Right person, right place, right time
In 2011, a joint working party was set up between the Royal College of Surgeons of England and the Department of Health to set out how care for the higher risk surgical patient was failing and provide a list of recommendations as to how care can be improved. In this article Dr Philip Sherrard, anaesthetic consultant in Brighton, provides a summary of the report, which can be found in full in the See Also section.
Whilst this document refers only to the situation in the UK, the problem of poor outcomes after surgery is not unique to this country, as we find out later when we explore the so called EuSOS and ISOS studies. The learning here is relevant to all.
Surgery is a common and effective treatment for a diverse range of diseases. However, it is now more frequently being performed on elderly patients and those with co-morbidities and advanced disease.
In the UK 170 000 patients undergo higher-risk non-cardiac surgery each year (2011 figures). Of these 100 000 will develop complications resulting in 25 000 deaths. Advanced age and co-morbid disease combined with major and urgent surgery are associated with a higher risk group that accounts for less than 15% of in-patient procedures, but over 80% of post-operative deaths .
This report recommends that all patients with a predicted mortality of >5% should be identified as “high-risk” for major complications and death in the perioperative period. We will look at risk assessment more extensively in week 2, but in general this would cover most co-morbid patients having emergency laparotomy procedures or complex elective general and vascular surgery.
Variations in outcomes
There is mounting evidence that there is significant variation in the perioperative pathway for the higher risk general surgical patient. Management of their care is frequently disjointed and not always patient centred. Reviews of 2008/9 hospital episode statistics show a ≥ 2-fold variation in relative risk of 30-day mortality after non-elective general surgery between trusts.
Major shortfalls identified in NCEPOD (National Confidential Enquiry into Patient Outcome and Death) reports included delays in assessment, decision making, access to theatre, radiology and critical care . In the UK less than 1/3 of the high-risk patients are admitted to critical care following surgery with a median stay of only 24 hours ,. There were also delays in administration of medical therapy such as fluids, antibiotics and venous thrombo-embolism prophylaxis .
The vast majority of poor outcomes come not from deaths on the operating table but from post-operative complications. Minor complications are extremely common but delays or sub-optimal management of these can result in more serious complications. Most of the life-threatening problems involve sepsis resulting in organ failure.
Key recommendations for change
The working party made a list of recommendations to help improve the care of the higher risk surgical patient. The aim was to streamline the perioperative pathway to deliver consistent, continuous and well communicated high level multidisciplinary care that should improve outcomes. The document states that “complications can be greatly reduced by optimal perioperative care.”
These recommendations are summarised below:
All hospitals should have a pathway for unscheduled adult general surgical care. A monitoring plan must be in place that is compliant with the national standards (NICE Guidelines CG50). The pathway should also include timing of diagnostic tests, timing of surgery and post-operative destinations for patients.
Prompt recognition and treatment of emergencies and complications. Adoption of an escalation strategy is strongly advised.
Emergency theatre access should match need and ensure prioritisation of access is given to emergency surgical patients ahead of elective patients.
Each patient should have his or her expected risk of death estimated and documented prior to surgery with due adjustments made in urgency of care and seniority of staff
High risk patients are defined by a predictive mortality of ≥ 5%. They should have active consultant input in the diagnostic, surgical, anaesthetic and critical care elements of their pathway.
Surgical procedures with a predicted mortality of ≥ 10% should be conducted under direct supervision of a consultant surgeon and consultant anaesthetist unless they are confident their juniors can perform the case without them.
Each patient should have their risk of death re-assessed by the surgical and anaesthetic teams at the end of surgery. Their optimal location for immediate post-operative care should be determined.
All high-risk patients should be considered for critical care. At a minimum, all patients with an estimated risk of death ≥ 10% should be admitted to critical care.
A national audit of outcomes should be conducted for adult patients undergoing unscheduled general surgery. Local assessment of outcome is fundamental in improving care and results should be shared appropriately.
Consider these key recommendations published in 2011. Which of them has been applied in your place of work and which do you consider to be sup-optimally performed?
If you choose to reference your own place of work, please ensure that any detailed, identifying, or confidential information is removed from your response.
Further calls for improved perioperative care
This call for improved perioperative care for the high risk surgical patient was reflected in the 2011 NCEPOD report ‘Knowing the Risk’. This report used prospective data to robustly investigate care of the high risk surgical patient. Its conclusion was that less than half of the patients were receiving the care they should. It recommended a defined package of care, or pathway, for the high risk surgical patient. The full report makes for very interesting reading and can be accessed in the See Also section.
Jhanji, S., Thomas, D., Ely, A., Watson, D., Hinds C.J., Pearse, R.M. Mortality and utilisation of critical care resources amongst high-risk surgical patients in a large NHS trust. Anaesthesia 2008 Jul;63(7):695-700
Pearse, R.M., Harrison, D.A., James, P., Watson, D., Hinds, C., Rhodes, A., Grounds, R.M., Bennett, E.D. Identification and characterisation of the high-risk surgical population in the United Kingdom. Crit Care 2006;10(3)
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