Methods Of The 7th National Audit Project (NAP7) Of The Royal College .

Kane et al. Methods of the 7th National Audit Project (NAP7)Anaesthesia 2022their local co-ordinators when they had completed theiranaesthesia or sedation in the emergency departmentsurvey to enable the calculation of a response rate. All(if administered by an anaesthetist); out of hours work; andanaesthetists in the UK, including consultants, specialty,regional anaesthesia. Any patient returning to theatre for aspecialist, staff grade and SAS grades, trainees andsecond procedure was entered as a separate case. Similarly,anaesthesiaparticipate.obstetric patients could be entered separately for eachThe second baseline survey assessed departmentalencounter. The following scenarios were not studied:organisation concerning peri-operative cardiac arrest.sedation or anaesthesia solely for critical care or proceduresSurvey questions focused on staff mix, case mix, procedureson critical care; newborn resuscitation; inter- or intra-for summoning emergency help, access to emergencyhospital transfers.associates,wereinvitedtoguidelines, resuscitation equipment, including eeonlineQuestion design combined building on previousiterations of the activity survey used in previous NAPs andcollecting individual case data pertinent to understandingSupporting Information, Appendix S2).andperi-operative cardiac arrest. Data fields included: patientdepartmental baseline surveys were formulated and agreedcharacteristics; comorbidities; resuscitation status; frailty;upon by the NAP7 steering panel. Both surveys were testedanaesthetic technique; monitoring; and complicationsinternally within the panel, with multiple iterations leading toduring anaesthesia (see online Supporting Information,final versions. The surveys were distributed before the launchAppendix S3). Where questions had been asked in previousdate of the case registry component of NAP7. They remainedactivity surveys, the format of the question was kept, thusopen for approximately 4 and 9 months, respectively. Theenabling trends over time to be assessed. The stakeholdersurveys were undertaken using an electronic survey toolpanel tested the activity survey internally before Monkey , Momentive.ai, San Mateo, CA, USA). Dataapproval. Local co-ordinators were provided with a link towere extracted and cleaned using Microsoft Excel 2022the survey via SurveyMonkey for distribution at their site,(Microsoft Inc., Redmond, WA, USA) and checked forand a QR code on the help sheet provided direct access.duplicates. Quantitative analysis was performed usingRespondents were advised to complete the survey at theMicrosoft Excel, and qualitative data analysis was undertakenend of each case. After analysis, data will be presented asafter importing on Pulsar v2022 (Pulsar TRAC, first-party datasummary measures of raw data. Where frequencies oftool, Pulsar Platform, Los Angeles, CA, USA). The activityevents within groups are shown, they may be normalised tosurvey comprised a cross-sectional observational study tothe population size. Confidence intervals will be calculatedcollect denominator data about anaesthetic activity, patientas appropriate. Where appropriate, the differences withincharacteristics and adverse events during anaesthesia care,groups will be assessed by appropriate statistical tests.building on the previous methodology [5, 10]. The surveyAn annual caseload will be estimated by multiplying theenables the incidence of events occurring during the one-number of cases by a scaling factor, which accounts foryear case reporting phase of the project to be comparedscaling the 4-day survey to a year and accounts for missedagainst the caseload.data and uninterpretable forms [5]. To exclude erroneousAll sites were assigned randomly a continuous 4-daydata and data entry mistakes, we will examine the data todata collection period, with an equal chance of starting onensure the fields are compatible for low-frequency eventsany day of the week. Case collection included all cases that[14, 15]. For example, a malignant hyperthermia reportstarted from 00.00 on day 1 until 23.59 on day 4 of the localwithout hyperthermia or metabolic complications is likelycollection period. Local co-ordinators were advised toto be a mistake. Two reviewers will assess these events andcapture all cases under the care of an anaesthetist duringrefer discrepancies to a third for overall decision-making.the period, including cases requiring general anaesthesia,Reports will be removed if judged to be a mistake. The studyregional anaesthesia/analgesia, sedation, local anaesthesiaundertook a registry of peri-operative cardiac arrest cases.or monitored anaesthesia care (i.e. care by anaesthetistThe registry was open for cases occurring between 00.00 onwithout administration of anaesthetic drugs). Local co-16 June 2021 and 23.59 on 15 June 2022, with a plan toordinators were reminded to include: emergency andremain open for approximately 3 months to allow datatrauma theatres; labour ward and obstetric theatres;entry.procedures occurring away from their main site (e.g. dayTo be reported, the NAP7 steering panel definedsurgery unit, electroconvulsive therapy unit); interventionalperi-operative cardiac arrest as five or more chestpain procedures in operating theatres or pain clinics;compressions and/or defibrillation in a patient having adiagnosticprocedure under the care of an anaesthetist (Table 1).andinterventionalradiology;emergency 2022 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists.3

