The NCEPOD Classification of Intervention

This classification came into effect in December 2004, and replaced the categories of
Emergency, Urgent, Scheduled and Elective previously used by NCEPOD

IMMEDIATE – Immediate life, limb or organ-saving intervention – resuscitation simultaneous with intervention. Normally within minutes of decision to operate.

1. Life-saving
2. Other e.g. limb or organ saving

URGENT – Intervention for acute onset or clinical deterioration of potentially life-threatening conditions, for those conditions that may threaten the survival of limb or organ, for fixation of many fractures and for relief of pain or other distressing symptoms. Normally within hours of decision to operate.

EXPEDITED – Patient requiring early treatment where the condition is not an immediate threat to life, limb or organ survival. Normally within days of decision to operate.

ELECTIVE – Intervention planned or booked in advance of routine admission to hospital. Timing to suit patient, hospital and staff.

Whilst it is recognised that additional categories or sub-categories could be defined it is important that the classification remains as simple as possible to use.

Practical application of the classification

The reason for allocating such a classification to each case is to define the urgency of the patient’s intervention to:

• inform clinicians and managers responsible for preparing procedure lists and allocating theatres ‘on the day’ (day to day communications)
• check that patients are operated on within the time frame appropriate for their condition (patient experience)
• check that medical staff are operating out-of-hours only when it is appropriate (clinical governance)
• review the allocation of types of patient to types of theatre session (split into ‘daytime’ and ‘out-of-hours’) in order to take appropriate corrective action within the current organisation of surgical/radiological/cardiological services and to aid further development of these services (organisation and planning).

However, it is important to note that this classification does not describe the type of theatre session in which the intervention was performed. ‘Patient urgency’ and ‘type of list’ are independent variables and must be kept distinct from one another. Managers need to be able to monitor data and detect instances of say, ‘immediate’ or ‘urgent’ cases being operated on in routine ‘elective’ theatre sessions. This monitoring will be inaccurate if someone changes the patient’s category to ‘elective’ just because they are on an elective list.

NCEPOD recommends that the consultant who will perform the intervention should assign the category. This should be done at the time of the decision to operate and when the theatre is booked. To be a useful tool to assist in the organisation of ‘emergency’ lists the correct classification needs to be supplied to the theatre co-ordinator when the patient is booked so an appropriate priority can be assigned to the case. The classification should be recorded in both the Theatre Management System and in the patient’s casenotes.

In the practical allocation of the category to each intervention, it is recognised that the same operation could be undertaken on patients falling into all four of the categories. Therefore it is not possible to group operations within a category to make it easy for allocation. For example:

• Hemicolectomy:
  • Immediate – for life threatening GI bleeding
  • Urgent – for perforated large bowel
  • Expedited – developing large bowel obstruction
  • Elective – resection for non-obstructing carcinoma
• Splenectomy:
  • Immediate – for life-threatening traumatic bleeding
  • Urgent – for on-going bleeding post-splenic injury
  • Elective – for malignant or haematological disease

A summary is provided below to assist in the classification of intervention. These have been drawn up with help of the surgical specialist societies, the British Cardiac Society and the Royal College of Radiologists. This summary excludes obstetrics.

Code	Category	Description	Target time to theatre	Expected location	Example Scenarios	Typical procedures
1	Immediate	Immediate (A) lifesaving or (B) limb or organ-saving intervention. Resuscitation simultaneous with surgical treatment.	Within minutes of decision to operate	Next available operating theatre – “break-in” to existing lists if required	Ruptured aortic aneurysm Major trauma to abdomen or thorax Fracture with major neurovascular deficit Compartment syndrome Acute myocardial infraction (AMI)	Repair of ruptured aortic aneurysm Laparotomy/ thoracotomy for control of haemorrhage Fasciotomy Coronary angioplasty
2	Urgent	Acute onset or deterioration of conditions that threaten life, limb or organ survival; fixation of fractures; relief of distressing symptoms.	Within hours of decision to operate and normally once resuscitation completed	Day time “emergency” list or Out-of-hours emergency theatre (including at night)	Compound fracture Perforated bowel with peritonitis Critical organ or limb ischaemia Acute coronary syndromes (ACS) Perforating eye injuries	Debridement plus fixation of fracture Laparotomy for perforation Coronary angioplasty
3	Expedited	Stable patient requiring early intervention for a condition that is not an immediate threat to life, limb or organ survival	Within days of decision to operate	Elective list which has “spare” capacity or Day time “emergency” list (not at night)	Tendon and nerve injuries Stable & non-septic patients for wide range of surgical procedures Retinal detachment	Repair of tendon and nerve injuries Excision of tumour with potential to bleed or obstruct Coronary anlgioplasty
4	Elective	Surgical procedure planned or booked in advance of routine admission to hospital	Planned	Elective theatre list booked & planned prior to admission	Encompasses all conditions not classified as immediate, urgent or expedited.	Elective AAA repair Laparoscopic cholecystectomy Varicose vein surgery Joint replacement Coronary angioplasty