NAP7 FAQs

If you question is not addressed below, please contact nap@rcoa.ac.uk. We will update these FAQs regularly as needed.

Section 1 - General organisation and reporting process FAQs

General Organisation

Others Helping

Someone else in the department would like to help me with parts of NAP7. Is this ok?

Yes, we encourage you to get others in your department that can help you with the local organisation of NAP7. This may include fellow consultants, trainees, anaesthesia associates, operating department practitioners, anaesthetic nurses, resuscitation officers, research nurses and others. Please inform Laura Cortés, RCoA Audit and HSRC Coordinator by emailing nap@rcoa.ac.uk, of all people formally contributing to the project organisation so they can be acknowledged on the NAP website and at the publication stage. The Research and Audit Federation of Trainees (RAFT), Association of Anaesthesia Associates and College of Operating Department Practitioners are all represented in the NAP7 Stakeholder group and will be encouraging their members to contact local coordinators to offer help where possible.

Partially filled form

I have started to report a case, but now want to delegate this to another person locally. How do I do this?

A unique login will be provided for each case report. This login may be used by the most appropriate individual or individuals to report the case or provide additional details.

SPAs

How much time will this take me? SPAs and support for Local Coordinators.

As in previous NAPs, it is our view that all activity related to the NAP7 LC role is valid for inclusion in SPA activity, and should be used to help support the SPA allocation in consultant and career grade job plans. Where doctors who wish to act as LCs are prevented from doing so by inappropriate allocation of SPAs, or where Trusts/Boards fail to recognise this activity as appropriate for SPAs, the Royal College of Anaesthetists will provide evidence in support of relevant activity (contact nap@rcoa.ac.uk). In recognition of the role played by the NAP LCs, we will send a certificate confirming the role, which you may include in your portfolio and as evidence for appraisal/revalidation. We will not however specify the amount of SPA time as this should be a joint discussion between the Local Coordinator and their Organisation.

Need to change Local Coordinator

I am unable to continue to be a Local Coordinator (e.g. due to a change of job, long term sickness, too busy). What should I do?

We are sorry that circumstances mean you cannot help us further with the project. Please contact us at nap@rcoa.ac.uk as soon as you are able. If you are able, please try to identify a consultant colleague who may be willing to take on the role.

Reporting without involvement of the LC

An anaesthetic colleague wishes to report a case without involving me as their local coordinator. Is this ok?

We expect that most individual case reports will be made via or in collaboration with a Local Coordinator. However, there may be circumstances where an anaesthetist wishes to report their case direct to NAP7, in which case they should contact nap@rcoa.ac.uk

Any anaesthetist is free to report their case, but we suggest that they inform their Local Coordinator that they have made a report. This will help ensure coverage and reduce the risk of duplication.

Informing Information Governance and Audit Departments

Do I need to involve my local information governance department or seek local ethical approval?

No patient-identifiable information is being collected by NAP7 but you may wish to inform your Hospital's Caldicott Guardian that NAP7 is taking place. This person is often the Medical Director of the trust. They may wish to know that NAP7 has been endorsed by all UK Chief Medical Officers and has been approved by the National NHS patient information governance bodies in England, Northern Ireland, Scotland, and Wales. Further details of the approval process are given in the LC pack, which can be found on the resources page at https://www.nationalauditprojects.org.uk/Local-Resources#pt

Trainees

The resources say all anaesthetists will be included. Will this include trainees?

Yes, all anaesthetists of all grades providing anaesthetic care will be included.

Case Reporting

How to report

I am a Local Coordinator and have a case that I am confident meets inclusion criteria. How do I report?

Please contact the NAP7 team (nap@rcoa.ac.uk) who will be able to issue you a unique login for your case for the online database.

The moderator for uncertain cases

I have a case for which I have checked the inclusion criteria and on-line NAP7 resources - I am still unsure if the inclusion criteria are met. Is there anyone I can contact to ask?

