Carotid Endarterectomy Audits

Round 1

Round 1 included operations between 1 December 2005 and 31 December 2007.

Key recommendations:

All staff involved in organising and delivering care to patients who require carotid surgery need to examine their data and assess their performance against standards within NICE Guideline CG68.

Clinicians should ensure that data from patients having carotid surgery are included in national clinical audit. Appropriate time within job plans must be made available for consultants to validate and act upon their data.

Systems should be in place to ensure that coding of patients with carotid surgery is accurate. This requires close collaboration between hospital coding departments and clinicians and is likely to require regular (at least monthly) coding review meetings with the vascular team.

Every health economy offering carotid surgery must have a clearly documented pathway of care. This should state how the patient accesses services and how they flow through to surgery if required.

Clinicians involved in providing care to patients with TIA and minor stroke should ensure that there are agreed referral protocols to minimise delays in the pathway.

It is recommended that referrals to vascular surgery or interventional radiology should go to a central point within the department, rather than individual clinicians. There should be someone available to deal with referrals on a daily basis. These processes should work both during the working week and at the weekend.

Patients requiring carotid endarterectomy should be allocated to the next available operating list (ideally within 3 days of referral).

Carotid intervention should be prioritised as urgent/emergency in all symptomatic cases.

Clinical teams should seek feedback from patients to help improve the quality of care offered.

Stroke teams should publicise their services to primary care and the public. Attention should be given to highlighting the importance of amaurosis fugax as this diagnosis is associated with significantly greater delays in the pathway.

Round 2

Data were returned by 93% of eligible surgeons, reporting 70% (6970/10,022) of cases reported in HES in the same time period (1st January 2008 to 30th September 2009).

Aims

To assess the current speed of delivery of CEA in the UK.
To assess variations in access and quality of care for patients needing CEA.
To assess 30-day mortality and complications rates following CEA.
To stimulate improvements over time in the quality of care provided to patients of CEA.

While data reporting has improved, rates of data capture to national audits needs to improve further. Commissioners should require this from all vascular units. While there has been a reduction in delay from symptoms to treatment, there is significant room for improvement. Many patients are not being treated within the timeframe set by NICE or the National Stroke Strategy.

Significant delay occurs between symptom and presentation. Better public awareness of TIA and stroke is needed.

Delays in referral or due to lack of operating staff and facilities need to be addressed by trusts.

The reported complication rates are much lower than those reported from clinical trials, it is recommended that all patients undergoing Carotid Endarterectomy should have both surgical and stroke physician/neurologist follow up

Round 3

The Round 3 Report showed that there continued to be an increase in the percentage of cases being submitted to this audit in England compared to the number recorded in Hospital Episode Statistics, from 67% round 1, 72% in round 2, 81% in round 3.

This was submitted from 96% of eligible trusts in England and 97% of trusts overall in the UK.

The National Stroke Strategy’s 10-year target of 48 hours between symptom and surgery was set in 2007, and the current National Institute for Clinical Excellence guidelines recommend 14 days.

The key delays in the pathway between initial symptom and surgery were continuing to decrease, and in round 3 the median number of days between symptom and surgery was 21 days, compared with 28 days in round 2.

UK Carotid Audit Report 2011

Round 4

Increase in the percentage of cases being submitted to this audit in England compared to the number recorded in HES, from 67% round 1, 72% in round 2, 81% in round 3, to 90% in round 4.

Cases were submitted from 97% of eligible trusts in England and 98% of trusts overall in the UK.

The National Stroke Strategy’s 10-year target of 48 hours between symptom and surgery was set in 2007, and the current National Institute for Clinical Excellence guidelines recommend 14 days.

The key delays in the pathway between initial symptom and surgery were continuing to decrease, and in round 4 the median number of days between symptom and surgery was 15 days, compared with 21 days in round 3 and 28 days in round 2. This trend can also be seen within each round.

In round 4;

4% of patients had surgery within 48 hours and 49% within 14 days.
30-day mortality was 0.8% and 2% of patients with follow-up had a stroke.
2% of patients had surgery within 48 hours and 40% within 14 days.
30-day mortality was 0.8% and 3% of patients with follow-up had a stroke.

UK Carotid Audit Report 2012

Round 5

The main aims of the audit:

To assess the current speed of delivery of carotid endarterectomy in the UK.
To assess variations in access and quality of care for patients needing carotid endarterectomy.
To assess 30-day mortality and complications rates following carotid endarterectomy.
To stimulate improvements over time in the quality of care provided to patients undergoing carotid endarterectomy.

5,723 carotid endarterectomies tperformed between 1st October 2011 and 30th September 2012 from a total of 117 NHS trusts/health boards in the UK.

More than half of NHS patients who require a carotid endarterectomy are accessing it within the two week guideline as set by the National Institute for Health and Care Excellence (NICE).

UK Carotid Audit Report 2013