NAP5 Archive: FAQs
A recovery nurse mentions that a patient the previous week said in passing they were aware. She cannot recall the date, the patient or any details that help in identify the case. Is this reportable to NAP5?
This case should be notified if the patient can be identified, and we would hope an effort would be made to do this. However if you are not able to confirm that a report was made and identify the patient the case cannot be notified to NAP5.
My critical care colleagues inform me that a patient recalls being ventilated for pneumonia. The patient recalls the intubation event when no drugs were used as it was during a period of resuscitation. Is this reportable to NAP5?
Yes, if it is a report of awareness during intubation we would like to know about it.
My critical care colleagues report to me that a patient recalls being ventilated for pneumonia. The patient does not recall intubation and there were no surgical interventions during his stay on ICU, but the patient recalls periods when he was 'lightened' for attempted weaning, which he found distressing.
Although this is a report of awareness, there has been no specific interventional procedure for which there was an expectation of unconsciousness. Rather, the therapeutic intention here seemed to be purposefully to create awareness. Therefore, this does not really fall within the main interest of NAP5. However, if you have a compelling reason to report the case you may to do so. If you choose to notify us of the case, when you start to upload to the secure website you will see the questions will direct you in a specific way.
My critical care colleagues inform me that a patient recalls being ventilated for pneumonia. The patient does not recall intubation and there were no surgical interventions during his stay on ICU, but he did require a transfer for scanning and during this time there was an IV disconnection causing awareness which he recalls.
Yes; this is a report of awareness. However, when you start to upload to the secure website you will see the questions will direct you in a specific way.
My critical care colleagues inform me that a patient was ventilated for pneumonia and during his stay on ICU underwent a tracheostomy. The patient recalls the procedure; is this notifiable to NAP5?
Yes, this is a specific intervention with specific recall and we would like to know about it.
The Trust legal department have received a complaint but have quarantined the patient casenotes, making it impossible to gain access. What shall we do?
First, you will need to explain to them that the anaesthetic department does need to examine the case anonymously in line with good clinical governance practice. You will need to stress your need to have access to some patient information to enable you to do this (eg, all information about the case other than the patient's name and address). This should be sufficient explanation to give you access to the required information.
Second, you may also need to explain the background to NAP5 and the absolute security and anonymity embedded within it, stressing the importance of national databases and registries which require a minimum level of non-identifiable information. The point to emphasise is that NAP5 is a national registry of anonymised complications, requiring a minimum dataset so that we can all collectively know the magnitude of the problem. It may then be possible to access the notes under supervision or to view a copy (the purpose of quarantining is simply to prevent their being tampered with and often only involves making a copy).
Third, you might be able to obtain case details by contacting the colleague who was responsible for the case, since s/he may have a copy of the casenotes and may be prepared to help and upload the relevant anonymised information.
If you still encounter difficulty or make no progress, please contact NAP5
The Trust legal department have received a complaint (July 2012) but have quarantined the patient casenotes, making it impossible to gain access. Furthermore, my regular monthly email to anaesthetic colleagues has elicited no response; a colleague may not wish to reveal they have been involved in a case of AAGA. What shall we do?
It is unlikely that you will make much progress in obtaining full case details. Please avoid causing local conflicts in your desire to obtain the information and please do be sensitive to the views of others in such difficult scenarios. We suggest some possible avenues for progress:
It is possible the surgeon or other non-anaesthetic practitioner involved in the case also has access to the case notes and is prepared to co-operate with anonymous data upload.
Also, recall that the NAP5 secure website will be open until the end of June 2013. If by this time the case is closed, then the Trust legal department will likely release the notes and you may notify us of the case up to then. If this is the case, make a statement in your 'Feedback of the 15th' (in this case 15 Aug 2012) to us to the effect that 'yes', you have had a report of AAGA. In the same form, make a statement that you will upload a fuller report to NAP5 later, when you have the case notes. This way, we can track 'pending' cases whose data upload is delayed for these sorts of reasons.
A colleague informs you that a patient at a private hospital has reported a AAGA during a previous operation conducted in an NHS hospital. Is that reportable to NAP5?
Yes, the care was provided in an NHS setting and this is notifiable to NAP5.
The surgeon/psychiatrist/other source has received a report of AAGA, but refuses to divulge any details saying that the patient is so distressed that they do not wish the anaesthetic department to know anything about it. What shall we do?
We advise sensitivity in dealing with these potentially difficult scenarios.
We hope such circumstances will be unusual. However it might be argued that it is not appropriate for the anaesthetist responsible for the case, or the anaesthetic department who need to discuss it, to be denied this knowledge. The scenario is akin to a patient suffering wound infection or dehiscence not wishing the surgeon or the surgical department even to know anything about it, as this would be a serious barrier to essential clinical governance. We hope you will be able to discuss the case with the source and overcome this impasse. You might usefully stress that primarily (regardless of the existence of NAP5) it is a matter of normal clinical practice and sound clinical governance that the case is examined and then discussed like all other complications. The scenario described is certainly one where it is inadvisable to send the patient any letter of the type outlined in Appendix 4.