Yes. First, gather as much information about the case as you can from the case notes and the anaesthetists involved in the care of the patient. As with previous NAPs, there is a moderator who can advise whether a case meets inclusion criteria. Please email nap@rcoa.ac.uk for further details. Where the situation is unclear the default will be to report the case. The moderator is a consultant anaesthetist with appropriate expertise and will be independent of the NAP7 Review Panel so any discussions with the moderator will not reach the Review Panel.

Difficulty getting access to case notes

A local investigation has been launched into the case and the notes have been quarantined (e.g. by the trust legal team or coroner). They are not allowing me to see them. How do I proceed?

Please explain that the anaesthetic department needs to examine the case anonymously in line with good clinical governance practice. Explain that you are reporting to a national audit project that has the support of the RCoA and your clinical director. It may be helpful to explain the background of NAP7 and the security and anonymity of reporting. Explain the database has the minimum level of identifiable information. The point to emphasise is that NAP7 is a national registry of anonymised complications, requiring a minimum dataset. It should then be possible to access the notes or to view a copy. The database has been set up so that reported cases cannot be linked to a specific hospital, anaesthetist or patient.

If you still encounter difficulty or make no progress, please contact the NAP7 team for further advice at nap@rcoa.ac.uk

Activity Survey

Local Coordinator absence

I (the local coordinator) will be away during the assigned dates for the activity survey, can they be changed?

If it is possible to reliably delegate organisation of the activity survey to colleagues this would be ideal. However, if this is problematic please contact nap@rcoa.ac.uk as soon as possible if there are problems with your allocated activity survey dates.

Multiple anaesthetic episodes for one patient

Can a patient have more than one form in the activity survey?

For example, epidural for labour and then later has epidural top-up for Caesarean section?

Yes, this would require 2 separate forms, one for each anaesthetic activity. The activity survey is assessing anaesthetic activity which may include multiple anaesthetic encounters with the same patient. Another example where a second form would be completed may be a patient returning to theatre with complications of surgery.

External sites

We are responsible for providing anaesthesia for a service outside our trust (e.g. anaesthesia for ECT in a nearby mental health hospital, or dental chair sedation). Do we include these patients in the activity survey?

Yes, these patients are included at all stages of the project: activity survey, case registry and baseline survey.

Baseline Survey

Individual anaesthetist baseline survey

I work across more than one site. Should I complete an individual anaesthetist baseline survey at each site?

No, please only complete one individual anaesthetist baseline survey regardless of the number of sites that you work at.

Should the baseline survey be completed by intensivists?

If the intensivists cover elective or emergency anaesthetic sessions they should be included in the baseline survey.

Do anaesthetists who work in Critical Care only need to complete the baseline survey?

If staff members undertake anaesthesia outside ICU They should complete a form for the hospital In which they do this. Those who NEVER do this need not do so



Section 2 - Inclusion Criteria FAQs

General questions

Children

Are children included?

Yes, patients of all ages are included. Resuscitation at birth (newborns) is excluded.

Cardiac Surgery

Are cardiac surgery patients included?

Yes, all surgical specialties are included in line with the inclusion and exclusion criteria described in the LC pack, which can be found on the resources page here https://www.nationalauditprojects.org.uk/Local-Resources#pt

Patients already anaesthetised

Are patients included if they come to theatre already anaesthetised (e.g. from critical care or a direct transfer from another hospital)?

Yes. Any patient that comes under the direct care of an anaesthetist would be included.

When does hands-on contact start

What counts as 'hands-on contact'?

Hands-on contact relates to the first time you perform any intervention for a patient. Most commonly this will be the insertion of a cannula. Other examples include, but are not limited to, a gas induction, skin cleaning with chlorhexidine, giving a drug through a cannula already in situ etc. It may also include airway manoeuvres such as a jaw thrust.

Does giving a premedication count as the 'first hands on contact'?

Giving an oral premedication is not the first hands-on contact, and the start time of the NAP7 inclusion window.

Attending a patient who has already arrested

An anaesthetist is called to help where some sedation has already been given by a non-anaesthetic practitioner (e.g. gastroenterologist for OGD). The patient has had a cardiac arrest and chest compressions started before the anaesthetist arrives. Is this case included?