Kane et al. Methods of the 7th National Audit Project (NAP7)Anaesthesia 2022There must be at least five compressions, which maysubmission website. Before accessing the secure webpage,be direct compression of the heart, mechanical chestthe reporter was required to change their password. Thecompressionorsteering panel designed the structured case report ryarrest.(see online Supporting Information, Appendix S4) toDefibrillation was defined as an unsynchronised directcapture the breadth and depth of data needed for eachstartedduringcardiaccurrent (DC) shock for ventricular fibrillation (VF) orcase whilst minimising the risk of patient, clinician orpulseless ventricular tachycardia (pVT). It included externalhospital identification. No patient, clinician or hospital dataor internal defibrillation, manual or automated externalwill be admissible on the form. Neither the project team nordefibrillation (AED), shocks by implanted cardioverterthe RCoA can identify which local co-ordinator entereddefibrillators (ICDs) for VF/pVT and/or a precordial thump.which case(s). The reporting site reminds reporters to checkSynchronised DC shock for cardioversion does notfor identifiers before submitting and locking an entry torepresent defibrillation. The steering group chose a cut-offthe registry. Once completed and finalised ( locked ), theof five compressions to exclude cases with a very briefsubmitted form was automatically transferred to the clinicalperiod of chest compression in which cardiac arrest waslead to enable analysis.unlikely to have occurred.In cases where it was not clear that a case may orPatients under the care of an anaesthetist include thosemay not have met inclusion criteria, an independentundergoing general anaesthesia, regional anaesthesia/moderator was available to discuss this. If there is stillanalgesia, sedation, local anaesthesia or monitoreddoubt, the default was to report the case. The moderator(s)anaesthesia care with an anaesthetist or anaesthesiawere not on the review panel and had no contact withassociate present.the review panel throughout the project. They were notThe peri-operative period was defined as from eitherpermitted to discuss cases with review panel members.the WHO sign-in or first hands-on contact with a patientThis process was vital to maintain confidentiality betweento 24 h after the handover of the patient to recovery orreports and reviewers.another clinician (e.g. ICU, ward care) or hospital discharge.The NAP7 review panel met monthly to review andIn addition to these core definitions, there are severalclassify a representative sample of submitted cases usingspecial inclusion circumstances. We included: critically illthe methodology established in previous NAPs [7, 10,children anaesthetised for retrieval or awaiting transfer to12]. Each case was reviewed by a group of three to fiveanother hospital; emergency department cases in whomclinical and patient representative panel members, witha procedure was planned but in whom cardiac arrestseveral groups performing reviews concurrently. Theoccured before this is possible; cases of regional blockoutputs of the reviews are used to populate a structuredperformed by anaesthetist outside the operating theatre;outputand obstetric analgesia (including remifentanil patient-Appendix S5). This report form guides review groupscontrolled analgesia). Cases where a patient was already inthrough assessment of anaesthetic care, managementcardiac arrest before an anaesthetist attends will not beduringstudied (Table 2). Other exclusions include defibrillationdebrief and anaesthetist well-being, contributory andduring electrophysiological procedures when this is acausal factors to the event. The severity of harm wasplanned, normal, or expected part of the procedure (e.g.assessed according to the National Patient Safety Agencyduring VT ablation) and ASA physical status 6 patients(NPSA) grading [16]. After the case review in small(patients being prepared for, or undergoing, organ donationgroups was complete, review groups presented casesafter diagnosis of death using neurological criteria).and analyses to the whole review panel (typically resuscitationInformation,care,caseCase reporting was confidential, and all patient,members) at the end of each session to moderate thehospital, and clinician details were anonymised at thefindings and note points of interest. Key lessons andsource by the reporting clinician or the local co-ordinator.keywords from each case are recorded. Case reviewersWhen a local co-ordinator or other anaesthetist needed towere not permitted to discuss case details outside thereport a case, they contacted the NAP7 administrator. Thereview meetings. If a review panel member had anyreporter confirmed that this was a peri-operative cardiacknowledge of a case from direct involvement or indirectarrest as defined above and that the case occurred duringmeans (e.g. local morbidity and mortality meetings), theythe data collection period. After confirmation that the casewere not permitted to highlight this or bring thatmet inclusion criteria, the reporter was issued a uniqueknowledge to the process as either of these actionsidentifier and password to a secure encrypted casewould risk de-anonymising the case record.4 2022 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists.

