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Cardiothoracic proposals promise less delays and more successful outcomes for patients

GIRFT report makes 20 recommendations to improve practice, process and outcomes

Smarter bed management and using designated specialist teams for key cardiothoracic surgery procedures will deliver better outcomes for thousands of patients suffering life-threatening or debilitating chest, heart, and lung conditions, according to a new national report from the Getting It Right First Time (GIRFT) programme.

The report finds that changes to the way cardiothoracic surgical services are organised and delivered in England will bring substantial benefits for patients suffering from conditions such as blocked arteries, lung cancer, and heart valve disease.

Mr David Richens, cardiothoracic surgeon and author of the report, identifies 20 recommendations to improve practices, process and outcomes.  His national report into cardiothoracic surgery in England follows an in-depth outcomes data review of the specialty combined with insight from the clinicians and managers that deliver the service across the 31 cardiothoracic units in the NHS in England.

Among the core recommendations are:

• more efficient bed management by ensuring surgery on day of admission is delivered routinely for cardiothoracic patients, helping reduce delays and time spent in hospital;
• ring-fencing beds on intensive care units (ITU) and general wards for the care of cardiothoracic patients;
• sub-specialisation for certain critical procedures;
• the use of less invasive thoracic surgery known as VATS (video-assisted thoracoscopic surgery) for lung resection surgery. According to the report, VATS reduces complication rates and length of hospital stay.

The report recognises the importance of using specialist surgical teams for certain critical procedures, such as aortovascular surgery for aorta rupture, and mitral valve surgery, and it calls for emergency surgery rotas for major trauma to be covered by both thoracic and cardiac surgeons, ending the practice of using cardiac-dedicated surgeons to provide cover for emergency thoracic surgery. It also proposes that all patients should be reviewed by a consultant pre- and post-operatively, seven days a week, which will support more timely patient discharge particularly over weekends.

Mr Richens said: “This is a ground-breaking report that will make a difference.  I believe the recommendations offer the potential to achieve significant improvements in patient care such as shorter waiting times for surgery, fewer cancellations and better outcomes from surgery for thousands of patients every year.”

Mr Richen’s recommendations bring wider benefits to the NHS and its patients.  Other cost efficiencies to be made through procedural changes, include improved pricing transparency in procurement of equipment, and litigation costs.   Together these potential efficiencies could save the NHS up to £52m.

Further recommendations detailed in the report include:

• Pooling non-elective cases ready for next available theatre session and next available appropriate surgeon.
• Ensuring that individual cases of deep sternal wound infection (DSWI) are reviewed by a multidisciplinary team, led by a consultant microbiologist.
• Establishing a national formal policy for complex and very high-risk cases.
• Establishing collective responsibility for clinical outcomes.
• Attributing outcomes for complex and very high-risk cases to units rather than to individuals.
• Centralising and reducing the number of lung cancer multidisciplinary teams (MDTs).
• Ensuring that a thoracic surgeon is present at every lung cancer MDT meeting.
• Improving the accuracy and quality of coding for cardiothoracic surgery, and including coders in multidisciplinary team meetings (MDTMs) and morbidity and mortality meetings.
• Providers to work with NICOR to improve the quality of data submitted and stored, specifically for return to theatre, deep sternal wound infection, new CVA and post-operative renal replacement therapy.
• Implementing the GIRFT 5-point plan for reducing litigation costs.

The recommendations have been fully endorsed by the Society for Cardiothoracic Surgery (SCTS).

The SCTS together with The Royal College of Surgeons (RCS) said:

“Patients undergoing cardiothoracic surgery are some of the most ill that the NHS cares for, suffering conditions such as heart valve disease, lung cancer and blocked arteries.

“Cardiothoracic surgeons have pioneered the collection and publication of clinical outcomes data and since monitoring and publishing survival rates for adult cardiac surgery, we have seen a progressive improvement in outcomes. Survival rates for patients having cardiothoracic surgery in the UK are now amongst the best in the world.

“With the far wider range of clinical and process measures that are now available as a result of the GIRFT report, cardiothoracic units can now benchmark performance against the national average, a powerful tool for continued improvements in services to patients.  As an example, the report suggests that more efficient bed management for cardiothoracic patients will help reduce delays, cancellations and long stays in hospital.

“SCTS and the RCS strongly support the report’s recommendation that certain conditions, such as aortovascular surgery for aorta rupture, and mitral valve surgery, must be treated by surgeons who are specialists in these areas. We also support GIRFT’s recommendation on the greater use of minimally invasive thoracic surgery for the treatment of early stage lung cancers.

“We now urge the NHS to act upon the recommendations made in this report.”

The recommendations will be carried out by GIRFT’s implementation teams, working with NHS Improvement and alongside bodies such as NHS England, NHS RightCare, the Society for Cardiothoracic Surgery and the Royal College of Surgeons, as well as directly with the trusts, Clinical Commissioning Groups and Sustainability and Transformation Partnerships.