analysis was based on these 11,130 (67.5%) cases in hospitals with high case ascertainment with the objective of describing current practice and variation in care - to inform the ongoing development of an consensus regarding best anaesthesia practice. Hospitals which returned a lower proportion of cases were excluded from this analysis, to maximise its reliability. However, data for all but 23 hospitals (who did not participate in ASAP) are reported so that clinicians and managers in individual departments and hospitals can review their performance against the ASAP standards, and against that of other units in their region and throughout England, Wales and Northern Ireland (Appendix 2).

## Anaesthetic Sprint Audit Of Practice Standards

Based on the guideline *The Management of Proximal Femoral Fracture*, Association of Anaesthetists of Great Britain and Ireland, 2012

Standard 1
Patients should be anaesthetised by a consultant or specialist with similar clinical experience. 
Standard 2
Spinal/epidural anaesthesia should be considered for all patients
Standard 3
Spinal anaesthetics should be administered using hyperbaric bupivacaine (< 10mg) with the patient positioned laterally (bad hip down)
Standard 4
Co-administration of intrathecal opioids should be restricted to fentanyl
Standard 5
If sedation is required this should be midazolam or propofol
Standard 6
Supplemental oxygen should always be provided
Standard 7 
Inhalational agents should be considered for the induction of general anaesthesia
Standard 8 
Spontaneous ventilation should be used in preference to mechanical ventilation
Standard 9 
Consider intraoperative nerve blocks for all patients undergoing surgery
Standard 10
Neuraxial and general anaesthesia should not be combined
Standard 11
Hypotension should be avoided
Standard 12
Patients should be routinely assessed for the occurrence of Bone Cement Implantation Syndrome

## Key Findings

Where the seniority of both the surgeon and the anaesthetist present in theatre was recorded, it is encouraging to find that in over 90% of cases both were consultants or specialists, and that in only 0.4% of cases were both unsupervised trainees. However, we cannot exclude the possibility of an element of reporting bias here and there certainly remains substantial inter-hospital variation in the seniority of staff dealing with these high-risk cases. Pain relieving nerve blocks were administered to 56% of patients. This indicates an impressive adoption of this technique during recent years, particularly since its recommendation in the 2011 NICE Guidance on Hip Fracture2. However in this audit, nearly half of patients still do not receive a nerve block. The marked variation in provision of nerve blocks between different hospitals could suggest that this is more a reflection of organisational differences, than of individual patient need or preference. There was striking inter-hospital variation in the proportion of patients being given spinal and general anaesthesia. Some units administered spinal anaesthesia in over 80% of cases, while others used this approach in less than 10%. This would suggest that the mode of anaesthesia is often determined by local departmental or individual anaesthetist preference, rather than being a response to the needs, comorbidities and preferences of individual patients.

Considerable inter-hospital variation is similarly noted in the use of intrathecal opioids, of sedation, of supplemental oxygen, and in the dose of hyperbaric bupivacaine administered during spinal anaesthesia. Despite the seniority of anaesthetic expertise, the prevalence of low blood pressure during hip fracture surgery is a major concern. Relative hypotension (systolic BP reduction >20% from pre-operative value) occurred in 89% of patients, and absolute hypotension (lowest intraoperative systolic BP <100 mmHg) in 77%. Hypotension was consistently less prevalent among patients receiving spinal anaesthesia, compared to those receiving general anaesthesia.

Finally, ASAP supports previous work indicating that Bone Cement Implantation Syndrome (BCIS) is not uncommon after the insertion of cemented prostheses3. Possible BCIS events were recorded in 19% of cases, with reactions involving severe hypoxia and/or hypotension, or cardiovascular collapse in 2.7% and 0.5% of operations respectively. 

## Key Recommendations

These recommendations highlight the areas where ASAP identified substantial variation in practice against those standards for which evidence base is most robust.

>
> Peri-operative nerve blocks should be offered to all patients who suffer hip fracture [Standard 9]
>
> The reduced incidence of hypotension observed with spinal anaesthesia supports the AAGBI 
recommendation that this approach should be considered for all cases. [Standard 2]
>
> Departments of anaesthesia should develop evidence based standardized approaches to spinal 
anaesthesia, to reduce inconsistency in the dose of bupivacaine, and in the administration of sedatives, oxygen and intrathecal opioids. [Standards 3,4,5, and 6]
>
> Departments of anaesthesia should develop protocols to raise awareness of Bone Cement Implantation 
Syndrome and specific training for its recognition, avoidance and management. [Standard 12]
The AAGBI plans to hold a series of meetings to promote the findings of the ASAP audit. Those involved in collecting the data will be asked to share examples of good practice with other departments. There will be a dedicated ASAP session at the Annual Congress of the AAGBI in Harrogate in 2014. This will be recorded for the video library of the AAGBI. This will enable all members to see the results and presentation of the data. These ASAP findings need to be linked to the NHFD outcome measures - so that continuation of this work can establish whether outcome is affected by the anaesthetic approach, by hypotension during surgery, or by Bone Cement Implantation Syndrome. We believe that the level of participation in ASAP demonstrates that a collaborative approach to data collection by local teams including an anaesthetist can improve the scope and integrity of data submitted to NHFD. Consideration should be given to inclusion of key fields such as anaesthetist seniority and occurrence of hypotension when planning future development of the NHFD dataset. 

## Introduction

Hip fracture is the commonest reason for a frail older person to need surgery and anaesthesia. The average age of people sustaining a hip fracture is 83 years. One in six of the UK population is aged over 65 years, and the rapidly expanding over 85 year old age group already numbers half a million people4. The age-specific risk of suffering a hip fracture is reducing, but the total number of cases continues to rise in line with expansion of this age group5.

In the UK, hip fracture is estimated to carry an annual health and social care cost of one and a half billion pounds. Patients recovering from this injury occupy 4,000 NHS beds at any one time. The 2013 annual report of the National Hip Fracture Database (NHFD) identified that 8.2% of patients died within 30 days of hip fracture, and that only 46.2% of those admitted from home were able to return there within the same time period6. 

Surgical management of hip fracture is the default treatment, as it ensures effective analgesia and facilitates rehabilitation thus reducing the risk of complications related to immobility7.

The last half a century has seen a quest to identify the best anaesthetic practices to improve survival and reduce morbidity in these patients. Randomised controlled trials in this area have suffered from serious design, implementation and recruitment difficulties8. Large-scale audits have the potential to explore links between structure and process measures and outcome, through comparison of data on large numbers of patients between different centres. Collaboration between the Association of Anaesthetists of Great Britain and Ireland (AAGBI) and the National Hip Fracture Database (NHFD), led to the development and completion of the Anaesthesia Sprint Audit of Practice (ASAP). This document reports the results and analysis of this project, and attempts to provide a picture of current approaches to peri-operative care across England, Wales and Northern Ireland. 

## Background

The rehabilitation of frail elderly patients with hip fractures was pioneered in the 1940s by Cosin. Successful surgeon-physician collaboration between Devas and Irvine in the 1960s revolutionised the care and outcomes of these patients9. However, in 2000, the Audit Commission published a follow up to their 1995 report *United They Stand*10,11, which identified the high prevalence of severe inadequacies in the management of hip fracture patients. 

In 2001 the National Service Framework for Older People12 encouraged close cooperation between surgeons, anaesthetists and geriatricians in the care of these patients. In 2007 the British Geriatrics Society (BGS) and British Orthopaedic Association (BOA) collaborated in writing the 'Blue Book'13, to set standards for the hip fracture patient care. At the same time they established the NHFD, which is the largest hip fracture database in the world. This includes surgical and mortality data on a third of a million patients. It captures 95% of all cases of hip fracture, collects data from all hospitals in England, Wales, Northern Ireland and the Channel Islands, and provides an ideal infrastructure for large audits. The Scottish Intercollegiate Guidelines Network (SIGN), and the National Institute for Health and Care Excellence (NICE) have also issued clinical guidelines14,2 which reinforce the Blue Book's message. The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) publication of An Age Old Problem15 in 2010 advanced the issue higher on the government agenda. 

The NHFD is a component of the Falls and Fragility Fracture Audit Programme (FFFAP), managed by the Clinical Effectiveness and Evaluation Unit of the Royal College of Physicians (RCP). The work is commissioned by the Healthcare Quality Improvement Partnership (HQIP) as part of the National Clinical Audit and Patient Outcomes Programme (NCAPOP). During the same period, evidence was growing indicating how anaesthetic management influences outcomes in these patients16,17,18,19,20. Clinicians interested in promoting better anaesthetic management of these patients established the Hip Fracture Anaesthesia Network (HIPFAN) in 2007, and this was renamed to Hip Fracture Perioperative Network (HipPeN) in 2011. 