Kane et al. Methods of the 7th National Audit Project (NAP7)Anaesthesia 2022Table 1 Extended definition of cardiac arrest.Under the care of ananaesthetistIncludesExcludes General anaesthesia, regional anaesthesia/analgesia,sedation, local anaesthesia or monitored anaesthesia carewith an anaesthetist presentPatients who are directly managed by an anaesthesiaassociate Sedation or local anaesthesia where ananaesthetist is not presentThere must be at least 5 compressions. Four compressions or fewer Synchronised DC shock for cardioversion. Chest compressions Includes:sssDefibrillationdirect compression of the heart;mechanical chest compression; andextracorporeal cardiopulmonary resuscitationstarted during cardiac arrest Defibrillation is an unsynchronised direct current (DC)shock for ventricular fibrillation (VF) or pulselessventricular tachycardia (pVT) Includes:ssssExternal or internal defibrillationManual or automated external defibrillationShocks by implantable cardioverter defibrillatorsfor VF/pVTPrecordial thumpThe review panel refers to published guidelines ascompared using Chi-squared or Fisher’s exact test asindications for current best practices, including, but notappropriate. The incidence rates of events (e.g. cardiaclimited to, those from the Resuscitation Council (UK) andarrest) will be calculated using denominator data from theEuropean Resuscitation Council for adult and paediatricactivity survey. Logistic regression will be used toadvanced life support [17–21], Association of Anaesthetistscalculate ORs and 95%CIs for outcomes of interest. DataQuick Reference Handbook [22], and specialist societyanalysis will be performed using R (R Core Team, Vienna,guidelines (e.g. Cardiac Advanced Life Support [23]), andAustria).guidance covering treatment escalation plans and end-of-themes, potential areas for separate analysis and possiblelife care (e.g. ReSPECT) [24]. The panel judged overallrecommendations. These will be revisited and synthesisedquality of care as good , poor , good and poor or unclear at the point of report writing. Keywords will be recordedbased on guidelines, the specific circumstances of the case,for each case.QualitativeanalysiswillidentifyemergingFor the 12-month case registry, all data will beand ultimately by panel consensus.Previous NAPs have reviewed approximately 200 cases.uploaded via a secure web-based tool using SSLIn NAP7, up to 1000 cases may be reported. Once theencryption. The NAP7 team at the RCoA will control accessreview process is established, a complimentary rapid reviewto the tool, with security and confidentiality maintainedprocess will be used to allow learning from all cases to bethrough a registration process and the use of usernamesincorporated into the final report. Rapid review cases will beand passwords. No identifiable patient, clinician or hospitalassessed by two panel members independently. Where theinformation will leave any site; only anonymised data will becase requires subspecialty expertise, one reviewer will bereceived and analysed at the RCoA. The RCoA hasfrom the relevant stakeholder group. The review outcomeestablished suitable physical, electronic and managerialwill focus on the quality of care and learning points. If eitherprocedures to safeguard and secure the informationpanel member records that the case should be reviewed bycollected online (see online Supporting Information,the full panel or there is a notable disagreement betweenAppendix S6). The project was approved by all four Chiefpanel members in their assessment, the case will beMedical Officers of the UK (see online Supportingsubmitted for full panel review.Information, Appendix istics and clinical variables will be presented withDiscussioncontinuous variables as percentiles and discrete variablesThis project is likely to be the largest and mostas frequencies and percentages. Categorical data will becomprehensive prospective study of peri-operative cardiac 2022 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists.5