No, the cardiac arrest occurred before the start of anaesthesia care. If the anaesthetist had hands-on contact with the patient before chest compressions and/or defibrillation, the case would be included.

Attending a patient who is just about to arrest

There has been an urgent call to the cardiac catheterisation laboratory for help. A patient undergoing emergency angiography is agitated. Following induction of anaesthesia there is a cardiac arrest and chest compressions are started. Is this case reportable?

Yes. Provided the cardiac arrest and need for chest compressions and or defibrillation occurred after the start of anaesthesia care.

Transfers

Are patients being transferred included?

Patients undergoing transfer to a location for a procedure under the care of an anaesthetist would be included, e.g. to theatre, interventional radiology or the cardiac catheterisation laboratory. However, patients being transferred for diagnostic radiology, or moving between units (both intra- and inter-hospital transfers) are not included.

Why are we not including cardiac arrests during transfer between units?

The issue of arrests during transfer was considered but again for practical purposes it was decided that arrests occurring during transfer were outside the scope of the project as is would not always be practicable for local coordinators to collect and report these events. In addition, more and more of these transfers will be done by specialist retrieval services.

Initiating Critical Care

Are patients anaesthetised solely for initiation of critical care included?

Adults - no.
Children - only if this is prior to transfer to another hospital for critical care.

Why are we including critically ill children who have cardiac arrests although they are not having a procedure when we are not including adults for the same?

Sick children in non specialist paediatric centres who require anaesthesia from the local hospital team prior to transfer to a specialist hospital were flagged up as a particular group that required study - this is uncommon, cardiac arrests are rare, it is an important issue for anaesthetists and patients, and there is no data on these cases.

Studying this for adults would also be of interest, but we do need to make NAP7 manageable for local coordinators, and cannot address every single issue. Care of critically-ill adults and cardiac arrests occurring on wards are already addressed by the National Cardiac Arrest Audit, and the ICNARC Case Mix Programme. ICNARC and and Resuscitation Council UK are supporting a 1 year study of all cardiac arrests in the ICU (CIRCA) that is about to complete.

Second procedures

A patient returns to theatre for a second procedure at some point after an initial operation and has a cardiac arrest within 24h. Is this patient included or was their inclusion period only after the first operation?

This patient would be included. A new 24-hour inclusion period will apply for each occasion a patient comes under the care of an anaesthetist.

Synchronised DC Cardioversion

A patient has a synchronised shock during a DC cardioversion. Do I need to report this?

No, this will be a synchronised DC shock and is therefore excluded from NAP7. Shocks must be unsynchronised for the treatment of ventricular fibrillation or pulseless ventricular tachycardia to be eligible to enter NAP7.

What if the cardioversion patient goes on to have a cardiac arrest? Are they then included?

Yes. If the patient has chest compressions and/or defibrillation (i.e. unsynchronised DC shock), then the patient would be included in NAP7 and should be reported.

Chest compressions

Why is CPR defined as 5 or more chest compressions?

We have chosen 5 Compressions to exclude cases that only receive a small number of compressions - eg. brady-asystole. We will be able to estimate how often less than 5 compressions are given from the activity survey.

DNACPR

In cases where a patient has a DNACPR in place if they were to have a cardiac arrest on the ward in the 24 hours post-op and do not receive CPR (in line with the DNACPR decision) would you still want them to be included in the data collection?

Patients with a do-not-attempt CPR (DNACPR) recommendation who have a cardiac arrest and do not have chest compressions and, or defibrillation are excluded. As for all patients, if they did have chest compressions and, or defibrillation they would be included.

Transfers

Are patients who are anaesthetised (e.g. a head injury) and then transferred or retrieved to another hospital for a procedure included?

All patients anaesthetised for a procedure by an anaesthetist are included.

Often, the final decision for surgery is not made until after the patient arrives at the receiving hospital.

Patients are excluded if they are only being anaesthetised for the purpose of intensive care at the host hospital or following transfer or retrieval to another hospital for the purpose of intensive care.

Any arrest occurring during transfer would be excluded.

The inclusion time window would start once anaesthesia care for a procedure starts at the receiving hospital.