The network produced its first report in 2010 highlighting wide variations in anaesthetic practice21. It has since completed several projects enquiring into existing anaesthetic practices, and into the management and consequences of key perioperative issues such as anaesthetic technique, blood transfusion, and hypotension. These developments led to publication of the AAGBI guidelines on the anaesthetic management of the hip fractures1 in 2012.

A number of anaesthetists were part of the collaboration that developed the Blue Book, but anaesthetic management was not specifically addressed by the six standards set in the Blue Book13, and as a result the initial NHFD dataset did not attempt to profile details of anaesthetic care. 

## National Hip Fracture Database: Anaesthesia Sprint Audit Of Practice 2014

In 2011 HipPeN and NHFD developed a dataset that would allow eight new anaesthetic fields to be incorporated into the NHFD. Later in the same year the Anaesthetic Sprint Audit of Practice (ASAP) was planned and a project steering group of representatives from the NHFD, the AAGBI and the National Institute of Academic Anaesthesia (NIAA) Health Services Research Centre was established. 

## Methods

The aim of the audit was to profile individual hospitals' compliance with the guidelines for peri-operative care set by the AAGBI1 in 2012, and we set out to collect data on all patients over the age of 60 years, who underwent hip fracture surgery between 1st May and 31st July 2013. 

An audit data set was agreed for this purpose, and after pilot studies in 2012 a final data collection sheet was agreed (Appendix 1). Each of the 182 hospitals which routinely contribute to the NHFD was invited to form a local team comprising of trauma anaesthetists, coordinators, nurses and local NHFD representatives. The composition of a team varied from place to place. The teams liaised with colleagues involved in trauma anaesthesia to encourage audit form completion by the attending anaesthetist(s) for every case of hip fracture surgery. They oversaw inputting of the data from completed forms into the NHFD's online data collection tool, with online data entry completed by 
27 September 2013. 

Staff responsible for uploading the data were registered for each site, and secure access was granted through the NHFD lead clinician for each site. Use of the NHFD's pre-existing website, with its security and confidentiality safeguards simplified the handling of anonymised data in respect of such a large number of patients. Data were collected and processed with specific approval of the Secretary of State for Health on the recommendation of the Health Research Authority (HRA) Confidentiality Advisory Group (CAG)22 
under the Health Service (Control of Patient Information) Regulations 2002. This is more commonly referred to as section 251 approval and references to 'section 251 support or approval' actually refer to approval given under the authority of the Regulations. Section 251 was established to enable the common law duty of confidentiality to be overridden to enable disclosure of confidential patient information for medical purposes, where it was not possible to use anonymised information and where seeking consent was not practical, having regard to the cost and technology available. Personal confidential data items for this audit were processed by Crown Informatics under section 251 approval prior to anonymisation and transfer to Brighton & Sussex University Hospitals NHS 
Trust for analysis. Reported data and data files released under government transparency guidance23 are managed in line with UK statistics authority guidance on the handling of small numbers24 to prevent the identification of individuals. Data for English hospitals included in all provider level charts in this report can be found at http://www.data.gov.uk/

## Key To Participating Hospitals

Hospitals which contributed data on over 80% of cases - and were therefore eligible for inclusion in the charts used to defining current patterns of anaesthesia practice, and in tables of individual performance (appendix 2)
Hospitals which contributed data to the overall report but captured less than 80% of patients - and were therefore reported in tables of individual performance (appendix 2)

## Non Participating Hospitals

ADD	
Addenbrooke's Hospital, Cambridge AIR	
Airdale General Hospital RED	
Alexandra Hospital, Redditch
	
Altnagelvin Hospital WIR	
Arrowe Park Hospital, Wirral

BNT	
      Barnet Hospital
BAR	
      Barnsley Hospital
BAS	
      Basildon and Thurrock University Hospital

BSL	
Bassetlaw Hospital
	
Bedford Hospital

EBH	
      Birmingham Heartlands Hospital
BRD	
      Bradford Royal Infirmary

BRI	
Bristol Royal Infirmary

BRG	
      Bronglais Hospital, Aberystwyth
BFH	
      Broomfield Hospital, Chelmsford

CHS	
Chase Farm Hospital WES	
Chelsea and Westminster Hospital
	
Cheltenham General Hospital CHE	
Chesterfield Royal Hospital COL	
Colchester General Hospital
	
Conquest Hospital, Hastings COC	
Countess of Chester Hospital HCH	
County Hospital, Hereford

CRG	
     Craigavon Hospital, Portadown
MAY	
     Croydon University Hospital, London
CMI	
     Cumberland Infirmary, Carlisle

DVH	
Darent Valley Hospital, Dartford

DAR	
      Darlington Memorial Hospital
DER	
      Derbyshire Royal Infirmary, Derby PLY	
       Derriford Hospital, Plymouth
GGH	
       Diana Princess of Wales Hospital, Grimbsy

DID	
Doncaster Royal Infirmary, WDH	 Dorset County Hospital, Dorchester Ealing Hospital
	
East & North Hertfordshire Hospital ESU	
East Surrey Hospital, Redhill

DGE	
     Eastbourne Hospital
FRY	
     Frenchay Hospital, Bristol

FRM	
Frimley Park, Camberley

FGH	
     Furness General Hospital, Barrow-in-Furness
NUN	
     George Eliot Hospital, Nuneaton

CLW	
     Glan Clwyd Hospital, Rhyl

GLO	
      Gloucestershire Royal Hospital, Gloucester
GHS	
      Good Hope Hospital, Birmingham 
GRA	
      Grantham and District Hospital
GWY	
      Gwynnedd Ysbyty, Bangor
HAR	
      Harrogate District Hospital
HIL	
      Hillingdon Hospital
HIN	
      Hinchingbrooke Hospital
HOM	 Homerton Hospital, London
SLF	
      Hope Hospital, Salford

HOR	
     Horton Hospital, Banbury
HUD	
     Huddersfield Royal Infirmary

	
              Hull Royal Infirmary IPS	
        Ipswich Hospital SCM	
     James Cook University Hospital, Middlesbrough

JPH	
      James Paget University Hospital, Great 
      Yarmouth
RAD	
      John Radcliffe Hospital, Oxford
KGH	
      Kettering General Hospital
KCH	
      King's College Hospital, London
KMH	 King's Mill Hospital, Sutton in Ashfield
KTH	
      Kingston Hospital

LGI	
       Leeds General Infirmary LER	
      Leicester Royal Infirmary Leighton Hospital, Crewe LIN	
       Lincoln County Hospital

LDH	
     Luton and Dunstable Hospital
MAC	
     Macclesfield General Hospital
WRX	
     Maelor Hospital, Wrexham

MRI	
      Manchester Royal Infirmary Manor Hospital, Walsall

MDW	 Medway Maritime Hospital 
MKH	 Milton Keynes General Hospital
MOR	 Morriston Hospital, Swansea
MPH	
      Musgrove Park Hospital, Taunton

NEV	
      Nevill Hall Hospital, Abergavenny NCR	
     New Cross Hospital, Wolverhampton

NWG	 Newham General Hospital, London NOB	
Nobles Hospital, Isle of Man NOR	
Norfolk and Norwich University Hospital NDD	
North Devon District Hospital, Barnstaple

NHH	 North Hampshire Hospital, Basingstoke
NMG	 North Manchester General Hospital
	
       North Middlesex Hospital

NTY	
North Tyneside General Hospital, North Shields

NTH	
     Northampton General Hospital
NGS	
     Northern General Hospital, Sheffield
NPH	
     Northwick Park Hospital, London
PET	
     Peterborough District Hospital
PIL	
     Pilgrim Hospital, Boston
PIN	
     Pinderfields General Hospital, Wakefield
PGH	
     Poole General Hospital
PCH	
     Prince Charles Hospital, Merthyr Tydfil
POW	
     Princess of Wales Hospital, Bridgend

	
Princess Royal Hospital, Telford

BRO	
      Princess Royal University Hospital, Bromley
QAP	
      Queen Alexandra Hospital, Portsmouth QEB	
      Queen Elizabeth Hospital, Birmingham
QEG	
      Queen Elizabeth Hospital, Gateshead

QKL	
Queen Elizabeth Hospital, King's Lynn
	
Queen Elizabeth Hospital, Woolwich

QEQ	
     Queen Elizabeth the Queen Mother Hospital, 
     Margate
BRT	
     Queens Hospital, Burton upon Trent

	
Queens Hospital, Romford

ROT	
      Rotherham District General Hospital
AEI	
      Royal Albert Edward Infirmary, Wigan
RBE	
      Royal Berkshire Hospital, Reading
BLA	
      Royal Blackburn Hospital
BOL	
      Royal Bolton Hospital
RDE	
      Royal Devon & Exeter Hospital, Exeter
RFH	
      Royal Free Hospital, London
RGH	
      Royal Glamorgan Hospital, Llantrisant