Kane et al. Methods of the 7th National Audit Project (NAP7)Anaesthesia 2022Table 2 Specific inclusion and exclusion criteria.IncludesExcludesCardiology and cardiacsurgery Obstetrics Anaesthesia for cardiology and cardiac surgicalprocedures Cardiopulmonary bypass from arterial/aortic cannula insertion to removalDefibrillation during electrophysiologicalprocedures when this is a planned,normal, or expected part of theprocedure (e.g. during VT ablation)Patients with obstetric epidural and/or spinal up to24 h after deliveryPatients with remifentanil patient-controlled analgesia Cardiac arrest before the start ofanaesthesia care (as defined above) orwith no anaesthetic interventionPaediatrics (aged 18 y) As for adults, with the addition of special inclusioncriteria for children anaesthetised for resuscitationbefore retrieval or transfer to another hospital Newborn resuscitationCritical care Patients on critical care within 24 h of the end of theirprocedure/handover to the critical care teamPatients on critical care having an interventionalprocedure in another location under the care of ananaesthetist (excludes diagnostic imaging) from firsthands-on intervention, including transfer Sedation or anaesthesia solely for criticalcareProcedures performed in the critical careunit (e.g. percutaneous tracheostomy).Any intra-hospital or inter-hospitaltransfers originating in critical care. ECMO for any other indication Extracorporealcardiopulmonaryresuscitation Veno-arterial ECMO started during cardiac arrestStart defined as the initiation of extracorporeal flow tothe patient after cannulation and circuit connection tocannulaePain medicine As per general inclusion criteria (includes proceduresin pain clinic)Radiology Patients under the care of an anaesthetist for imagingin the radiology departmentInterventional radiology procedures, as per generalinclusion criteria – including stroke thrombectomy/coiling for subarachnoid haemorrhage Patients transferred forradiology from critical careRegional blockade performed by an anaesthetistoutside of the theatreUntil 24 h after the procedure Procedures performed on critical carePatients under the care of an anaesthetist who wouldmeet the general criteria for NAP7 inclusion in whomanaesthesia care for an interventional procedure startsin the Emergency Department Adult patients who are anaesthetisedsolely for critical care (paediatric patientsmay be included as per inclusion criteriaabove)Patients anaesthetised solely for transferto critical care Regional anaesthesia andanalgesia Emergency Department Other locations Electroconvulsive therapy suite, even if in a separatebuilding and/or hospital trust diagnosticPatients in the pre-assessment clinicPatients undergoing exercise testingPatients who are not in the hospitalPatients in the surgical admissions unit,ward or theatre complex before theirprocedureVT, ventricular tachycardia; ECMO, extracorporeal membrane oxygenationarrest to date. A strength of the NAP methodology iscontextualised in light of the baseline surveys, giving insightmatching numerator (from the case review process) andinto how individuals and departments train for cardiac arrestdenominator data (from the activity survey) to provideand report their experiences.incidences of events and to enable the calculation of riskCentral to the project has been how to define what aestimates. Further, the granularity of the data will enable usperi-operative cardiac arrest is. We have adopted theto explore how the risks vary with age, sex, ASA physicaldefinition of cardiac arrest as chest compressions and/orstatus, comorbid status, frailty and more. These data will bedefibrillation , and our outcome measures are based on6 2022 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists.

Kane et al. Methods of the 7th National Audit Project (NAP7)Anaesthesia 2022the internationally agreed Utstein template [25]. We[27], and there may be similar high-impact learning fromacknowledge that some cases where a cardiac arrest hasNAP7 in this environment.occurred but chest compressions or defibrillation are notAs with previous NAPs, there is a need to examine aperformed will be excluded, e.g. patients with do notstable healthcare system that is not in fluctuation or crisis.attempt cardiopulmonary resuscitation recommendationsThe project was due to launch May 2020, and when thewhich have been kept active in the peri-operative phase.COVID-19 pandemic led to major healthcare

College of Anaesthetists chose peri-operative cardiac arrest as the 7th National Audit Project topic. The study was open to all UK hospitals offering anaesthetic services and had a three-part design. First, baseline surveys of all anaesthetic departments and anaesthetists in the UK, examining respondents'