Emergency surgery patients’ lives at risk as NHS services focus on planned operations, warn surgeons
21 Dec 2018
Patients who need to undergo high-risk emergency abdominal surgery are being discriminated against, as finite NHS resources, such as consultant staff, operating theatres and critical care beds, are still systematically targeted at lower-risk patients having planned procedures, a report from the Royal College of Surgeons (RCS) has warned. These patients may have potentially life-threatening conditions such as bowel obstructions, strangulated hernias or peritonitis.
An RCS report published today (21 December), The High-Risk General Surgical Patient: Raising the Standard1, says that while there have been some improvements in care for patients needing high-risk abdominal surgery in recent years, notably for those patients undergoing emergency laparotomy who now benefit from greater consultant involvement and increased access to critical care beds, current evidence indicates that many patients still receive surgical care that is unreliable with respect to diagnosis, recognition of deterioration and provision of high-quality treatment.
The report’s authors warn that some patients are 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. Today’s report is an update on standards published by the RCS in 2011 to improve the care of high-risk general surgery patients. The RCS says the updated standards should be mandatory in all acute hospitals with adult general surgical services.
Mr Nick Lees, one of the report’s authors and a Consultant General and Colorectal Surgeon, said:
“Surgeons and other senior doctors involved in this field are very concerned that some high-risk general surgical patients are being systematically discriminated against because of the way NHS services are designed within and between hospital units. These patients are receiving a lesser standard of care because they happen to present as emergencies and, generally speaking, NHS resources are better organised for dealing with patients undergoing lower risk, planned operations, such as hip replacements and routine gallbladder removal.
“Too often seriously ill patients with abdominal conditions such as bowel perforation or strangulated hernia face delays in assessment, decision making and treatment. These are common emergency conditions, seen in almost every NHS hospital. However, there are still too few senior staff on duty, too many obstacles to performing timely scans, operations and procedures and too little access to critical care beds for these patients to get high quality care reliably, irrespective of when or where they go to hospital.
“When there are several critically ill general surgical patients all needing emergency care at the same time, as inevitably happens, hospitals are sometimes slow to respond to that increased demand. Unfortunately, this group of patients can come to serious harm if that results in a delay in diagnosis or treatment.”
The report also highlights the complexities of treating the growing number of high-risk patients that are elderly or frail. Patients over 70 years of age represent 60% of those having planned major bowel surgery and 45% of the emergency laparotomy population2. Postoperative delirium (confusion or agitation following surgery) is among the more common complications following abdominal surgery in older people, with incidence increasing with age3 and it impacts significantly on the likelihood of a successful outcome. There is a particular need for preoperative assessment of cognition to establish a baseline against which to measure change; for example, establishing whether a patient has pre-existing dementia or is at particular risk of postoperative delirium. Both add considerably to the risk of this type of surgery but those risks can be reduced if recognised and properly planned for.
According to the report, sepsis, which is a serious complication of infection that without immediate treatment can lead to organ failure or death, remains the principal cause of avoidable death and serious morbidity in general surgical patients. It is present in nearly 20% of emergency general surgical patients4. The report highlights the importance of clinicians recognising sepsis quickly in high-risk general surgery patients and administering antibiotics as soon as possible, and always within one hour. The need for immediate access to an operating theatre or to radiologically-guided drainage in order to eradicate the source of infection is also emphasized.
Mr John Abercrombie, Royal College of Surgeons Council Member, and a Consultant Surgeon, said:
“There have been modest improvements since the RCS published standards in 2011. The most important improvement has been the establishment of the National Emergency Laparotomy Audit (NELA) which tracks data from all providers of emergency laparotomy, so that units can compare their performance to others and make the changes necessary to provide high quality care.
“That said, we cannot be complacent. There is still too much variation in the standard of care that these very ill general surgery patients receive. Hospitals need to think carefully about how resources are allocated between planned, urgent and emergency pathways so that all groups of patients get the best possible care.”
The report recommends hospitals should review the number and complexity of both high-risk general surgical patients and general surgical patients overall, and formally consider, at least annually, the resources required for safe general surgical care. It says they should put in place systems to track, detect and respond to an acutely increased risk of harm to general surgical patients caused by individual or collective patient demand on staff, equipment or estate that exceeds the capacity for safe care.
This should include encouraging and empowering staff to raise concerns when they believe that emergency general surgical patients are endangered and should specify how and when escalation will trigger deployment of more staff and prioritised access to hospital facilities, including diagnostics, theatre and critical care.
Notes to editors
1. A full copy of the report The High-Risk General Surgical Patient: Raising the Standard is attached and available here.
2. NELA Project Team. Third Patient Report of the National Emergency Laparotomy Audit (NELA) December 2015 to November 2016. London: Royal College of Anaesthetists; 2017.
3. Chen CC, Li HC, Liang JT et al. Effect of a modified hospital elder life program on delirium and length of hospital stay in patients undergoing abdominal surgery: a cluster randomized clinical trial. JAMA Surg 2017; 152(9): 827–834.
4. UK National Surgical Research Collaborative. Multicentre observational study of adherence to Sepsis Six guidelines in emergency general surgery. Br J Surg 2017; 104(2): e165–e171.
5. The Royal College of Surgeons of England is a professional membership organisation and registered charity, which exists to advance surgical standards and improve patient care.
6. For more information, please contact the RCS Press Office: telephone: 020 7869 6047/6041; e-mail: firstname.lastname@example.org; for out of hours media enquiries: 07966 486832.