GWE	
Royal Gwent Hospital, Newport RHC	
Royal Hampshire County Hospital, Winchester
	
Royal Lancaster Infirmary

RLU	
      Royal Liverpool University Hospital
OHM	 Royal Oldham Hospital
RPH	
      Royal Preston Hospital RSS	
       Royal Shrewsbury Hospital
RSU	
       Royal Surrey County Hospital, Guildford
RSC	
       Royal Sussex County Hospital, Brighton

BAT	
Royal United Hospital, Bath
	
Royal Victoria Hospital, Belfast

RVN	
     Royal Victoria Infirmary, Newcastle
RUS	
     Russells Hall Hospital, Dudley
SAL	
     Salisbury District Hospital

SAN	
Sandwell General Hospital 

SCA	
      Scarborough General Hospital
SCU	
      Scunthorpe General Hospital
STD	
      South Tyneside District Hospital, South Shields

SGH	
Southampton General Hospital SEH	
Southend Hospital
	
Southport & Formby Hospital

GEO	
     St George's Hospital, London
SHC	
     St Helier Hospital, Carshalton
SPH	
     St Peter's Hospital, Chertsey
STR	
     St Richard's Hospital, Chichester

STH	
      St Thomas' Hospital, London St. Mary's Hospital, Isle of Wight STM	
     St. Mary's Hospital, Paddington Staffordshire General Hospital SHH	
     Stepping Hill Hospital, Stockport

SMV	
     Stoke Mandeville Hospital, Aylesbury SUN	
      Sunderland Royal Hospital TGA	
      Tameside General Hospital, Manchester

PMS	
      The Great Western Hospital, Swindon
PAH	
      The Princess Alexandra Hospital, Harlow
RCH	
      The Royal Cornwall Hospital, Treliske

LON	
     The Royal London Hospital TOR	
      Torbay District General Hospital Trafford Hospital Tunbridge Wells Hospital

NUH	
     Ulster Hospital, Belfast
UCL	
     University College Hospital London 
STO	
     University Hosp. of North Staffordshire, Stoke 
     on Trent 
FAZ	
     University Hospital Aintree
UHC	
     University Hospital Coventry 

DRY	
      University Hospital Of North Durham, 
      Darlington NTG	
     University Hospital of North Tees, Stockton on 
     Tees

UHW	 University Hospital of Wales, Cardiff
LEW	
       University Hospital, Lewisham 
UHN	
       University Hospital, Nottingham

VIC	
      Victoria Hospital, Blackpool
ASH	
      Wansbeck Hospital

WDG	 Warrington Hospital
	
      Warwick Hospital

WAT	
     Watford General Hospital 
WMU	 West Middlesex University Hospital, Isleworth
WSH	
     West Suffolk Hospital, Bury St. Edmunds

	
              West Wales Hospital, Carmarthen

WGH	 Weston General Hospital, Weston-Super-Mare
WEX	
       Wexham Park Hospital, Slough 

WHC	 Whipps Cross University Hospital
WHI	
       Whiston Hospital, Prescot
WHT	 Whittington Hospital, London
WHH	 William Harvey Hospital, Ashford
WYB	
       Withybush Hospital, Haverford West

WRC	
     Worcestershire Royal Hospital, Worcester
WRG	
     Worthing & Southlands Hospital
WYT	
     Wythenshawe Hospital, Manchester

YEO	
      Yeovil District Hospital
YDH	
      York Hospital

## Findings Ascertainment Of Cases

During the three-month ASAP study period routine NHFD data entry continued as normal in all 182 hospitals in England, Wales and Northern Ireland. This identified 16,904 patients that were treated for a hip fracture and 16,498 that underwent surgery between 1 May and 31 July 2013. ASAP data were submitted for 11,186 (67.8%) and analysed for 11,130 (67.5%) of these operations. The median case ascertainment rate (the percentage of patients undergoing hip fracture surgery for whom ASAP data were submitted) was 80.6% (interquartile range 51.2 - 92.4% [range 0–100%]). Twelve hospitals (6.5%) achieved a 100% case ascertainment rate - CHE, CHS, HIN, NOB, NTH, OHM, PET, RFH, SCA, SHH, UCL and WDH. Twenty-three hospitals (12.5%) did not submit any ASAP data. A key objective of ASAP was to develop a national consensus regarding the optimal anaesthetic management of patients with hip fracture. A picture of variation in practice across the country will be key to the discussion and debate that will be generated when ASAP findings are reported to anaesthetists at national, regional and local scientific and clinical governance meetings over the coming year. To minimise the effect of selective reporting the charts that illustrate key findings were therefore based on those hospitals which provided the most complete data. 95 hospitals (51.6%) achieved a case ascertainment rate of greater than 80%, and these units were therefore used to develop the charts reported here. Hospitals with less complete case ascertainment carry the potential for bias and were excluded from such analysis, though their performance against the ASAP standards is reported in detail in the regional tables (Appendix 2).

## Patient Characteristics

The age, sex and American Society of Anesthesiologists (ASA) grade distributions of ASAP patients were similar to previously published NHFD data (table 1). Sex was recorded for 11,129 (99.9%) patients; 71.9% were female, 28.1% male. Age was reported for 11,110 (99.8%) patients. The median age of patients was 83 years (interquartile range 7789 years [range 24–104]), with a negatively skewed distribution (figure 1). Only data for patients aged >60 years are included, in line with NHFD reports.

| Characteristic   | NHFD    |   ASAP |
|------------------|---------|--------|
| 2011/12          | 2012/13 | 2013   |
| Gender, %        |         |        |
| Male             | 26.0    |   26.8 |
| Female           | 74.0    |   73.2 |
| Age in years, %  |         |        |
| 60–69            | 8.3     |    8.7 |
| 70–79            | 22.2    |   21.7 |
| 80–89            | 48.2    |   47.4 |
| 90+              | 21.3    |   22.1 |
| ASA grade, %     |         |        |
| ASA 1            | 2.4     |    2.2 |
| ASA 2            | 30.7    |   29.7 |
| ASA 3            | 55.1    |   55.5 |
| ASA 4            | 11.4    |   12.2 |
| ASA 5            | 0.4     |    0.4 |

## Comorbidities

Comorbidity data were recorded for 10,387 (93.3%) of patients; 8,752 (84.3%) of patients had at least one recorded comorbidity and 2,696 (26.0%) had three or more recorded comorbidities. The frequencies of the types of comorbidity recorded are shown in figure 2. 

## Standard 1: Patients Should Be Anaesthetised By A Consultant Or Specialist With Similar Clinical Experience.

ASAP finding: A consultant or specialist anaesthetist was present in theatre for 95% of hip fracture operations

>
> There was considerable national variation in the seniority of surgeons and anaesthetists recorded as 
present in theatre during each hip fracture operation (figure 3).
>
> There may be a recording bias obscuring senior involvement within the 24% of cases in which either 
grade of surgeon or anaesthetist were not recorded. However, it is encouraging that of the operations in which the seniority of both surgeon and anaesthetists were recorded very few (0.4%) were performed by unsupervised trainees.
>
> The specialist expertise of each anaesthetist relating to hip fracture care irrespective of grade was not 
assessed in the current project. 
The grade of the most senior surgeon and the most senior anaesthetist were both recorded for 75.6% of operations. The most senior personnel present during these operations are shown in table 2, and by hospital in figure 3.

Most senior surgeon present in theatre
Consultant/specialist
Trainee
Most senior anaesthetist present in theatre
Consultant/specialist
91.7
2.9
Trainee
  5.0
0.4

## Standard 2: Spinal/Epidural Anaesthesia Should Be Considered For All Patients

ASAP finding: Only 44% of patients were administered spinal, and only 0.2% epidural anaesthesia

>
> There was very striking variation across the country with some units administering spinal anaesthesia 
in over 80% of cases, while others used this approach in less than 10%. This suggests that the mode of anaesthesia is often determined by local departmental or individual anaesthetist preference, rather than being a response to the needs, comorbidities and preferences of individual patients. 
>
> Questions of patient preference could not be directly addressed in our audit. We did not record whether 
spinal or epidural anaesthesia was 'considered' by the anaesthetist and patient, but a substantial number of units were using general anaesthesia in over three-quarters of cases suggesting that this approach is routinely selected in some hospitals. 
Mode of anaesthesia was recorded by NHFD data collectors for 10,876/11,130 (97.7%) patients, and by ASAP data collectors for 10,936 (98.3%) of patients. There was concordance between the mode of anaesthesia recorded by NHFD and ASAP data collectors for 7,173 (64.5%) patients. In the ASAP recorded data, general anaesthesia (+/- nerve block/epidural) was administered to 5,640 (50.7%) of the ASAP patient group, spinal anaesthesia (+/- nerve block/epidural) to 4,916 (44.2%), and both general and spinal anaesthesia (+/- nerve block/epidural to 380 (3.4%) patients; 194 patients (1.7%) had 'other' anaesthesia, mainly repair under local anaesthesia (figure 4). Epidural anaesthesia was administered to 21 (0.2%) patients. The mode of anaesthesia varied markedly between hospitals (figure 5). General anaesthesia was administered to between 19.6% and 92.4% of patients. Nerve blocks were administered to between 8.3% and 91.1% of patients.