Cardiac Surgery and Cardiopulmonary Bypass

A patient planned for cardiac surgery becomes unstable following induction of general anaesthesia and has a cardiac arrest and chest compressions. The patient is then started on cardiopulmonary bypass. Is this patient included?

Yes. Any patient who has external chest compressions, or internal cardiac massage, and/or defibrillation before the arterial/aortic cardiopulmonary bypass cannula is inserted would be included.

A patient is on cardiopulmonary bypass and has several unsynchronised DC shocks for VF following the release of the aortic cross-clamp. Is this patient included?

No. This patient is on established cardiopulmonary bypass and therefore this does not meet inclusion criteria. However, after removal of the aortic/arterial cannula, the patient may then meet the inclusion criteria.

A cardiac surgery patient comes off bypass (flow is off and oxygenation via the lungs), but the aortic/arterial cannula is still in situ. They then develop an arrhythmia and have internal cardiac massage and/or unsynchronised defibrillation before re-heparinisation and restarting cardiopulmonary bypass. Is this patient included?

No. Although the cardiopulmonary bypass machine is not providing any perfusion, the period up until the aortic/arterial cannula is removed is excluded from NAP7.

A patient is on cardiopulmonary bypass and it cannot be weaned. They are switched from cardiopulmonary bypass to veno-arterial extracorporeal membrane oxygenation and transferred to the intensive care unit. Are they included?

No. The patient is on bypass during this period and therefore not included. If the extracorporeal support is successfully weaned and the arterial cannula removed, then this patient may be included if they have a subsequent cardiac arrest that fulfils entry criteria.

A patient is on cardiopulmonary bypass and it cannot be weaned. A decision to stop treatment is made and the patient dies in theatre. Is this patient included?

No. Events that happen during cardiopulmonary bypass, from insertion to removal of aortic/arterial cannula, are excluded.

A patient goes to the cardiac intensive care unit and has a cardiac arrest, resternotomy, direct heart massage/compressions and, or defibrillation. Is the patient included?

Yes, if the cardiac arrest, compressions or defibrillation are within 24h of handover of care to the cardiac intensive care team.

A patient has a deep hypothermic cardiac arrest. Is the patient included?

No, as the patient will be within a period that classifies as cardiopulmonary bypass. Similarly, cardiac standstill following administration of cardioplegia solution on bypass does not meet inclusion criteria.

Obstetrics

Epidural Anaesthesia

A patient has an epidural running in a labour room and has a cardiac arrest. Is the patient included even if there is no operative procedure?

Yes, any patient who has anaesthetist-administered analgesia for labour (i.e., spinal, epidural, combined spinal-epidural, or remifentanil PCA) is included until 24 hours after delivery.

Arrest in a labour room

A patient on labour ward has a cardiac arrest in the room and an anaesthetist attended and later took the patient to theatre. Is this case reported?

If the cardiac arrest occurred before the start of anaesthesia care - i.e. before WHO sign-in or first hands-on pre-procedure contact by an anaesthetist - then the case is excluded.
If the cardiac arrest occurred in a patient after the start of anaesthesia care - e.g. an epidural had been sited - then the case is included.

Post-partum haemorrhage

A patient had a post-partum haemorrhage and subsequent cardiac arrest in the delivery room. Is this patient included?

As above. If the cardiac arrest occurred before the start of anaesthesia care, the case is excluded.

What is 'perioperative' for obstetric patients?

When does the inclusion window end for eligible obstetric patients who do not have an operative procedure (i.e. those with anaesthetist-administered labour analgesia)?

24 hours after delivery.

Paediatric Anaesthesia, Critical Care and Transfer

A critically unwell child presenting to a non-specialist paediatric centre is taken to an anaesthetic room or operating theatre for stabilisation before transfer to another hospital and has a cardiac arrest following induction of anaesthesia. Is this case included?

Yes. Critically-ill children anaesthetised in non-specialist centres for retrieval or transfer to another hospital are included from the start of anaesthesia care to the point of leaving the hospital.

A critically unwell child presenting to a specialist paediatric centre is taken to paediatric intensive care for resuscitation and has a cardiac arrest following induction of anaesthesia. Is this case included?

