Hospital Dr News

Focus on elective operations threatens quality of emergency surgery, RCS warns

Patients who need to undergo high-risk emergency abdominal surgery are being discriminated against, a report from the Royal College of Surgeons (RCS) has warned.

The college report says NHS resources – such as consultants, operating theatres and critical care beds – are being targeted at lower-risk patients having planned procedures.

However, the patients may have potentially life-threatening conditions such as bowel obstructions, strangulated hernias or peritonitis.

The High-Risk General Surgical Patient: Raising the Standard says that many patients 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.

The 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 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.”

On the positive side, 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.

However, 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 population.

Postoperative delirium is among the more common complications following abdominal surgery in older people, with incidence increasing with age 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.

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.”

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