A lack of consistent care for patients undergoing high-risk emergency bowel surgery may be negatively affecting patient outcomes and placing major strain on scarce NHS resources, a report claims.
The joint national report led by the Royal College of Anaesthetists (RCoA) makes 12 recommendations to health commissioners and providers to reduce the variations in care.
The annual cost of ward care alone is in excess of £200 million, despite £22m in savings due to reducing length of hospital stays.
Commissioned by the Healthcare Quality Improvement Partnership as part of the National Clinical Audit Programme, the National Emergency Laparotomy Audit (NELA) report analyses the care received by more than 20,000 emergency bowel surgery patients treated in NHS hospitals in England and Wales between December 2014 and November 2015.
Analysing patients’ short-term survival, the report found 1 in 9 patients died within 30 days of surgery, but that risk of death ranged from under 5% to over 30%, depending on the patient’s condition at the time of surgery.
The 30-day mortality rates for individual hospitals were in the range expected given the number of patients and the range of conditions treated; however the report shows substantial variation in the delivery of care against pre-existing national standards.
Data from this report highlights that the current provision of care is falling short of that provided for adult patients undergoing other major elective surgery of comparable or lesser risk. NELA’s first patient report, published in 2015, revealed that more patients die from emergency bowel surgery than from any other type of high-risk planned surgery.
Office for National Statistics and NELA data indicate that emergency laparotomy carries an 11 percent mortality rate, confirming the high-risk nature of emergency bowel surgery. More than a quarter remained in hospital 20 days after surgery, with older patients more likely to remain in hospital longer.
Examples of where hospitals fall short of the standards of care referenced within the NELA report include:
- prior to surgery, 36% of patients do not receive a documented assessment of risk of death
- 29% of emergency bowel surgery patients identified as urgent do not arrive in theatre within the stipulated two hour timeframe
- 39% of patients are not admitted directly to a critical care unit after surgery
- 90% of elderly patients did not receive input from Elderly Medicine Specialists.
Though the proportion of patients receiving a formal risk assessment prior to bowel surgery has increased from 56% to 64% over the last year, there remain large differences in standards of care between hospitals. Furthermore, little improvement has occurred at an organisational level to raise standards of care such as timely access to operating theatres, critical care provision, and input from Elderly Medicine Specialists for older patients.
Rectifying this will require greater engagement between clinicians, health care managers and commissioners.
Professor Mike Grocott, Chair of NELA and Council Member of the Royal College of Anaesthetists, said: “Shortfalls in the perioperative care of these patients before, during and after major surgery may be negatively affecting patient outcomes and use of resources. There is still much work to be done and it is vital that, clinicians, hospital managers and commissioners of healthcare examine these data to determine why standards are not always met and how improvements can be made. This will lead to better care and efficiencies that will benefit both patients and the NHS.”
A summary of the 12 recommendations:
– assessing and documenting patient risk to guide allocation of resources
– providing sufficient critical care and emergency operating theatre capacity to allow emergency surgery
to occur in a timely fashion
– ensuring consistent medical staffing at all times
– implementing care pathways for emergency surgical patients
– planning and reviewing essential processes of care by multi-disciplinary team working.