Standard 3: Spinal anaesthetics should be administered using hyperbaric bupivacaine  
(< 10mg) with the patient positioned laterally (bad hip down)
ASAP finding: Nearly 80% of patients receiving spinal anaesthesia were administered over 1.9mls (9mg) of 0.5% hyperbaric bupivacaine, the median dose being 2.5mls (12.5mg).

>
> Evidence suggests that lower doses of 0.5% hyperbaric bupivacaine are associated with lower degrees 
of relative intraoperative hypotension. 
>
> Further work is planned to analyse this association, and to establish whether the use of lower doses 
of bupivacaine are associated with an increased rate of failed spinal anaesthesia, and whether the use of lower doses, or other agents (eg isobaric bupivacaine) confers benefit in terms of intraoperative blood pressure. 
Spinal anaesthesia was administered to 5,638 (50.7%) patients, but failed in 342 (6.1%). The most frequently used local anaesthetic agent was 0.5% hyperbaric bupivacaine, which was administered to 3,336 (59.2%) patients receiving spinal anaesthesia. The median volume of 0.5% hyperbaric bupivacaine administered intrathecally was 2.5mls (interquartile range 2.22.8 [range 0.65–4.7]), with 79.5% of patients receiving more than 1.9mls (figure 6).

## Standard 4: Co-Administration Of Intrathecal Opioids Should Be Restricted To Fentanyl

ASAP finding: 22% of patients successfully administered spinal anaesthesia received intrathecal fentanyl

>
> There is very little evidence concerning the use of intrathecal opioids for hip fracture patients. Fentanyl 
appears to have a bupivacaine-sparing effect, reducing intraoperative hypotension7, but there is no 
specific evidence for the use of other opioids in these patients. There is concern that higher doses of 
intrathecal diamorphine and morphine do not extend the duration of postoperative analgesia, but 
are associated with additional side-effects25 (postoperative confusion, respiratory depression, itching), 
particularly in the age group sustaining hip fracture.
In the 3,617/5,296 (68.2%) successfully administered spinal anaesthetics for which opioid coadministration was recorded, fentanyl was used in 31.9%, diamorphine in 49.7% and morphine in 3.9% (14.5% other opioid or no opioid used), but there was wide variation between hospitals in the type of opioid used (figure 8).

## Standard 5: If Sedation Is Required This Should Be Midazolam Or Propofol

ASAP finding: Midazolam and propofol were administered as single sedative agents to around 15% and 25% of patients receiving sedation during spinal anaesthesia, respectively

>
> Sedation was administered to 74% of patients having spinal anaesthesia. There was marked variation 
between different units with sedation being given to less than a quarter of patients in some units, and to all patients in others (Figure 9). 
>
> Over-sedation is relatively common during hip fracture repair under spinal anaesthesia, and 
might contribute both to intraoperative hypotension, and to postoperative confusion and delayed rehabilitation. 
>
> The use of propofol is associated with reduced postoperative confusion when compared to 
benzodiazepines and opioids. 
>
> At low doses ketamine is analgesic, but it is unclear whether it has any additional clinical analgesic 
benefit when spinal anaesthesia is used. At higher doses, its use is associated with postoperative confusion. 
Of the 5,638 patients receiving spinal anaesthesia, 4,195 (74.4%) were sedated with one (53.6% cases), two (40.7%), three (5.4%) or four (0.3%) sedative agents. A benzodiazepine was administered in 33.2% of cases, propofol in 29.0%, ketamine in 22.0% and an opioid in 15.9% of all those who were sedated. Information about the mode of administration (singledose, infusion) was not collected. 

## Standard 6: Supplemental Oxygen Should Always Be Provided

ASAP finding: Supplemental oxygen was administered to 71% of patients receiving sedation during spinal anaesthesia

>
> Age-related reductions in pulmonary gas transfer when supine suggest that supplemental oxygen 
should routinely be administered to patients receiving sedation, although there is little evidence to support this standard. 
>
> Hypoxia can contribute to postoperative confusion and delayed recovery, but whether supplemental 
oxygen is necessary provided the arterial oxygen saturations exceeds a monitored 95% requires further investigation.
Supplemental oxygen was provided for 71.1% of patients administered sedation during spinal anaesthesia (figure 10).

## Standard 7: Inhalational Agents Should Be Considered For The Induction Of General Anaesthesia

ASAP finding: Inhalational agents were used to induce general anaesthesia in around 5% of hip fracture patients

>
> General anaesthesia was administered to more than half (54.1%) of patients, although there was a 
marked range of prevalence between hospitals. 
>
> Inhalational induction with sevoflurane, particularly at lower inspired concentrations, reduces mean 
arterial pressure less than occurs with intravenous propofol induction, and may confer greater cardiostability in this patient group. 
>
> It remains uncertain whether it is the dose or rate of administration of inhalational or intravenous 
anaesthesia during induction that is of the greater importance.
>
> The AAGBI 2014 guidelines Peri-operative Care of the Elderly26 advocate the use of a Lerou nomogram 
(or similar dosage chart) in order to guide age-adjusted delivery of inhalational anaesthetic agents to maintain general anaesthesia (as received by 88% of patients administered GA in this audit), and so avoid relative overdose. 
General anaesthesia was administered to 6,020 (54.1%) of patients. Modes of general anaesthesia induction and maintenance are summarised in table 3.

Induction of  
general anaesthesia
Maintenance of  
general anaesthesia
Intravenous
93.0
  5.4
Inhalational
  3.9
88.4
Intravenous and inhalational
  2.6
  0.7
Not recorded
  0.5
  6.2

## Standard 8: Spontaneous Ventilation Should Be Used In Preference To Mechanical Ventilation Asap Finding: 44% Of Patients Breathed Spontaneously Throughout General Anaesthesia

>
> Endotracheal intubation reduces the risk of aspirating gastric contents into the lungs. Mechanical 
ventilation permits control of end-tidal carbon dioxide levels, but may contribute to pulmonary and 
systemic inflammation even if lung protective ventilation strategies are used27.
>
> Evidence specific to the hip fracture population is very limited27, and it remains uncertain whether the 
balance of benefits and risks favours mechanical or spontaneous ventilation. 
The airway was maintained using an endotracheal tube in 44.2% and a laryngeal mask airway in 51.1% of patients administered general anaesthesia (both/not recorded 4.7%). The mode of ventilation and degree of neuromuscular paralysis administered to patients receiving general anaesthesia are summarised in table 4.

Airway device used
Endotracheal tube
Laryngeal mask airway
Paralysed, mechanical ventilation
81.3
  8.6
Non-paralysed, mechanical ventilation
  9.1
13.0
Spontaneous ventilation
  0.0
73.0
Other
  9.3
  5.4

The mode of ventilation and degree of paralysis varied considerably by hospital (figure 12), with between 2 and 93% of patients being paralysed and mechanically ventilated.

## Standard 9: Consider Intraoperative Nerve Blocks For All Patients Undergoing Surgery

ASAP finding: Nerve blocks were administered to 56% of patients.

>
> Most nerve blocks (54%) were administered without ultrasound-guidance or peripheral nerve 
stimulation. However, 56% of patients received a fascia iliaca block, which can be performed relatively safely using a non-guided landmark technique.
>
> There are relatively few contraindications to nerve blocks, particularly femoral nerve or fascia iliaca 
compartment blockade. Supplemental nerve blockade helps to control acute and perioperative pain and to reduce the need for perioperative opioid, both of which are considerations when seeking to prevent post-operative delirium.
>
> The administration of a functional nerve block may also avoid the use of sedation when moving a 
patient into the lateral or sitting position for administering spinal anaesthesia, and may reduce the volume of intrathecal bupivacaine necessary for anaesthesia.
Analgesic peripheral nerve block was administered to 6,233 (56.0%) patients; 7,332 blocks were performed. More than one block was performed in 1,073 (17.2%) patients. Peripheral blocks were established before anaesthesia in 15.5% of cases. Ultrasound guidance only was used in 26.4% of cases, peripheral nerve stimulation only in 13.4%, both in 6.0% and neither in over half (54.1%) of patients. The most frequently performed single peripheral nerve blocks were the fascia iliaca compartment block (55.9%) and the femoral nerve block (26.6%). The proportion of all patients receiving a peripheral nerve block varied from eight to 92% between hospitals (figure 13).

