Correspondence
7 Hamid B.R., Fereshtehnejad S.M., Khanbabazadeh S. et al. (2014) Munster correlation’’ in temporal bone: surgical relevance of an anatomical study. Anat. Sci. Int. 89, 112–117 8 Lee J.Y., Shin K.J., Kim J.N. et al. (2013) A morphometric study of the semicircular canals using micro-ct images in three-dimensional reconstruction. Anat. Rec. (Hoboken) 296, 834–839 9 Nitek S., Wysocki J., Niemczyk K. et al. (2006) The anatomy of the tympanic sinus. Folia Morphol. 65, 195–199
A service evaluation of HDU-related adenotonsillectomy cancellations in one hundred and sixty-nine children at a University Teaching Hospital Bowles, P.F.D., Moore, A., Dezoysa, N. & Watts, S. Department of Otorhinolaryngology, Head and Neck Surgery, Royal Sussex County Hospital, Brighton, UK Accepted for publication 21 June 2015
Dear Editor, Obstructive sleep apnoea (OSA) affects around 2% of children1–4 and is characterised by prolonged partial upper airway obstruction and/or intermittent complete obstruction causing disruption to normal ventilation during sleep.1,5 The cardiorespiratory and neurodevelopmental sequelae of OSA are well recognised, with adenotonsillectomy (AT) remaining the mainstay of treatment. Chronic nocturnal hypoxia and resultant depression of the central ventilatory drive puts a proportion of this patient group at risk of postoperative respiratory complications.1 While consensus exists that children with severe OSA should be monitored postoperatively, including in some cases elective admission to a paediatric high dependency (HDU) or intensive care units (PICU), guidance regarding the specific level of care required is lacking.3,4,6–8 Demand for paediatric critical care resources typically exceeds availability creating a clinical dilemma in the routine advanced booking of such facilities for elective procedures for which they may ultimately not be required. In our unit, advanced HDU booking is based on a combination of polysomnography findings and clinical assessment by an experienced ENT surgeon. However, patients with pre-booked HDU beds are frequently deemed suitable for ward care postoperatively by the anaesthetist on the day of surgery raising the question of whether HDU beds Correspondence: P. Bowles, Department of Otorhinolaryngology, Head and Neck Surgery, Royal Sussex County Hospital, Eastern Road, Brighton BN2 5BE, UK. Tel.: + 07854514790; Fax: +01273626653; e-mail: philbowles@ doctors.org.uk © 2015 John Wiley & Sons Ltd Clinical Otolaryngology 41, 176–196
are over-requested. It was also observed that procedures are frequently cancelled on the day of surgery due to a lack of an available HDU bed, leading to anxiety and disappointment for patients and families, under utilisation of operating theatre capacity and increased pressure on waiting lists. A 2009 consensus statement produced by a UK expert panel sets out criteria for identifying children at high risk of postoperative respiratory complications.6 We applied this guidance as qualifying criteria for advanced HDU bed requests. Methods Ethical considerations
This service evaluation study was registered with the local hospital trust Clinical Audit department. Data were anonymised and 128 bit encrypted. Method
This was a retrospective review of case notes and hospital computerised databases carried out in two cycles (January– December 2012 & May 2013–March 2014). The setting was a tertiary referral University Teaching Hospital. All cases of paediatric adenotonsillectomy for treatment of OSA for the study periods were included. Records were examined for evidence of (i) pre-booked HDU bed, (ii) indication for advanced HDU booking, (iii) cancellation on day of surgery due to lack of an available HDU bed. The chosen audit
CORRESPONDENCE: OUR EXPERIENCE
3 Ahmed R.M., Pohl D.V., MacDougall H.G. et al. (2012) Posterior semicircular canal occlusion for intractable benign positional vertigo: outcome in 55 years in 53 patients operated upon over 20 years. J. Laryngol. Otol. 126, 677–682 4 Parnes L.S. & McClure J.A. (1990) PSCCO for intractable BPPV. Ann. Otol. Rhinol. Laryngol. 99, 330–334 5 Hildmann H., Sudhoff H., Dazert S. et al. (2011) Manual of Temporal Bone Exercises. Springer Berlin Heidelberg, ISBN: 978-3-642-19497-9 6 Aoki S., Takei Y., Suzuki K. et al. (2012) Planer orientation of the bilateral SCC in dizzy patients. Auris Nasus Larynx 39, 451–454
193
194 Correspondence
Fig. 1. Reduction in the number of advanced HDU bed requests and HDU-related cancellations on day of surgery.
standard was published national guidance.6 Following the first audit cycle, an HDU booking card adapted from the audit standard was introduced (Appendix S1). Completed booking cards were submitted to the waiting list manager when listing patients for surgery. Advanced HDU requests made without completed booking cards were returned to respective clinicians. The audit was repeated for the subsequent 11-month period. Results were collated and analysed using Microsoft Excel.
