Recent NICE guidance of interest to surgeons BRUCE CAMPBELL Chair, Interventional Procedures and Medical Technologies Advisory Committees, National Institute for Health and Care Excellence

Quality standards Surgical site infection (QS49) NICE quality standards cover high priority areas of practice. Each consists of a series of statements designed to underpin and enable measurement of improvements in quality of care. The quality standard on surgical site infection was published in October 2013 and included the following statements: Statement 1: People having surgery are advised not to remove hair from the surgical site and are advised to have (or are helped to have) a shower, bath or bed bath the day before or on the day of surgery. Statement 2: People having surgery for which antibiotic prophylaxis is indicated receive this in accordance with the local antibiotic formulary. Statement 3: Adults having surgery under general or regional anaesthesia have normothermia maintained before, during (unless active cooling is part of the procedure) and after surgery. Statement 4: People having surgery are cared for by an operating team that minimises the transfer of microorganisms during the procedure by following best practice in hand hygiene and theatre wear, and by not moving in and out of the operating area unnecessarily. Statement 5: People having surgery and their carers receive information and advice on wound and dressing care, including how to recognise problems with the wound and who to contact if they are concerned. Statement 6: People with a surgical site infection are offered treatment with an antibiotic that covers the likely causative organisms and is selected based on local resistance patterns and the results of microbiological tests. Statement 7: People having surgery are cared for by healthcare providers that monitor surgical site infection rates (including post-discharge infections) and provide feedback to relevant staff and stakeholders for continuous improvement through adjustment of clinical practice. If surgeons regard some of these statements as remarkably obvious and even banal, that suggests they have been well chosen. Quality statements should describe practice that most thoughtful doctors would see as fundamental to good care. As with all NICE guidance, it is important that recommendations are read carefully and that any subtext is heeded. In this instance, the first recommendation (about not removing hair from the surgical site) is about advising patients not to do so themselves. Necessary shaving on the

day of surgery by healthcare staff, with single use electric clippers, is explicitly supported in the quality statement. Quality statements will be used increasingly by commissioners in monitoring the services they purchase from hospitals. This makes the recognition and pursuance of them important for all those involved in the care of surgical patients.

Clinical guidelines Intravenous fluid therapy in adults in hospital (CG174) All surgeons should be aware of this clinical guideline, which was published in December 2013. Much of the text is based around the ‘five Rs’: resuscitation, routine maintenance, replacement, redistribution and reassessment. The advice is simple and straightforward, and is supported by useful flowcharts. The guideline emphasises that intravenous fluids should only be used when oral or enteral routes are inadequate. It offers explicit details about assessment of patients, and advises seeking expert advice when fluid and electrolyte management is complex. One interesting recommendation is to consider delivering intravenous fluids for routine maintenance during daytime hours to promote sleep and wellbeing. For resuscitation, a crystalloid containing sodium (130–154mmol/l) is advised. There is a clear recommendation not to use tetrastarch and to only use albumin in patients with severe sepsis. For fluid replacement, restricting the initial volume prescribed to 25–30ml/kg/day of water is suggested, with lower volumes still for the elderly and frail as well as patients with renal or cardiac impairment. Evidence-based advice is given on amounts of electrolytes required and suggestions are made about what type of fluids to prescribe. Exactly what the best fluid is for use as a standard seems to have been the subject of authoritative but changing advice since my student days. I now anticipate retirement without ever being sure of the right answer to that dilemma – thoughtful guidance notwithstanding.

Varicose veins in the legs: the diagnosis and management of varicose veins (CG168) This clinical guideline was published in July 2013. It provides helpful information and advice for general practitioners but poses challenges for commissioners, hospitals and vascular specialists. Three particular aspects of the guideline invite comment.

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First, the recommendations about referral of people with varicose veins from primary care to a vascular service both repeat and revitalise those published by NICE in 2001. They specify that people with complications from their varicose veins (bleeding, skin pigmentation, eczema, ulcers or phlebitis) should be referred. In addition, they recommend that people with ‘symptomatic primary or symptomatic recurrent varicose veins’ should be referred to secondary care. Recent years have seen the introduction of severely restrictive practices and policies by commissioners so that referral of people with symptoms (but without complications) due to varicose veins no longer occurs in most areas of the UK. These restrictions have been because commissioners classify symptomatic varicose veins as low priority and they have decided that referral for treatment is not affordable in the present hard financial climate. It will be interesting to see what effect the new NICE recommendations have on referral policies as the friction that now exists between the two will be awkward for both general practitioners and vascular specialists. The second recommendation I have chosen for comment is a technical and organisational one, for vascular specialists. It states: ‘Use duplex ultrasound to confirm the diagnosis of varicose veins and the extent of truncal reflux, and to plan treatment…’ It should be clear to one and all that duplex imaging is not necessary to make a diagnosis (as opposed to planning treatment) when big, obvious varicose veins are present. Indeed, duplex imaging could be construed as wasteful of both time and money when clinical assessment is sufficient to conclude that no treatment is required; those who wrote the guidance are clear that that was not its intention. The ways in which duplex imaging is incorporated into management algorithms vary on the basis of opinion and local preferences. Some vascular specialists configure their clinics to scan all patients (even when imaging is arguably unnecessary), some scan patients rapidly themselves and some rely on vascular


Ann R Coll Surg Engl 2014; 96: 157–160

technologists to perform more detailed imaging, especially when veins are complex. There does need to be some reflection about the most efficient and useful way of obtaining imaging on the right patients at the right time. The third (and most controversial) aspect of this clinical guideline is its ‘ranking’ of treatments in a hierarchical manner, especially when much of the evidence on which this was based was judged to be of low or very low quality. It recommends endothermal ablation (using radiofrequency or laser) as the treatment of first choice, followed by ultrasonography guided foam sclerotherapy and surgery as third choice if the first two are ‘unsuitable’. This hierarchy was based on evidence that showed no differences in clinical effectiveness between endothermal treatment and surgery but slight superiority of endothermal ablation over foam sclerotherapy. Cost modelling had a strong influence on the recommendations because it indicated that endothermal ablation was the most cost effective method of treatment. There are a great many variables that affect the cost of varicose veins treatments: the setting in which they are done, which staff are used, what kind of anaesthesia is used and whether adjunctive phlebectomies or foam treatment is done at the same time as endothermal ablation or subsequently. The debates about which type of treatment is best for which patient and how to organise endothermal ablation in the most cost effective way are by no means concluded. In the context of all these doubts, the research recommendations are a highlight of this guideline. They identify very astutely the pivotal uncertainties and research questions that will guide our future management of varicose veins. These include whether and when to use adjunctive treatment with endothermal ablation, whether compression is useful for symptomatic varicose veins and the effect of using compression on the outcomes of treating varicose veins. Hopefully, researchers and research funders will be quick to grasp the various nettles and to generate evidence that will resolve the dilemmas.

Recent NICE guidance of interest to surgeons.

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