## Standard 10: Neuraxial And General Anaesthesia Should Not Be Combined

ASAP finding: General and spinal (neuraxial) anaesthesia were given in combination to 3.4% of hip fracture patients

>
> Use of a combination of both spinal and general anaesthesia was associated with the highest 
prevalence of hypotension, possibly reflecting the combined effect of reduced heart rate, contractility and blood vessel tone in people without the reserve to cope with such stresses.
Reported rates of combined general and spinal anaesthetic varied from 0 to 25.4% across the hospitals shown in figure 14. The combined technique is more popular for elective hip arthroplasty, which tends to be a fitter and younger patient group. Figure 11 shows that only in a small number of units is the combination technique popular. In units where only a few combined techniques were recorded, this may reflect a failed or inadequate spinal anaesthetic being converted into a general anaesthetic.

## Standard 11: Hypotension Should Be Avoided

ASAP finding: Intraoperative hypotension occurred for the majority of hip fracture patients; in 56–89%, depending on which of several commonly used definitions was used

>
> Despite the widespread presence of senior anaesthetic expertise in theatre, the prevalence of 
intraoperative varied markedly between units. The mean prevalence of relative hypotension (systolic blood pressure reduction >20% from pre-operative value) was 90% and that of absolute (lowest 
intraoperative SBP <100 mmHg) hypotension was 77%.
>
> Hypotension was consistently less prevalent among patients receiving spinal anaesthesia, compared to 
those receiving general anaesthesia.
>
> When interpreting these figures it is important to remember that they were derived from two single 
measures of perioperative BP, immediately before administration of anaesthesia and at the lowest recorded blood pressure. As a result they do not provide information about the rate of decline of blood pressure, frequency of measurement, duration of hypotension, repeated episodes of hypotension, fluid status or use of vasopressors/invasive arterial blood pressure monitoring. 
>
> This high prevalence of hypotension indicates that this is an important area for future consideration. A 
consistent definition of 'hypotension' is urgently required20. 
Data were recorded for pre-induction and lowest recorded intra-operative systolic (SBP) and diastolic (DBP) blood pressures for 10 244 (92.0%) patients. Mean arterial pressures (MAP) were calculated from these data as a (third of the pulse pressure + diastolic blood pressure). Mean (SD) pre-induction blood pressures were 147(25)/74(14) (MAP 97(16)) and lowest intraoperative blood pressure 88(18)/47(11) (MAP 60 (12)). The mean (SD) fall in SBP for all patients in which type of anaesthesia was also known was 38(14)%, 40(14)% for patients administered general anaesthesia, 34(13)% for patients administered spinal anaesthesia and 41(13)% for patients administered general and spinal anaesthesia. The prevalence of hypotension was analysed according to a variety of criteria, there being no commonly agreed definition of 'hypotension': 

## Absolute Values

>
> Lowest intraoperative SBP < 100 mmHg
>
> Lowest intraoperative SBP < 90 mmHg
>
> Lowest intraoperative MAP < 70 mmHg
>
> Lowest intraoperative MAP < 55 mmHg

## Relative Changes

>
> SBP reduction > 20% from pre-operative value
>
> SBP reduction > 30% from pre-operative value
>
> MAP reduction > 20% from pre-operative value
>
> MAP reduction > 30% from pre-operative value

Type of anaesthesia
All
GA
GA + SA
SA
Fall SBP > 20%
88.9
92.3
92.8
84.6
Fall SBP > 30%
71.3
78.2
81.8
62.3
Lowest SBP < 90mmHg
56.2
66.6
74.9
42.7
Lowest SBP < 100mmHg
77.0
85.2
92.2
66.3
Fall MAP > 20%
87.8
90.8
93.1
83.9
Fall MAP > 30%
69.2
76.1
81.0
60.3
MAP < 70mmHg
79.2
86.1
91.1
70.3
MAP < 55mmHg
32.4
40.3
47.3
21.9

The prevalence of recorded hypotension varied from 68.3% to 100.0% for relative hypotension (figure 15) and from 36.6% to 96.2% for absolute hypotension (figure 16) between hospitals, according to the 'least bad' definitions of hypotension used (SBP reduction > 20% from pre-operative value, and lowest intraoperative SBP < 100 mmHg, respectively).

## Standard 12: Patients Should Be Routinely Assessed For The Occurrence Of Bone Cement Implantation Syndrome (Bcis)

ASAP finding: Data about the possible occurrence of BCIS were recorded for 84% of operations in which a cemented prosthesis was inserted

>
> Possible Bone Cement Implantation Syndrome - shortly after cement or reaming was reported in 19% 
of these cases
>
> Possible reactions involving severe hypoxia and/or hypotension, or cardiovascular collapse, were less 
prevalent - occurring in 2.7% and 0.5% of operations respectively.
Cemented prostheses (hemi- or total arthroplasty) were used in 4,487/11,120 (40.4%) of recorded operations. Data about possible Bone Cement Implantation Syndrome (BCIS) reactions were recorded for 3,757 (83.7%) of these. Possible BCIS occurred in 19.0% of operations in which a cemented prosthesis was used. The severity of the reaction was recorded as moderate (hypoxia <94% SpO2 or hypotension >20% fall in systolic blood pressure) in 15.8% of operations, severe (hypoxia <88% SpO2 or hypotension > 20% fall in systolic blood pressure or loss of consciousness) in 2.7%, and resulting in cardiovascular collapse (requiring cardiopulmonary resuscitation) in 0.5%. The prevalence of possible BCIS was similar between patients receiving cemented hemiarthroplasty and total arthroplasty for hip fracture repair, but varied between hospitals (figure 17).

## Conclusion

The relative contribution of anaesthesia to outcome after hip fracture repair remains uncertain28, but experience across medicine suggests that better outcomes are associated with standardisation of practice. ASAP has highlighted great variability in adherence to its standards; reflecting the paucity of high quality research in this field. A key objective of ASAP has been to define current practice - so as to develop a consensus regarding best practice. These results will help individual anaesthetists and departments of anaesthesia to understand the standards described in the AAGBI guideline. Research in the complex, heterogeneous hip fracture population is difficult, making it difficult to formulate evidence-based guidelines. The AAGBI guidelines resulted from review of current evidence by specialists in the perioperative care of hip fracture patients. However, in some instances, the guidelines were based only on expert opinion, and ASAP standards were proposed to focus attention on an important clinical question. Until specific peer-reviewed evidence is published to the contrary, the guidelines and standards describe a minimum standard of care to which all hip fracture anaesthetists should aspire. The ASAP dataset includes over 11,000 patients, and is the largest prospective, multicentre collection of anaesthesia-specific data about hip fracture patients ever collected. Data were entered contemporaneously by anaesthetists to improve accuracy compared to routine audit work, which normally relies on nonanaesthetists to retrospectively collate operative and anaesthetic details. Despite the scale, and comprehensive coverage achieved in ASAP it is important not to over interpret the meaning of observational and audit data - these are not a replacement for scientific research studies that can be designed to formally test an hypothesis. However, there are some striking findings, most notably the high prevalence of intraoperative hypotension, the limited use of nerve blockade in addition to spinal and/or general anaesthesia and the wide inter-hospital variation in type of anaesthesia administered. Furthermore, this work supports previous studies indicating that Bone Cement Implantation Syndrome3 is not uncommon after the insertion of cemented prostheses. 

## Future Work

Brighton and Sussex University Hospitals, who analysed data for this report are currently seeking approval for a further piece of work linking ASAP data with NHFD measures of outcome, including mortality and return to residence. This will seek to establish how the approach to anaesthesia, and the occurrence of intraoperative hypotension or BCIS might affect outcome. This work will also consider whether the Nottingham Hip Fracture Score is an accurate risk score for case-mix adjustment. The results of this extension to ASAP will be submitted for publication in a peer reviewed journal.

## Appendix 1

ASAP audit data collection sheet

## Aagbi / Boa / Bgs / National Hip Fracture Database Hip Fracture Anaesthesia Sprint Audit Project (Asap)–2013

                                                                                                                                   

                
2.01 General Anaesthesia 
 
2.02 Nerve block 
 
2.03 Spinal anaesthesia 
 
2.04 Injectate (freehand) 
Induction 
Intravenous 
 
 
Femoral 
 
 
No sedation 
 
 
Spinal drug 
Bupivacaine 
 
Inhalational 
 
Fascia Iliaca 
 
Intravenous 
 
 
Lateral Cutaneous Nerve Thigh 
 
 
Benzodiazepine 
 
Concentration (%) 
 
Maintenance  
Sedation 
Inhalational 
 
 
Psoas/Lumbar Plexus 
 
 
Ketamine 


Epidural 
 
 
Opioid 
 
plain 
 
Airway 
Endotracheal tube 
 
 
Local to skin 
 
 
Supplemental oxygen administered 
 
Volume (ml) 
 
 
Laryngeal mask 
 
 
Peri-articular 
 
 
Opioid added…. 
Ventilation 
Spontaneous 


Patient position (for spinal insertion) 
Mechanical 
 
 
Ultrasound guided 
 
 
lateral bad side down 


Peripheral nerve stimulator used 
 
 
lateral bad side up 
 
Other drugs added… 
Muscle relaxant used? 
 
