EMERGENCY SURGERY
Tackling variation in emergency surgery
Variation in outcomes between different surgical units and individual surgeons remains a challenge, according to the latest reports on emergency surgery.
Published earlier this year (April 2016), a report by the Nuffield Trust, commissioned by the Royal College of Surgeons (RCS), showed there are unacceptable differences between hospitals in outcomes for patients undergoing emergency general surgery, with death rates for major operations in this field almost 12 times higher at some Trusts than others.
The procedures performed in emergency general surgery are typically abdominal to treat conditions such as gall bladder removal, perforated gut and obstructed hernia. Patients undergoing these procedures tend to be older and more frail – frequently with other co-existing conditions. As a result, the risk of death from such surgery tends to be high, with more than one in 10 patients dying within 30 days of major emergency general surgery.
The authors looked at outcomes for patients undergoing high-risk emergency general surgery. The main problems involving this type of surgery identified by the report are: l Significant variation in outcomes between different hospitals – for example, a previous study found that mortality for emergency laparotomy (an incision in the abdomen to carry out major surgery) ranges from 3.6% to 41.7% in 35 NHS hospitals.
l An increasing trend towards greater specialisation among surgeons means that there are fewer surgeons with the skills to carry out general surgery, particularly in emergency situations. Because of this, units can find it difficult to provide round-the-clock emergency consultant cover.
l Demographic and epidemiological trends, with a rapidly ageing population, mean that demand for this type of surgery will continue to increase.
Recommendations
The report’s main recommendations included: l The quickest way to improve outcomes would be the systematic use of all
There are significant variations in outcomes between hospitals – especially for mortality following emergency laparotomy.
protocols and pathways drawn up by experts in this field. In particular, Trusts should ensure compliance with best practice for laparotomy and cholecystectomy. The report identified the Emergency Laparotomy Pathway Quality Improvement Care (ELPQuiC) bundle as a straightforward clinical tool that may lead to considerable survival benefit in emergency laparotomy patients. A number of other pathways for the management of emergency laparotomy patients are available on the NELA website (
www.nela.org.uk), and the Association of Upper Gastrointestinal Surgeons (AUGIS) has published a pathway for the management of acute gallstone disease (AUGIS, 2015).
l The most comprehensive way to address the challenges faced by emergency
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general surgery would be to develop managed clinical networks, such as those already set up in the NHS for patients who suffer strokes or trauma.
l Other professional roles – such as advanced nurse practitioner or physician associates – should be developed to address potential gaps in staffing in the discipline, in terms of both numbers and skills.
l Centralisation of services in ‘fewer, bigger, better’ units will not necessarily improve outcomes. The report contains an analysis of all major emergency general surgery across 154 sites in England over four years, and demonstrates that centres that carried out a high volume of procedures did not have lower death rates than those carrying out a smaller number of operations, and vice versa.
OCTOBER 2016
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