The care given to high-risk surgery patients is falling short of acceptable standards, an independent review says.
The National Confidential Enquiry into Patient Outcome and Death found four in 10 received poor or inadequate treatment. The expert panel described the findings as “disturbing” after reviewing nearly 20,000 patients in England, Wales and Northern Ireland.
NCEPOD says the study’s findings are particularly significant because there are many remediable factors in the peri-operative care pathway of high risk surgical patients.
It highlighted deficiencies in pre-operative assessment. Management of patients prior to surgery was a concern, particularly in non-elective patients, and fluid management was a common problem. Other issues include:
• Intra-operative monitoring for high risk patients rarely included cardiac output monitoring despite the evidence base.
• Critical care was the post operative location for 1 in 5 high risk patients. Most high risk patients return to ward care.
• The high risk group 30 day mortality was almost 7% and this encompassed three quarters of the postoperative deaths.
• Advisors’ opinion was that care was good in less than half the cases.
These points indicate that there are major deficiencies in how high risk surgical patients are cared for, and improvement will require both a change in thinking from health professionals about the needs of this group and support from health service managers to provide the resources to do so.
The returns could be significant - less postoperative death and morbidity, quicker return to health and independent living, more efficient care and less cost to the NHS.
The Royal College of Surgeons identified similar concerns in two separate reports published during 2011 into standards of care for emergency and higher-risk surgical patients. Prof Norman Williams, president of the Royal College of Surgeons, commented: “The Department of Health has been able to establish good monthly data on waiting lists for years and we have seen improvements as a result. It is now time for government to grasp the nettle and ask hospitals to routinely provide publicly available evidence on how they manage high-risk cases.”
Key findings
The NCEPOD study’s findings include:
1. 72.5% of NHS hospitals had availability of dedicated emergency theatres 08.00-17.59 during Monday to Friday but this was significantly lower out-of-hours.
2. 23% of hospitals could not provide ventilatory support and ongoing management in the post anaesthetic recovery area, many of those that were able to, could only provide for a short time.
3. 12% did not have a formal policy in line with NICE Clinical Guideline 50 for the recognition and initial response to acutely unwell patients.
4. 16% did not provide pre-admission anaesthetic assessment clinics.
5. 17% did not provide pre-admission surgical assessment clinics.
Anaesthetists involved in the surgery identified 20% of patients as high risk, and 79% of the deaths were in the high risk group. Urgency of surgery did not correlate well with risk category - half of the high risk patients were elective procedures. And while higher ASA grades had a higher proportion of high risk patients - there were still substantial numbers of high risk patients in ASA grades 1-2.
Report recommendations
1. The NCEPOD report says there a need to introduce a UK-wide system that allows rapid and easy identification of patients who are at high risk of postoperative mortality and morbidity.
2. The decision to operate on high risk patients (particularly non-elective) should be made at consultant level, involving surgeons and those who will provide intra and postoperative care.
3. An assessment of mortality risk should be made explicit to the patient and recorded clearly on the consent form and in the medical record.
4. Once a decision to operate has been made there is a need to provide a package of full supportive care. This may include critical care admission or support, for the higher risk patients.
5. Better intra-operative monitoring for high risk patients is required. The evidence base supports the use of peri-operative optimisation and this relies on extended haemodynamic monitoring.
6. The postoperative care of the high risk surgical patient also needs to be improved, the report says. Each trust must make provision for sufficient critical care beds or pathways of care to provide appropriate support in the postoperative period.
7. To aid planning for provision of facilities for high risk patients, each trust should analyse the volume of work considered to be high risk and quantify the critical care requirements of this cohort. This assessment and plan should be reported to the trust board on an annual basis.
Conclusions
Overall the care of patients was good in only 48% of high risk patients. The review of the high risk cases by the NCEPOD advisors uncovered a lack of consensus as to what constitutes high peri-operative risk. All elective high risk patients should be seen and fully investigated in pre-assessment clinics, and the adoption of enhanced recovery pathways for high risk elective patients should be promoted.
Given the high incidence of postoperative complications demonstrated in the review of high risk patients, and the impact this has on outcome there is an urgent need to address postoperative care.
Read the full report.
Tags: Emergencies, Surgery