 
Inserted before anaesthesia 
 
Failed spinal 


Not applicable 
 
 
Not applicable 
 
 
Not applicable 
 
No Drugs given 2.05 Co-morbidities 
 
2.06 Specialist Grade in theatre 
 
2.07 Bone cement implantation syndrome - shortly after cement or reaming: 
Active malignancy in last 20 years 
 
 
Surgeon 
Cons 
SAS 
ST3+ 
 
Moderate hypoxia (SpO2 < 94%) or hypotension (Systolic BP fall > 20%) 
 
Hospital admission [Hb] <10 g/dl 


Operating 


Previous/current MI 
 
 
Supervising 


Severe hypoxia (< 88%) or hypotension (Systolic BP fall > 40%) or loss of consciousness 
Angina 
 
Anaesthetist 
Cons 
SAS 
ST3+ 
Atrial fibrillation 


Anaesthetising 


Cardiovascular collapse, requiring cardiopulmonary resuscitation 
 
Valvular heart disease 


Supervising 


No problems with cement 
 
Hypertension 


Stroke 
 
 
2.08 Intraoperative BP 
Transient ischaemic attack 
 
 
Presystolic 
mmHg 
induction 
Asthma 
 
 
diastolic 
mmHg 
COPD 


Addressograph 
Renal disease 
 
 
Lowest systolic 
mmHg 


Lowest diastolic 
mmHg 
Not applicable 


Propofol 
 
Other (name) 
 
