The High-Risk General Surgical Patient: Raising the Standard

The Royal College of Surgeons of England published the Higher Risk General Surgical Patient in 2011. The document drew attention to the high rate of mortality that was previously unappreciated in a readily recognisable group of adult patients undergoing high-risk elective or emergency abdominal surgery for a broad range of conditions seen in every acute NHS hospital; for example, bowel cancer, strangulated hernia, and peritonitis.

It described key issues and standards and made recommendations expected to make an appreciable difference to outcomes for a group that accounts for more deaths and admissions to critical care than any other surgical patients.

Perioperative processes and outcomes have improved significantly since 2011, notably for some patients undergoing emergency laparotomy, who now benefit from greater consultant involvement and increased access to critical care beds. However, current evidence indicates that many patients, particularly those presenting as an emergency with an abdominal condition, still receive surgical care that is unreliable with respect to diagnosis, recognition of deterioration and provision of high-quality treatment. Some are still suffering avoidable harm and on occasion dying, waiting for antibiotics, scans, procedures, operations or critical care beds because care is not focused enough on their life-threatening conditions. There is evidence that finite resources, such as consultant staff and theatre availability, are still systematically targeted at lower-risk patients having planned procedures, discriminating against sicker patients who need emergency abdominal surgical care.

This document is an update on the 2011 position. It reviews the progress made and identifies persisting and newly recognised issues. It describes revised and new standards for the management of high-risk patients, defined as those with a risk of dying of ≥ 5%, who should universally receive prompt multidisciplinary consultant-delivered care and perioperative critical care admission. It also details the improvements urgently needed for the large numbers of frail patients presenting with an abdominal surgical emergency. We recognise that a predicted mortality of ≥ 5% is a relatively high threshold for defining a ‘high-risk’ patient. However, given the existing shortfall in resources we have sought to focus on those patients with the greatest unmet need.

Where previous standards have not been revised, they remain recommended. The actions now required are clearly shown. Furthermore, it is the opinion of this expert group that implementation of the new key recommendations should be mandatory in all acute hospitals with adult general surgical services and that doing so would save lives and make further appreciable differences to patient outcomes. Many could be delivered within two years.

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