Guidance

AAA screening: guidance for the waiting times tracker report

Updated 12 April 2019

Waiting times are important in the current NHS abdominal aortic aneurysm screening programme (NAAASP) pathway standards. Waiting times standards have been monitored by the NAAASP team and screening quality assurance service (SQAS) teams since June 2013. This process has resulted in significant improvements in waiting times for patients to be seen at a vascular specialist appointment.

A quarterly report is produced within SMaRT (screening management and referral tracking) in order to monitor achievement of the standards and identify where improvements could be made. The report is populated by information entered by the screening providers relating to the assessments, surgery and delays. It is therefore important all providers enter information using consistent definitions.

This guidance outlines how delays in being seen by a vascular specialist, and in receiving specialist treatment, should be categorised.

1. Specialist assessment outcomes

1.1 Specialist assessment outcome categories

The date and outcome of specialist assessments can be recorded in ‘specialist assessment’ tab of SMaRT. There are 4 assessment outcome categories available.

Further investigation

The further investigation outcome should be used where the patient has a non-standard AAA. This is a patient thought unlikely to be fit for intervention and booked for non-standard investigation or referred for medical treatment (for example coronary angioplasty, bypass or chest referral). This category may also include referral to a tertiary centre outside of the ‘usual’ screening programme referral pathways. If the patient does not go on to have surgery, a further assessment with the final outcome, for example, ‘surgery declined’ or another suitable delay reason should be recorded.

Surgery declined

This is to be used when the patient declines any further assessment or intervention. It is not to be used when a patient chooses to defer their operation date.

Surgery planned

This is to be used for a patient who has a standard AAA and is undergoing routine pre-intervention tests. It also includes patients who have a planned surgery date.

Unsuitable for surgery

This is to be used where a patient is unsuitable for surgery and will not benefit from surgery. This might include:

• patients who have a terminal illness
• patients where the risks of complications from surgery outweigh the risk of AAA rupture
• patients who are temporarily unsuitable for surgery due to a co-morbidity (such patients require referral and treatment at another department, such as oncology, and will have a significant delay before the aneurysm can be operated on)

1.2 Alerts

SMaRT will prompt providers to enter a reason why a patient has not attended a first specialist assessment after his target assessment date. An alert will appear in a provider’s alert list if the patient has not attended an assessment within 14 calendar days of his last conclusive scan. Once the delay reason has been entered, the patient is removed from the alert. SMaRT will continue to put the patient back on the alerts every 2 weeks, prompting the provider for further reasons for delay until the appointment is attended or has one of the ‘not stated’ delay reasons as outlined below.

2. Assessment delays

Patients referred to a vascular service for treatment should be seen by a vascular specialist within 2 weeks (14 calendar days) of their last conclusive scan. If a patient is not seen within 2 weeks, local screening providers receive an alert through SMaRT. The local screening provider can then enter the reason for the delay in attending the first vascular specialist appointment in the ‘delays’ tab. The assessment may be delayed several times and each delay should be entered. Any delays for subsequent assessments or testing should be recorded under ‘surgical delays’ (not ‘assessment delays’).

Subsequent assessments can, however, be entered in order to record subsequent decisions such as ‘surgery planned’, ‘unsuitable for surgery’ or ‘declined surgery’. This information should be entered in the ‘specialist assessment’ tab.

2.1 Assessment delay categories

There are 7 assessment delay categories within SMaRT which are mapped to either ‘valid’ or ‘invalid’ categories of delays. Valid delays are related to the patient. Invalid delays are related to the hospital.

Delay due to patient factors (valid delay)

These delays will be related to patient choice. For example, the patient may:

• be on holiday and ask to defer their appointment to a later date
• forget the appointment, not attend and then have to rebook
• have problems with transport to the hospital
• have a mild illnesses (where a patient is not receiving medical treatment, such as for a cold, this should also be counted in this category)

Delay due to patient co-morbidities (valid delay)

These are delays due to co-morbidities which require medical treatment before the patient can be seen for assessment. For example, the patient may:

• be under the care of a cardiologist at the time of referral
• may hospitalised and receiving care, for example, for pneumonia

For less serious illnesses such as cold or flu, where the patient is not hospitalised, the delay should be categorised as ‘delay due to patient factors’.

Not seen: false positive (valid delay)

This category is for patients who did not have a first assessment because they should not have been referred. This can occur if the scan taken by the screening technician undergoes a QA review and the AAA is found to be less than 5.5cm. This category can also be used if a patient is referred for an iliac aneurysm in error. Selecting this category will discharge a patient from the referral pathway.

Not seen: patient declined (valid delay)

This category is for patients who did not have a first assessment because they declined the specialist assessment and further treatment. Selecting this category will discharge a patient from the referral pathway.

Not seen: co-morbidity preventing attendance (valid delay)

This category is for patients who will never be able to attend their first specialist appointment due to a co-morbidity. For example, if they have a terminal illness. Selecting this category will discharge a patient from the referral pathway.