Baricity 
heavy 
 
sitting up 
EAST MIDLANDS
Total number of ASAP cases submitted
100
83
30
46
66
230
55
80
76
97
863
11186
Percentage of eligible cases submitted
100
55
86
49
63
99
67
100
99
53
77
68
Consultant/specialist anaesthetist and surgeon (%)
  1
52
74
100
72
58
57
83
73
93
61
72
62
Spinal or epidural anaesthesia (%)
  2
59
82
67
30
56
48
56
55
48
48
55
40
Less than 10mg hyperbaric bupivicaine (%)
  3
0
1
5
0
0
0
0
0
2
0
1
2
Fentanyl as intrathecal opioid (%)
  4
8
76
5
0
24
11
40
0
11
24
20
19
Sedation with midazolam or propofol during spinal (%)
  5
29
44
75
82
42
28
4
11
21
62
40
33
Supplemental oxygen during spinal (%)
  6
65
77
83
64
75
82
77
49
88
54
71
62
Inhalational agent for GA induction (%)
  7
2
7
0
6
7
5
0
8
6
12
5
4
Spontaneous ventilation during GA (%)
  8
59
53
30
38
66
63
26
56
64
36
49
36
Nerve block provided (%)
  9
32
42
90
74
48
59
62
29
25
84
54
49
General and neuraxial not combined (%)
10
98
100
97
100
100
99
100
99
92
99
98
97
Relative hypotension (%)
11a
88
97
93
91
97
86
89
89
91
91
91
88
Absolute hypotension (%)
11b
75
83
87
73
78
77
79
74
70
74
77
79
No suggestion of possible BCIS (%)
12
75
89
92
75
100
79
90
90
86
95
87
87
EAST OF ENGLAND
Total number of ASAP cases submitted
61
107
0
87
60
0
55
43
37
56
162
88
94
70
100
15
85
1120
11186
Percentage of eligible cases submitted
60
99
–
76
44
–
100
36
34
97
72
95
100
69
93
14
93
64
68
Consultant/specialist anaesthetist and surgeon (%)
  1
61
97
–
75
76
–
89
65
97
84
42
80
79
83
92
47
49
66
62
Spinal or epidural anaesthesia (%)
  2
21
36
–
22
35
–
57
49
71
48
44
65
48
60
32
27
28
38
40
Less than 10mg hyperbaric bupivicaine (%)
  3
8
11
–
0
0
–
0
0
0
0
0
2
0
0
3
0
0
1
2
Fentanyl as intrathecal opioid (%)
  4
15
38
–
5
24
–
45
0
23
57
6
31
57
58
12
50
7
25
19
Sedation with midazolam or propofol during spinal (%)
  5
78
48
–
55
32
–
33
25
31
32
73
65
45
42
62
100
37
45
33
Supplemental oxygen during spinal (%)
  6
89
84
–
45
58
–
43
75
50
60
84
70
18
32
85
100
63
56
62
Inhalational agent for GA induction (%)
  7
2
0
–
5
18
–
0
4
33
0
1
0
0
0
0
0
0
4
4
Spontaneous ventilation during GA (%)
  8
28
12
–
23
21
–
61
57
22
55
46
23
18
54
6
9
29
27
36
Nerve block provided (%)
  9
67
52
–
83
62
–
89
58
38
50
59
28
69
81
69
100
86
58
49
General and neuraxial not combined (%)
10
97
100
–
94
100
–
98
95
100
98
98
98
99
100
100
100
99
99
97
Relative hypotension (%)
11a
87
85
–
92
96
–
75
93
100
88
62
85
87
90
93
100
96
90
88
Absolute hypotension (%)
11b
85
64
–
84
77
–
65
73
85
75
82
60
64
77
84
73
85
78
79
No suggestion of possible BCIS (%)
12
81
74
–
91
81
–
100
93
78
88
93
16
77
73
70
89
93
82
87
LONDON
Total number of ASAP cases submitted
72
76
32
35
0
57
19
31
80
20
15
39
0
65
27
0
46
69
53
68
14
32
45
24
46 965 11186
Percentage of eligible cases submitted
96
78 100
55
–
97
90
79
94
53
52
61
–
89
87
–
100
69
91
85 100
76
56
77
78
71
68
Consultant/specialist anaesthetist and surgeon (%)
  1
32
73
47
56
–
68
53
73
38
35
53
51
–
49
83
–
43
91
75
44
50
31
60
38
67
49
62
Spinal or epidural anaesthesia (%)
  2
13
76
19
46
–
63
37
43
70
25
13
44
–
22
46
–
28
28
28
28
50
65
4
75
70
36
40
Less than 10mg hyperbaric bupivicaine (%)
  3
0
4
0
0
–
0
0
23
2
0
0
12
–
0
8
–
0
5
0
0
0
15
0
0
3
3
2
Fentanyl as intrathecal opioid (%)
  4
42
9
57
25
–
58
22
23
33
0
0
59
–
50
62
–
71
21
30
39
43
20
0
20
16
28
19
Sedation with midazolam or propofol during spinal (%)
  5
13
65
0
33
–
15
0
80
21
0
0
15
–
13
0
–
17
11
36
40
50
25
0
64
63
22
33
Supplemental oxygen during spinal (%)
  6
75
63
60
73
–
72
78
40
69 100 100
92
–
75 100
–
58
83
86
70
67
80 100
50
79
67
62
Inhalational agent for GA induction (%)
  7
0
4
0
29
–
0
0
5
5
0
0
17
–
0
0
–
3
0
0
0
14
0
0
0
0
3
4
Spontaneous ventilation during GA (%)
  8
48
54
23
24
–
58
8
5
27
0
7
29
–
45
8
–
18
24
18
41
29
33
14
0
7
21
36
Nerve block provided (%)
  9
75
28
91
57
–
46
58
26
54
70
73
56
–
40
8
–
65
32
45
63
43
28
84
29
80
46
49
General and neuraxial not combined (%)
10
96
89 100
94
–
95
95
83
99 100
93
95
–
100
96
–
100 100
96
87 100
94
98 100
98
96
97
Relative hypotension (%)
11a
92
66
87
79
–
93
89
94
92
89
86
73
–
89
83
–
89
72
94
86 100
58
77
70
98
86
88
Absolute hypotension (%)
11b
76
75
81
59
–
70
79
80
78
60
46
76
–
82
70
–
69
85
96
70
92
65
81
86
78
78
79
No suggestion of possible BCIS (%)
12
100 100 100
92
–
95 100 100
91 100 100
94
–
97 100
–
95
80
74
86 100 100
68 100
74
94
87
NORTHERN IRELAND
Total number of ASAP cases submitted
0
44
77
0
121
11186
Percentage of eligible cases submitted
–
73
93
–
42
68
Consultant/specialist anaesthetist and surgeon (%)
  1
–
95
69
–
41
62
Spinal or epidural anaesthesia (%)
  2
–
48
14
–
16
40
Less than 10mg hyperbaric bupivicaine (%)
  3
–
0
0
–
0
2
Fentanyl as intrathecal opioid (%)
  4
–
57
0
–
14
19
Sedation with midazolam or propofol during spinal (%)
  5
–
6
40
–
11
33
Supplemental oxygen during spinal (%)
  6
–
61
70
–
33
62
Inhalational agent for GA induction (%)
  7
–
13
9
–
5
4
Spontaneous ventilation during GA (%)
  8
–
38
50
–
22
36
Nerve block provided (%)
  9
–
93
92
–
46
49
General and neuraxial not combined (%)
10
–
98
100
–
99
97
Relative hypotension (%)
11a
–
77
93
–
92
88
Absolute hypotension (%)
11b
–
90
87
–
94
79
No suggestion of possible BCIS (%)
12
–
76
94
–
93
87
CRG. Craigavon Area Hospital
RVB. Royal Victoria Hospital
ALT. Altnagelvin Hospital
NORTHERN IRELAND
NUH. Ulster Hospital
ASAP
NORTH EAST
Total number of ASAP cases submitted
72
37
50
94
37
72
100
103
42
88
695
11186
Percentage of eligible cases submitted
84
45
57
90
41
80
93
90
88
85
75
68
Consultant/specialist anaesthetist and surgeon (%)
  1
65
92
15
67
41
82
59
65
100
74
66
62
Spinal or epidural anaesthesia (%)
  2
54
53
36
60
67
35
12
41
70
75
50
40
Less than 10mg hyperbaric bupivicaine (%)
  3
2
5
0
0
0
0
0
2
0
0
1
2
Fentanyl as intrathecal opioid (%)
  4
0
11
0
6
0
4
6
2
47
25
10
19
Sedation with midazolam or propofol during spinal (%)
  5
23
56
43
29
48
17
40
64
32
31
38
33
Supplemental oxygen during spinal (%)
  6
88
25
64
67
57
83
70
85
91
80
71
62
Inhalational agent for GA induction (%)
  7
6
47
10
6
0
6
3
0
8
0
9
4
Spontaneous ventilation during GA (%)
  8
75
47
29
71
47
6
36
13
23
41
39
36
Nerve block provided (%)
  9
42
81
58
44
57
83
89
71
64
40
63
49
General and neuraxial not combined (%)
10
97
94
100
100
92
100
97
100
100
99
98
97
Relative hypotension (%)
11a
83
97
92
86
68
89
94
90
68
88
85
88
Absolute hypotension (%)
11b
78
81
76
73
61
78
77
74
37
78
71
79
No suggestion of possible BCIS (%)
12
83
94
74
100
75
88
77
77
88
86
84
87
FAZ. University Hospital Aintree
BLA. Royal Blackburn Hospital
CMI. Cumberland Infirmary
BOL. Royal Bolton Hospital
NOB. Noble's Hospital
FGH. Furness General
NORTH WEST
Total number of ASAP cases submitted
73
89
66
46
55
99
33
0
56
27
82
28
60
0
92
29
86
32
0
17
0
108
74
50
72
35 1309 11186
Percentage of eligible cases submitted
87
94
80
42
66
99
97
–
98
73
84 100 100
–
91
29 100
52
–
33
–
89
79
54
65
50
64
68
Consultant/specialist anaesthetist and surgeon (%)
  1
86
81
91
98
63
96 100
–
82 100
72
89
83
–
88
78
80
88
–
94
–
89
73
64
48
0
67
62
Spinal or epidural anaesthesia (%)
  2
19
71
42
54
82
14
44
–
65
48
52
31
37
–
8
69
41
66
–
94
–
80
18
16
30
49
40
40
Less than 10mg hyperbaric bupivicaine (%)
  3
0
0
0
0
4
0
0
–
0
0
0
0
0
–
0
0
0
0
–
0
–
1
0
13
0
1
1
2
Fentanyl as intrathecal opioid (%)
  4
0
9
0
28
4
29
0
–
2
23
0
14
3
–
0
0
8
5
–
0
–
1
23
0
14
5
7
19
Sedation with midazolam or propofol during spinal (%)
  5
25
55
46
5
31
33
62
–
26
14
60
56
36
–
0
7
31
69
–
23
–
69
44
29
73
6
31
33
  6
25
89
63
91
79 100
85
–
88
86
77
67
40
–
86
33
77
75
–
77
–
89
78
57
55
4
58
62
Supplemental oxygen during spinal (%)
Inhalational agent for GA induction (%)
  7
2
0
14
10
0
9
0
–
16
0
0
0
11
–
6
0
6
0
–
0
–
0
8
5
6
4
4
4
Spontaneous ventilation during GA (%)
  8
8
38
14
62
9
26
82
–
40
13
38
74
76
–
66 100
38
50
–
0
–
64
32
19
45
7
35
36
Nerve block provided (%)
  9
64
63
71
13
15
84
47
–
33
59
40
48
48
–
83
52
22
94
–
24
–
31
47
82
81
49
44
49
General and neuraxial not combined (%)
10
100
93
91 100
98 100
97
–
96
96
90
81
90
–
97
97
95
97
–
100
–
100
97
98
96
43
94
97
Relative hypotension (%)
11a
97
88
96
95
96
86
90
–
94
92
93 100
92
–
96 100
87
10
–
100
–
90
94
91
69
33
88
88
Absolute hypotension (%)
11b
84
64
77
73
67
74
84
–
80
81
81
96
83
–
92
86
72
89
–
100
–
63
76
79
74
0
80
79
No suggestion of possible BCIS (%)
12
93
82
89