This does not mean that the department or anaesthetist must be involved in future care, but simply they are made aware that a complication has arisen. Patients may be rightly concerned about future contact and these wishes need to be respected.
However - for avoidance of doubt - patients do not have any right to prevent anonymised data being transmitted to an approved database or registry for the purposes of service evaluation. This is the basis of the NIGB-PAG-NRES approvals explained in Section 1.
A colleague tells you that he had a report of AAGA relating to care given in the private hospital. Is that reportable to NAP5?
No, for pragmatic reasons NAP5 only concerns care given in NHS hospitals.
A patient who underwent egg retrieval for IVF has complained of AAGA. She expected to be unconscious, but because of facilities available in the unit, the anaesthetist can only provide sedation. This is really a complaint about differing expectations of sedation - is this reportable to NAP5?
Yes, we are very interested in any report or complaint in which the patient's expectations (of being unconscious) differed from the anaesthetist's. This type of scenario may apply to a range of situations involving sedation or regional anaesthesia, in which the patient expected to be unconscious but they were not.
However, a distinction should be made with complaints that are more generally about the level of service being provided rather than the feeling of unmet expectations during the event. For example, a statement like "I expected to receive a general anaesthetic but the anaesthetist explained that s/he could only provide sedation" is not a report of accidental awareness. Rather, it is a different comment on the limitations and nature of service provision.
Do I need to question every patient for awareness after their anaesthetic, and should our department institute such a policy? Should we purchase or start to use depth of anaesthesia monitors?
No, there is no such requirement, nor do we ask you to do this. The essential point is that you should not change your practice in any way.
A patient reports AAGA related to an anaesthetic at another NHS hospital. What shall we do?
This is a scenario where co-operation between LCs is very important.
The primary issue - regardless of the existence of NAP5 - is the need for clinical feedback and good clinical governance. These principles require you to contact a senior colleague (who may be the LC) at the other hospital to make them aware of the case of AAGA. As clinicians you are able - and indeed encouraged - to share this important information about a possible complication of anaesthesia, including patient-identifiable information. This is simply good clinical practice.
Secondarily, and again in line with good clinical practice, it is the responsibility of that 2nd anaesthetist to feed back to his department, or relevant colleagues (including the LC at the 2nd hospital), so that the case can be discussed and lessons learned locally.
Finally, in relation to the NAP5 project, the 2nd LC is in a position to retrieve the case notes and upload information to NAP5. The date of the AAGA report is the date made at the 1st (your) hospital. The date of anaesthetic is the date of procedure at the 2nd hospital.
Note that, depending upon circumstances, the letter outlined in Appendix 4 may be best sent by you rather than the other LC as it would seem the patient has moved to your area. However, LCs can liaise with each other on these points.
Note also that, in your 'Feedback of the 15th', use the free text option to explain that you have referred this case to the LC of the Trust where the report originated.
LCs from other Trusts/hospitals may be contacted directly using a facility we have set up to enable this. Please go to http://www.nationalauditprojects.org.uk/NAPLocalCoord and then search for the relevant hospital: the website enables you to email that LC directly.
An anaesthetist notices that the volatile agent in the vaporiser has been empty for some time, and the blood pressure and heart rate have been rising. He feels that the patient was very likely aware, but there is no report of complaint by the patient or representative between the dates of 1 June 2012 and 31 May 2013.
There is no report or complaint by patient or representative so strictly, the case is not notifiable to NAP5. Nonetheless, the anaesthetist may feel compelled to report this to NAP5 and the data entry portal will enable the details of the case to be reported, and ask for relevant details.
On 2 June 2012, a patient sits up during general anaesthesia for inguinal hernia surgery, removes the LMA, but is then quickly re-anaesthetised. Eeven by 31 May 2013 the patient has made no report or complaint.
There is no report or complaint by the patient or representative so strictly, the case is not notifiable to NAP5. Nonetheless, the anaesthetist himself may feel compelled to notify this as the actions of the patient implied some degree of 'wakefulness'. The data entry portal on the website will enable the details of the case to be reported, and ask for relevant details.
The parents of a 5 year old child report the child was aware during an operation. The child has not used the words 'awareness' and cannot recall a specific event during surgery, but the parents base their conclusion on disturbed behaviour; is this reportable to NAP5?
Yes, in this situation the carers of the patient have made a report that the patient may have been aware. The details are notifiable to NAP5.
Similar situations may arise in patients with limited mental capacity who may be disturbed postoperatively. If at any stage any person caring for the patient believes this may be related to the patient being conscious when the patient expected to be therapeutically unconscious, then the details are notifiable to NAP5.
A patient is told they will be sedated but awake and responsive and will be asked to perform certain movements during surgery and to answer certain questions. The patient does this happily. After surgery, the patient is asked about their experience and the patient says "I was aware".
This is difficult to justify as notifiable to NAP5 since there is neither a complaint nor is there suggestion that the experience was unexpected or unintended. If the anaesthetist feels compelled to report this case, the data entry portal will allow them to do so.