Address variations in care now for 'forgotten' patients, surgeons tell Trusts

The NHS must address the significant variations in care experienced by the 170,000 patients who have major emergency abdominal surgery each year, says a new report published by the Royal College of Surgeons. Poorly designed hospital services, particularly access to emergency operating theatres and radiology treatment, are among the problems highlighted. This results in patients missing out on early diagnosis and rapid life-saving care. In addition, there is a general lack of appreciation of the level of risk in emergency surgical patients - where death rates of 15 to 20 per cent are typical, and can be as high as 40 per cent in the most elderly patients. Surgeons say this imminent risk of death is not being reflected in the priority given to these patients whose chances of survival can more than double, depending on which NHS hospital they are treated in.


The report, The Higher Risk General Surgical Patient: Towards Improved Care for a Forgotten Group, makes nine detailed recommendations. If implemented within two years, they will reduce complications and deaths, as well as reduce the cost of treating a group of patients who account for almost 90 per cent of post-operative general surgical deaths. Among the recommendations are:

  • Recognition of the need for improved services, including access to operating theatres: Trust bosses should acknowledge the problems that exist within their organisation and work with clinical colleagues to address them by implementing the changes necessary as set out in this guidance. Delay in accessing appropriate emergency treatment, including surgery, is common and results in unnecessary complications and death. Hospitals must provide fast access to operating theatres within defined time periods and prioritise emergency cases over elective surgery wherever necessary. It may be that separation of planned and unplanned operations is necessary.
  • Routine risk assessment and tailored management of every patient: Hospitals should develop, clear, defined diagnostic and monitoring plans as well as assessing the risk of death and post operative complication for every patient. Those at highest risk should be treated under the direct supervision of consultant surgeons, anaesthetists and intensivists.
  • Better use of critical care: Patients at highest risk should be admitted to critical care after surgery. Due to a limited number of critical care beds, less than a third of high risk NHS patients are currently admitted to critical care following surgery; those who are stay on average only 24 hours. International comparisons show that NHS critical care bed usage runs at 50 per cent lower than in comparable countries and ranks among the lowest in the developed world. Delayed access to, and premature discharge from, critical care are both identified risk factors for post-operative death in general surgery. Routine admission to critical care after high risk surgery reduces complication rates and subsequent admissions to intensive care. This ultimately saves money through shortened length of hospital stay and reduced use of Intensive Care Units (ICU), which currently cost the NHS around £88 million per year.
  • Improved post operative care, including treatment of severe infection: Of the 170,000 patients who require high risk general surgery annually, 100,000 will suffer complications and 25,000 will die. Currently, treatment for post-operative complications, including severe infection, can be slow and often led by junior staff. Hospitals should adopt a defined strategy for urgent treatment of such conditions within specified timescales and which involve senior doctors rapidly when needed. A delay in treating severe infection of more than 12 hours can double mortality.
  • Routine audit of emergency patients: Emergency patients are a complex and diverse group making data collection difficult and preventing lessons being learned. Mortality for emergency general surgical patients exceeds that for cardiac surgery by up to threefold. Cardiac surgeons have proven in recent years that collecting and publishing outcome data drives up standards of patient care and emergency general surgery must be supported to follow suit.

Mr Iain Anderson, report author and Consultant General Surgeon at Salford Royal NHS Foundation Trust, said: "Every acute hospital in the UK deals with many emergency patients every single day, among who three or four will typically meet these higher risk criteria. Complications and death rates vary significantly between hospital and even within the same hospital depending on the time of admission. Trusts should acknowledge that these problems exist and work to review their services using this guidance. Every single emergency patient who comes through the door of an NHS hospital should have an individual risk assessment, diagnosis, treatment plan and post operative care plan prioritised according to need. Instead we have some of the NHS' sickest patients languishing on inappropriate wards, treated by juniors and with no plan in place to deal promptly with unexpected complications. These tend to be the patients who end up in intensive care units for lengthy periods of time or, sadly too sick to be helped. "

Norman Williams, President of the RCS, said: The focus on reducing waiting times for elective procedures has resulted in a large group, of mostly elderly patients, becoming seriously under prioritised to the point of neglect in the some NHS hospitals. These changes won't happen on their own and we are calling on all surgeons and managers to work together to deliver the high quality care that these patients need and which some hospitals are already proving can be delivered."

John MacFie, President of the ASGBI, said: "ASGBI is committed to raising standards of emergency care all over the UK and fully support the College's plans to help the development of strategies to improve the management of this important group of patients. Not only in the surgical management of the patient, but also in the administrative support that hospitals and other medical specialities need to provide to ensure the successful outcome of our patients."

Bruce Taylor, President of the Intensive Care Society said: "The recommendations are very much supported by the Intensive Care Society. In order to increase the number of patients accessing ICU beds there will need to be significant investment from the NHS. However, it is very much hoped that once the guidance is implemented the resultant provision of high-quality and detailed care for earlier and more prolonged post-surgical critical care sessions should definitely reduce complication rates and the need for more complex and lengthy ICU re-admissions. It is vital that the guidance is initiated as it in the best interest for potentially vulnerable patients who require surgical procedures."

The report is from the Royal College of Surgeons / Department of Health Working Group on Peri-operative Care of the Higher Risk Surgical Patient. It is published by the Royal college of Surgeons and approved by The Association of Surgeons of Great Britain and Ireland (ASGBI), The Association of Coloproctology of Great Britain and Ireland (ACPGBI), the Association of Upper Gastrointestinal Surgeons (AUGIS) and the Society of Academic and Research Surgeons (SARS).

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The Operating Theatre Journal, OTJ, is published monthly and distributed to every hospital operating theatre department in the UK. The distribution includes both the National Health Service and the Private Sector.

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