94 100
85 100
–
82
33
88 100
80
–
79 100 100
71
–
88
–
85
51 100
93 100
88
87
RLI. Royal Lancaster Infirmary
OHM. Royal Oldham Hospital
WYT. Wythenshawe Hospital
RPH. Royal Preston Hospital
SHH. Stepping Hill Hospital
WIR. Arrowe Park Hospital
WHI. Whiston Hospital
NORTH WEST
ASAP
SOUTH CENTRAL
Total number of ASAP cases submitted
47
0
62
37
125
111
82
59
78
24
63
688
11186
Percentage of eligible cases submitted
81
–
86
77
70
78
86
91
52
27
85
67
68
Consultant/specialist anaesthetist and surgeon (%)
  1
66
–
79
76
61
57
68
55
47
44
68
56
62
Spinal or epidural anaesthesia (%)
  2
36
–
21
70
60
57
18
57
54
50
38
42
40
Less than 10mg hyperbaric bupivicaine (%)
  3
0
–
0
0
0
0
0
0
0
11
3
1
2
Fentanyl as intrathecal opioid (%)
  4
18
–
47
65
13
70
47
11
10
11
23
29
19
Sedation with midazolam or propofol during spinal (%)
  5
54
–
53
85
82
26
11
67
27
0
38
40
33
Supplemental oxygen during spinal (%)
  6
92
–
40
85
84
44
67
82
78
100
54
66
62
Inhalational agent for GA induction (%)
  7
7
–
2
0
8
0
3
5
8
0
0
3
4
Spontaneous ventilation during GA (%)
  8
33
–
45
36
51
39
27
15
24
67
73
37
36
Nerve block provided (%)
  9
87
–
69
49
52
38
78
67
53
58
65
56
49
General and neuraxial not combined (%)
10
100
–
95
100
99
98
99
98
97
100
95
98
97
Relative hypotension (%)
11a
96
–
89
43
86
92
91
95
55
29
89
79
88
Absolute hypotension (%)
11b
84
–
77
90
76
77
91
80
85
83
70
83
79
No suggestion of possible BCIS (%)
12
71
–
79
90
92
100
100
96
100
86
92
91
87
SOUTH EAST COAST
Total number of ASAP cases submitted
0
95
73
55
31
86
110
117
56
37
78
0
76
102
916
11186
Percentage of eligible cases submitted
–
88
92
44
29
98
92
90
82
44
78
–
67
77
63
68
Consultant/specialist anaesthetist and surgeon (%)
  1
–
80
71
87
52
74
87
77
39
72
92
–
57
89
63
62
Spinal or epidural anaesthesia (%)
  2
–
63
66
13
61
60
25
78
20
25
74
–
73
42
43
40
Less than 10mg hyperbaric bupivicaine (%)
  3
–
12
0
0
0
7
3
76
0
0
0
–
0
19
8
2
Fentanyl as intrathecal opioid (%)
  4
–
1
29
0
16
13
3
37
0
13
0
–
15
10
10
19
Sedation with midazolam or propofol during spinal (%)
  5
–
53
42
43
71
70
32
49
27
75
40
–
41
14
40
33
Supplemental oxygen during spinal (%)
  6
–
73
78
86
86
67
82
100
73
75
89
–
41
76
66
62
Inhalational agent for GA induction (%)
  7
–
0
0
2
9
0
0
0
2
0
0
–
5
20
3
4
Spontaneous ventilation during GA (%)
  8
–
57
50
74
73
35
90
58
44
38
36
–
40
33
45
36
Nerve block provided (%)
  9
–
38
34
93
58
39
72
50
59
62
28
–
16
66
44
49
General and neuraxial not combined (%)
10
–
95
100
100
100
88
100
99
91
100
97
–
100
98
98
97
Relative hypotension (%)
11a
–
83
84
87
87
86
92
69
96
55
70
–
86
94
85
88
Absolute hypotension (%)
11b
–
77
57
71
70
83
92
45
92
72
81
–
77
81
78
79
No suggestion of possible BCIS (%)
12
–
100
61
89
73
97
84
98
79
100
85
–
89
80
88
87
SOUTH WEST
Total number of ASAP cases submitted
34
86
0
110
110
45
81
216
132
101
144
127
65
113
81
36
62
1543 11186
Percentage of eligible cases submitted
25
87
–
94
90
46
94
95
89
94
92
82
81
96
100
44
81
76
68
Consultant/specialist anaesthetist and surgeon (%)
  1
30
35
–
56
87
91
98
80
78
72
65
65
34
75
83
97
85
67
62
Spinal or epidural anaesthesia (%)
  2
58
26
–
9
51
53
12
21
43
74
40
37
25
69
33
31
21
36
40
Less than 10mg hyperbaric bupivicaine (%)
  3
0
0
–
0
1
0
4
5
3
1
1
0
10
0
0
0
0
1
2
Fentanyl as intrathecal opioid (%)
  4
0
0
–
15
9
4
24
17
3
25
7
4
10
2
9
0
15
8
19
Sedation with midazolam or propofol during spinal (%)
  5
77
32
–
33
26
33
36
24
50
54
29
63
67
48
59
50
20
41
33
Supplemental oxygen during spinal (%)
  6
62
79
–
83
34
67
55
64
82
74
75
38
73
95
70
88
80
66
62
Inhalational agent for GA induction (%)
  7
0
2
–
1
0
4
6
2
1
0
5
0
0
0
0
15
4
2
4
Spontaneous ventilation during GA (%)
  8
50
32
–
25
73
48
46
47
71
41
51
82
41
69
48
37
80
50
36
Nerve block provided (%)
  9
56
48
–
76
31
47
48
76
50
17
41
38
70
23
74
56
73
48
49
General and neuraxial not combined (%)
10
97
99
–
95
82
96
84
92
94
98
83
75
92
86
100
94
95
92
97
Relative hypotension (%)
11a
88
69
–
86
86
93
93
88
91
80
95
85
87
85
95
44
100
86
88
Absolute hypotension (%)
11b
78
76
–
85
86
73
91
84
72
69
85
79
76
82
90
73
95
82
79
No suggestion of possible BCIS (%)
12
94
66
–
75
87
91
68
83
87
92
86
79
94
47
81
90
82
82
87
WALES
Total number of ASAP cases submitted
16
67
64
58
132
64
71
69
48
54
50
0
50
Percentage of eligible cases submitted
70
72
74
81
94
97
96
92
94
41
82
–
98
76
68
Consultant/specialist anaesthetist and surgeon (%)
  1
100
95
50
98
18
86
83
81
40
38
86
–
88
66
62
Spinal or epidural anaesthesia (%)
  2
44
47
56
25
21
44
64
10
29
47
38
–
34
35
40
Less than 10mg hyperbaric bupivicaine (%)
  3
14
0
0
0
4
0
2
0
6
0
5
–
0
2
2
Fentanyl as intrathecal opioid (%)
  4
43
0
14
71
39
60
56
33
71
46
0
–
39
36
19
Sedation with midazolam or propofol during spinal (%)
  5
40
4
31
25
8
22
27
20
14
62
20
–
15
22
33
Supplemental oxygen during spinal (%)
  6
100
58
78
75
76
57
77
80
29
76
90
–
92
68
62
Inhalational agent for GA induction (%)
  7
22
3
3
0
2
0
4
10
0
7
0
–
15
5
4
Spontaneous ventilation during GA (%)
  8
22
29
34
24
41
33
21
28
56
41
39
–
33
31
36
Nerve block provided (%)
  9
38
61
61
45
80
45
39
90
67
72
58
–
88
57
49
General and neuraxial not combined (%)
10
100
100
98
100
100
100
99
99
100
100
98
–
100
100
97
Relative hypotension (%)
11a
40
97
97
100
94
94
87
85
85
100
90
–
94
89
88
Absolute hypotension (%)
11b
40
81
87
88
88
78
78
74
90
78
60
–
86
79
79
No suggestion of possible BCIS (%)
12
100
70
67
89
86
62
100
100
100
83
74
–
53
83
87
WEST MIDLANDS
Total number of ASAP cases submitted
57
64
80
67
85
49
100
14
74
120
64
0
127
0
126
0
0
85
1112
11186
Percentage of eligible cases submitted
83
51
86
96
78
83
86
26
81
98
68
–
84
–
96
–
–
77
61
68
Consultant/specialist anaesthetist and surgeon (%)
  1
89
53
95
88
80
90
55
29
78
85
77
–
30
–
26
–
–
71
53
62
Spinal or epidural anaesthesia (%)
  2
25
25
30
73
26
69
26
36
33
67
73
–
13
–
31
–
–
56
32
40
Less than 10mg hyperbaric bupivicaine (%)
  3
0
0
0
7
5
0
3
0
3
6
2
–
5
–
2
–
–
2
2
2
Fentanyl as intrathecal opioid (%)
  4
81
13
14
4
10
78
16
40
12
54
64
–
0
–
79
–
–
2
26
19
Sedation with midazolam or propofol during spinal (%)
  5
75
33
27
19
35
27
29
0
46
25
27
–
46
–
41
–
–
29
26
33
Supplemental oxygen during spinal (%)
  6
17
47
68
87
76
76
35
33
50
82
75
–
54
–
59
–
–
71
46
62
Inhalational agent for GA induction (%)
  7
2
11
4
0
12
7
4
0
11
0
0
–
9
–
9
–
–
3
4
4
Spontaneous ventilation during GA (%)
  8
88
41
46
65
12
43
26
88
72
61
12
–
73
–
41
–
–
78
41
36
Nerve block provided (%)
  9
91
73
70
31
44
45
72
64
51
57
28
–
56
–
83
–
–
47
45
49
General and neuraxial not combined (%)
10
100
98
99
95
100
100
98
100
90
96
100
–
98
–
100
–
–
94
98
97
Relative hypotension (%)
11a
95
92
89
92
93
87
92
93
91
81
80
–
91
–
91
–
–
100
93
88
Absolute hypotension (%)
11b
93
77
86
80
77
80
79
71
78
68
84
–
85
–
73
–
–
80
84
79
No suggestion of possible BCIS (%)
12
100
67
100
66
92
89
80
50
78
84
84
–
90
–
78
–
–
91
86
87
YORKSHIRE AND THE HUMBER
Total number of ASAP cases submitted
71
61
57
19
34
58
58
0
113
103
121
143
78
68
46
81
1111 11186
Percentage of eligible cases submitted
96
91
70
39
31
84
89
–
95
71
86
90
96
100
82
82
75
68
Consultant/specialist anaesthetist and surgeon (%)
  1
79
75
60
79
100
78
68
–
67
48
87
73
87
96
87
52
71
62
Spinal or epidural anaesthesia (%)
  2
52
52
64
95
62
29
49
–
79
49
80
68
77
47
72
56
58
40
Less than 10mg hyperbaric bupivicaine (%)
  3
0
0
3
0
10
0
0
–
5
0
0
7
8
3
0
4
2
2
Fentanyl as intrathecal opioid (%)
  4
69
0
6
0
10
21
3
–
51
4
36
28
2
8
6
0
15
19
Sedation with midazolam or propofol during spinal (%)
  5
6
36
32
69
45
60
48
–
9
35
59
68
36
29
14
59
38
33
Supplemental oxygen during spinal (%)
  6
88
59
71
69
64
60
56
–
76
86
62
74
82
24
71
68
63
62
Inhalational agent for GA induction (%)
  7
11
0
0
0
0
20
21
–
27
6
8
4
12
0
0
3
7
4
Spontaneous ventilation during GA (%)
  8
31
7
43
0
46
27
55
–
41
44
71
76
59
40
33
66
40
36
Nerve block provided (%)
  9
51
40
51
5
65
59
54
–
36
49
64
75
31
21
48
36
43
49
General and neuraxial not combined (%)
10
99
100
98
100
100
100
98
–
97
97
100
99
97
99
98
96
99
97
Relative hypotension (%)
11a
93
88
95
100
100
100
88
–
85
76
91
88
88
84
86
88
91
88
Absolute hypotension (%)
11b
83
67
85
63
79
86
70
–
66
59
61
68
65
80
64
75
73
79
No suggestion of possible BCIS (%)
12
90
88
100
83
83
78
91
–
85
79
88
93
88
60
100
88
87
87

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