No. Critically ill children anaesthetised solely for critical care within specialist centres are excluded.

What about if the child went for their airway to be secured with ENT present?

In this case, there was likely a possible planned ENT procedure, in which case the inclusion criteria are met.

Paediatric stabilisation for transfer is managed by our intensive care doctors-some of whom are anaesthetists. Would all these children be included or just the ones by anaesthetists?

There is variation between hospitals regarding how sick children who require transfer or retrieval to a hospital with a PICU are cared for.

Anaesthesia for sick children prior to transfer or retrieval was raised as an issue of concern by the project stakeholders.

If the child is managed by members of the anaesthetic department who are anaesthetists (e.g. these anaesthetists would have completed the baseline survey), the case would be included if the special inclusion criteria for critically-ill children are met.

We suspect that in most non-paediatric hospitals the children will be anaesthetised by an anaesthetist (consultant or senior trainee) who may or may not also work in intensive care.

Some hospitals will have anaesthetic consultants with a paediatric interest and some of these will also do intensive care.

Some hospitals will have intensivists only who may care for these children - if their cases are included will need to be decided locally e.g. did they take part in the baseline survey as members of the anaesthetic department.

We will aim to clarify current practices around these issues with our baseline surveys and activity surveys as we suspect considerable variation.

Why are we including critically ill children who have cardiac arrests although they are not having a procedure when we are not including adults for the same?

Sick children in non specialist paediatric centres who require anaesthesia from the local hospital team prior to transfer to a specialist hospital were flagged up as a particular group that required study - this is uncommon, cardiac arrests are rare, it is an important issue for anaesthetists and patients, and there is no data on these cases.

Studying this for adults would also be of interest, but we do need to make NAP7 manageable for local coordinators, and cannot address every single issue. Care of critically-ill adults and cardiac arrests occurring on wards are already addressed by the National Cardiac Arrest Audit, and the ICNARC Case Mix Programme. ICNARC and and Resuscitation Council UK are supporting a 1 year study of all cardiac arrests in the ICU (CIRCA) that is about to complete.

Adult Critical Care and Emergency Department

Anaesthesia in ICU

A patient is anaesthetised for a procedure on a critical care unit by an anaesthetist (e.g. percutaneous tracheostomy). During the procedure, whilst under the care of the anaesthetist, there is a cardiac arrest. Do I report this case?

No. Procedures undertaken within critical care units are excluded from NAP7.

Anaesthesia in the Emergency Department

An adult patient is brought into the resuscitation area of the emergency department and is critically unwell. Following induction of anaesthesia they have a cardiac arrest. Is this case included?

This depends on the indication for anaesthetic intervention and the likely patient trajectory. We wish to capture those patients under the care of an anaesthetist who would meet the general criteria for NAP7 inclusion in whom anaesthesia care starts in the Emergency Department.

This includes patients in whom a surgical/interventional radiology/interventional cardiology procedure is planned or likely who then arrest before this is possible.

We do not wish to include the following groups of patients sedated/anaesthetised in ED: solely for critical care; solely for diagnostic radiology (e.g. CT head); in whom no potential intervention is considered.

What if this patient later goes to the operating theatre?

See above. They then may meet the inclusion criteria if a procedure is planned.

Why are we not including critically ill adults who have cardiac arrests although they are not having a procedure when we are including children for the same?

Sick children in non specialist paediatric centres who require anaesthesia from the local hospital team prior to transfer to a specialist hospital were flagged up as a particular group that required study - this is uncommon, cardiac arrests are rare, it is an important issue for anaesthetists and patients, and there is no data on these cases.

Studying this for adults would also be of interest, but we do need to make NAP7 manageable for local coordinators, and cannot address every single issue. Care of critically-ill adults and cardiac arrests occurring on wards are already addressed by the National Cardiac Arrest Audit, and the ICNARC Case Mix Programme. ICNARC and and Resuscitation Council UK are supporting a 1 year study of all cardiac arrests in the ICU (CIRCA) that is about to complete.



If you have any further questions please contact nap@rcoa.ac.uk. We will update these FAQs regularly as needed.