pre-booked for 51% (n = 48) of cases. In total, 11% (n = 10) were cancelled on the day of surgery due to lack of an available HDU bed. In total, 42% (n = 21) of preoperative HDU bed requests were outside the chosen audit standard. A total of 74 procedures were performed between May 2013 and March 2014 following the introduction of an HDU booking card. During this cycle, HDU beds were pre-booked for 20% (n = 15) of cases with 5% (n = 4) of cases cancelled on the day of surgery due to HDU capacity (Fig. 1). All advanced HDU bookings met the criteria set out by the audit standard. During the second cycle, indications for HDU bed requests were severe OSA (n = 4), cerebral palsy (n = 2), weight
7 Hamid B.R., Fereshtehnejad S.M., Khanbabazadeh S. et al. (2014) Munster correlation’’ in temporal bone: surgical relevance of an anatomical study. Anat. Sci. Int. 89, 112–117 8 Lee J.Y., Shin K.J., Kim J.N. et al. (2013) A morphometric study of the semicircular canals using micro-ct images in three-dimensional reconstruction. Anat. Rec. (Hoboken) 296, 834–839 9 Nitek S., Wysocki J., Niemczyk K. et al. (2006) The anatomy of the tympanic sinus. Folia Morphol. 65, 195–199
A service evaluation of HDU-related adenotonsillectomy cancellations in one hundred and sixty-nine children at a University Teaching Hospital Bowles, P.F.D., Moore, A., Dezoysa, N. & Watts, S. Department of Otorhinolaryngology, Head and Neck Surgery, Royal Sussex County Hospital, Brighton, UK Accepted for publication 21 June 2015
Dear Editor, Obstructive sleep apnoea (OSA) affects around 2% of children1–4 and is characterised by prolonged partial upper airway obstruction and/or intermittent complete obstruction causing disruption to normal ventilation during sleep.1,5 The cardiorespiratory and neurodevelopmental sequelae of OSA are well recognised, with adenotonsillectomy (AT) remaining the mainstay of treatment. Chronic nocturnal hypoxia and resultant depression of the central ventilatory drive puts a proportion of this patient group at risk of postoperative respiratory complications.1 While consensus exists that children with severe OSA should be monitored postoperatively, including in some cases elective admission to a paediatric high dependency (HDU) or intensive care units (PICU), guidance regarding the specific level of care required is lacking.3,4,6–8 Demand for paediatric critical care resources typically exceeds availability creating a clinical dilemma in the routine advanced booking of such facilities for elective procedures for which they may ultimately not be required. In our unit, advanced HDU booking is based on a combination of polysomnography findings and clinical assessment by an experienced ENT surgeon. However, patients with pre-booked HDU beds are frequently deemed suitable for ward care postoperatively by the anaesthetist on the day of surgery raising the question of whether HDU beds Correspondence: P. Bowles, Department of Otorhinolaryngology, Head and Neck Surgery, Royal Sussex County Hospital, Eastern Road, Brighton BN2 5BE, UK. Tel.: + 07854514790; Fax: +01273626653; e-mail: philbowles@ doctors.org.uk © 2015 John Wiley & Sons Ltd Clinical Otolaryngology 41, 176–196
are over-requested. It was also observed that procedures are frequently cancelled on the day of surgery due to a lack of an available HDU bed, leading to anxiety and disappointment for patients and families, under utilisation of operating theatre capacity and increased pressure on waiting lists. A 2009 consensus statement produced by a UK expert panel sets out criteria for identifying children at high risk of postoperative respiratory complications.6 We applied this guidance as qualifying criteria for advanced HDU bed requests. Methods Ethical considerations
This service evaluation study was registered with the local hospital trust Clinical Audit department. Data were anonymised and 128 bit encrypted. Method
This was a retrospective review of case notes and hospital computerised databases carried out in two cycles (January– December 2012 & May 2013–March 2014). The setting was a tertiary referral University Teaching Hospital. All cases of paediatric adenotonsillectomy for treatment of OSA for the study periods were included. Records were examined for evidence of (i) pre-booked HDU bed, (ii) indication for advanced HDU booking, (iii) cancellation on day of surgery due to lack of an available HDU bed. The chosen audit
CORRESPONDENCE: OUR EXPERIENCE
3 Ahmed R.M., Pohl D.V., MacDougall H.G. et al. (2012) Posterior semicircular canal occlusion for intractable benign positional vertigo: outcome in 55 years in 53 patients operated upon over 20 years. J. Laryngol. Otol. 126, 677–682 4 Parnes L.S. & McClure J.A. (1990) PSCCO for intractable BPPV. Ann. Otol. Rhinol. Laryngol. 99, 330–334 5 Hildmann H., Sudhoff H., Dazert S. et al. (2011) Manual of Temporal Bone Exercises. Springer Berlin Heidelberg, ISBN: 978-3-642-19497-9 6 Aoki S., Takei Y., Suzuki K. et al. (2012) Planer orientation of the bilateral SCC in dizzy patients. Auris Nasus Larynx 39, 451–454
193
194 Correspondence
Fig. 1. Reduction in the number of advanced HDU bed requests and HDU-related cancellations on day of surgery.
standard was published national guidance.6 Following the first audit cycle, an HDU booking card adapted from the audit standard was introduced (Appendix S1). Completed booking cards were submitted to the waiting list manager when listing patients for surgery. Advanced HDU requests made without completed booking cards were returned to respective clinicians. The audit was repeated for the subsequent 11-month period. Results were collated and analysed using Microsoft Excel.
pre-booked for 51% (n = 48) of cases. In total, 11% (n = 10) were cancelled on the day of surgery due to lack of an available HDU bed. In total, 42% (n = 21) of preoperative HDU bed requests were outside the chosen audit standard. A total of 74 procedures were performed between May 2013 and March 2014 following the introduction of an HDU booking card. During this cycle, HDU beds were pre-booked for 20% (n = 15) of cases with 5% (n = 4) of cases cancelled on the day of surgery due to HDU capacity (Fig. 1). All advanced HDU bookings met the criteria set out by the audit standard. During the second cycle, indications for HDU bed requests were severe OSA (n = 4), cerebral palsy (n = 2), weight