Not seen: other (valid delay)

This covers delays for patients are not seen for their first specialist assessment for any other reason. The reason should be documented in the delay notes. It is expected that very few men would be included in this category. One example would be a man who ruptures between referral and their specialist assessment appointment and has to undergo emergency surgery. Selecting this category will discharge a patient from the referral pathway.

Delay due to hospital factors (invalid delay)

This reason is related to the hospital and its operational activities. For instance, if the first specialist appointment is delayed or rescheduled due to staff sickness or staff holiday. Another example is where the hospital offers the appointment outside of 2 weeks.

3. Surgery delays

Patients referred to a vascular service for treatment should be operated on within 8 weeks (56 calendar days) from the date of their last conclusive scan. If a patient is not operated on within 8 weeks local screening providers will receive an alert through SMaRT. The local screening provider can then enter the reason for the delay in surgery. The surgery may be delayed several times and the reason for each delay should be entered.

3.1 Alerts

Screening providers will be prompted to enter a reason in SMaRT for why the patient has not been operated on within 8 weeks. The alert will appear in a provider’s alert list if the man has no surgery date from either the National Vascular Registry or entered by the provider 56 calendar days after the patient’s last conclusive scan. Once the delay reason has been entered the patient will be removed from the alert. SMaRT will continue to put the patient back on the alerts every 4 weeks, prompting the provider for further reasons for delay until one of the following is entered:

• a surgery date
• a specialist assessment outcome of ‘unsuitable for surgery’, ‘surgery declined’, ‘not known’ or ‘other’
• one of the ‘no surgery’ delay reasons

3.2 Incidents arising from delays to surgery

Once a patient goes beyond waiting 12 weeks for his operation (they will be on an alert for a second time), they should be reported to the programme board and the regional SQAS team as outlined in the waiting times guidance. If a patient’s AAA ruptures after waiting for 12 or more weeks for surgery then this should be reported as a serious incident as outlined in the waiting times guidance.

3.3 Surgical delay categories

There are 9 surgical delay categories within SMaRT and they are mapped to ‘valid’ or ‘invalid’ categories of delays. Valid delays are related to the patient. Invalid delays are related to the hospital.

Delay due to patient factors (valid delay)

These delays relate to patient choice. For example, the patient may be on holiday and ask to defer their surgery to a later date. The patient could also have issues with transport to the hospital. Mild illnesses, where a patient is not receiving professional medical treatment, such as colds should also be counted in this category.

Delay due to patient co-morbidities (valid delay)

These are delays due to co-morbidities which require medical investigation or treatment before surgical repair can be undertaken and may result in a delay to the surgery following delays for the first specialist assessment. For example, the patient may:

• have a minor condition that needs to be treated first
• be hospitalised and receiving care.

Less serious illnesses where the patient is not hospitalised should be captured under ‘delay due to patient factors’.

No surgery: false positive (valid delay)

This category covers patients who do not require surgery as their aneurysm is either less than 5.5cm, or their finding is not an aneurysm. This is usually following the tests requested after the first specialist appointment. Selecting this category will discharge the patient from the referral pathway.

No surgery: patient declined (valid delay)

This category is for a patient who has declined surgery following one or more specialist assessments. Selecting this category will discharge the patient from the referral pathway.

No surgery: patient unsuitable for surgery (valid delay)

This category is for patients who are found to be unsuitable for surgery after initial referral, following testing at or after the first specialist appointment. Selecting this category will discharge the patient from the referral pathway.

Delay due to awaiting stent (valid delay)

This records a delay where a customised stent is required and has to be ordered. It can also be used to capture delays where there is a complex anatomy and the patient may require further work-up prior to surgery.

Not seen: other (valid delay)

This category is for patients who were not operated on for any other reason. This reason should be added in the delay notes. We expect that very few patients would be included in this category. One example would be a patient whose AAA ruptures after his specialist assessment appointment and he has to undergo emergency surgery. Selecting this category will discharge the patient from the referral pathway.

Delay due to referral to tertiary centre (valid delay)

Patients who are referred to a tertiary centre either by the vascular service or at the request of the patient should be assigned to this category. It is the responsibility of the referring screening provider to follow up on the outcomes of the patient with the tertiary centre. Any deaths that occur, either pre or post operatively, are counted within the referring provider but not against their service. When a mortality report on procedures undertaken in the referring centre is produced, deaths in the tertiary centre will be excluded.

Delay due to hospital factors (invalid delay)

This reason is related to the hospital and its operational activities. Examples include:

• delays in testing, receiving results and other administrative delays
• surgery being offered after 8 weeks
• surgery delayed due to staff illness or holiday
• surgery delayed due to lack of hospital beds

This category should also be used if the surgery has to be abandoned and rescheduled for another time.