Skip to 0 minutes and 17 seconds So ISOS was a big epidemiological study that was designed to give us basic data on activity in in-patient elective surgery in as many countries as possible.
Skip to 0 minutes and 32 seconds And that helped us describe the event rates for complications, which are new data. We’ve got data from places like the United States, which are quite detailed on complications, but not from other countries and also how that relates to mortality and other aspects of patient care. And that’s a really novel and helpful thing for us as we plan further research and further audit and improving quality of patient care. Why did you want to undertake ISOS?
Skip to 1 minute and 2 seconds Honestly? Yeah. Frustration. Frustration that you have conversations about surgical outcomes. You talk about the problem of poor outcomes after surgery, which I see on a day-by-day basis in my clinical care. Just this weekend, I was looking after a patient who had a relatively cosmetic procedure to her abdomen and had an outcome which wasn’t great and totally out of proportion to the problem that was being solved, certainly. And both her and family, very, very upset by it. And a lot of it is about mismatch of expectation, and a lot of that problem with expectation comes from the doctor’s belief about what we offer.
Skip to 1 minute and 54 seconds And I’ve talked to too many people in different countries who’ve said there isn’t a problem with surgical outcomes in my country. We’re great here. It’s really, really good. It’s Britain where the problem is, or it’s that other country over there that’s where the problem is, but not here. And the only way you can answer that question, the only way you can challenge that is to actually count their patients and see what their outcomes are. And in some cases, they may be right. They may have great outcomes, but not in every case.
Skip to 2 minutes and 24 seconds And until you have objective data that tells you how many patients have surgery, how many have complications, how many die and so on, you’re never going to be able to tackle the problem of improving quality of patient care. What are the main findings from ISOS?
Skip to 2 minutes and 41 seconds So some very interesting data we’re about to publish on critical care, for example, where we don’t show any benefit to postoperative critical care admission after surgery in terms of mortality. Now, that’s not what I as an intensive care doctor expected and hoped to find, but there’s a message there. And probably the message is that it’s not just the quality of the critical care that matters, that saves lives, it’s the quality of the ward care. And if you’re comparing critical care and ward care, the difference between the two is what’s going to result in a difference in outcome for your patient.
Skip to 3 minutes and 19 seconds And a lot of surgical patients don’t need those expensive, critical care treatments like inhaled nitric oxide or specialist ventilation or inotropes or renal replacement therapy. What they really need is good nursing care with easy access to a sensible doctor. And you can deliver that in the ward environment as well as in critical care, but it tends to happen in critical care, which is why we often send the high-risk patients there. I think what’s really been interesting with ISOS is that we’ve been able to look at the low and middle-income countries and compare them to the higher-income countries. And as we start to publish those data, it’s interesting in the peer review process.
Skip to 4 minutes and 0 seconds You hear from the peer reviewers lots of assumptions about what we will find and almost a suggestion that the data are wrong because it’s not what they assumed we would find. It’s fairly easy to get over that bit, but I think one of the biggest and most important findings is actually complications and death are not much less common in high-income countries. And the main reason for that is that we’re operating on a lot of quite high-risk people. So surgical outcomes are important in low and middle-income countries and in high-income countries, but for slightly different reasons.
Skip to 4 minutes and 36 seconds So in low and middle-income countries, it’s about provision of resources, about safety, about quality patient care, whereas in high-income countries it’s about are we offering surgical treatments to patients who are very high risk without the necessary infrastructure to underpin that. But even in the elective group, high-income countries offer way more surgery than low-income countries. And there’s got to be a question there about what the optimal amount of surgery is and whether some countries are offering more surgical treatment than perhaps they should be for the benefit of society. What are the implications of ISOS?
Skip to 5 minutes and 17 seconds We are starting to understand the scale and the complexity of surgical treatments, and therefore, the scale and the complexity of what great perioperative medicine needs to be to make these procedures safe and therefore, effective for the patients that are having them. We’re starting to understand just what the variation is. We’re starting to understand what the real problems that we encounter are after surgery and what the patients needs are going to be. And that’s meaning that we need to do more research.
Skip to 5 minutes and 54 seconds We need, in particular, to consider a routine audit, which is a massive opportunity to help us understand and improve the quality of patient care that currently we don’t take and also to ask questions about quality of research and other aspects of what we do. How can we improve quality of care?
Skip to 6 minutes and 17 seconds The quality of patient care is not about a doctor or whoever being a bad person or a hospital being a bad hospital. It’s about whether it could be a bit better, whether it could be more of the best of itself. Not that its best needs to improve, but more that it needs to be at its best more of the time. And if we could all as doctors, as nurses, as hospitals as health care systems be at our best more of the time, a lot of people would not get harmed because there’s so much surgery that goes on.
The International Surgical Outcomes Study (ISOS)
Professor Rupert Pearse was the chief investigator in the International Surgical Outcomes Study. In this video filmed prior to ISOS’s publication, he discusses his opinions on the findings of the study and his take on how we can start to improve care.
In 2011 a trial sponsored by the European Intensive Care Society and the European Society of Anaesthesiology set out to assess patient outcomes after non-cardiac surgery across Europe. The so-called EUSOS study caused controversy as it reported a higher than expected mortality rate with marked differences between countries.
ISOS was undertaken as a follow on from the EUSOS study to try to gain a better understanding of how common postoperative complications were, how important they were and the interaction between complications and postoperative deaths. It took the form of a prospective international seven-day cohort study looking into the outcomes following elective adult in-patient surgery. The full report is available here.
474 hospitals were included in the primary analysis which consisted of 19 high, 7 middle and one low income country. Later this week we will look in more detail about the role of perioperative medicine in middle and low income countries.
The raw data (of 44814 patients) showed:
- 7508 / 16.8% patients developed one or more postoperative complications
207 / 0.5% patients died
The overall mortality amongst those who developed complications was 2.8%. This is known as ‘failure to rescue’.
9.7% of patients were admitted to a critical care unit as routine after surgery:
- 50.4% of critical care admissions developed one or more complications
- 2.4% of critical care patients died
- 16.4% of patients had an unplanned admission to critical care to manage complications and of those 9.7% died.
Move on now to the next step where Dr Danny Wong explores the role of critical care in the postoperative period further, by describing the initial results of the SNAP2: EPICCS study.
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