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Rapid Responses: Rapid Responses published:
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Emergency Surgery: Experience and Rank of the Surgeon and Anesthetist influence outcome
- Abdul-Wahed N. Meshikhes (6 October 2006)
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Assistance to the emergency surgery. The Gustavo Aldereguía Lima University Hospital’s Model in Cienfuegos, Cuba
- Frank Carlos Alvarez-Li, Moisés A. Santos-Peña, Roberto Pérez-García, Reinaldo Jiménez-Prendes and Susana García-Buchaca (7 October 2006)
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Reducing the toll from emergency surgery: Time to change consultant working practices?
- Paul Frost, Matthew Wise, Consultant in Intensive Care Medicine, University Hospital of Wales (7 October 2006)
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How far possible
- Dr Raghesh varot kangath (7 October 2006)
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Reducing Morbidity and mortality after emergency surgery
- Mr H Hashimi, Dr H Hashimi, Dr W Dhahiri (9 October 2006)
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What is the role of juniors members of the surgical team?
- Jeremy E Oates (9 October 2006)
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Re: What is the role of juniors members of the surgical team?
- Kishore K Sridharan (11 October 2006)
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Don't drop your bundle
- Anthony P Morton (21 October 2006)
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Morbidity and mortality after emergency surgery
- Ajith K Siriwardena, Kolitha S Goonetilleke, Harsha R Hathurusinghe. (25 October 2006)
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Risk assessment
- Richard D Seigne (4 November 2006)
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Abdul-Wahed N. Meshikhes, Consultant Surgeon King Fahad Specialist Hospital, Dammam, Saudi Arabia
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Editor: I read with interest the editorial by Morris and Russell(1). I believe that every effort should be made to optimize the patient's clinical condition before performing any major emergency surgery. The timing of surgery is crucial and therefore, the time needed to deal with co-morbidities should be as fast as possible to avoid any further delay that may prove fatal. I agree with the authors that , management of such patients before and after surgery should in the intensive care unit (ICU)as the ward care is suboptimal. However, this may put an extra load on the already outstretched ICU beds and resources. In the under-developed and some developing countries, intensive care facilities are almost non-existent and if present, ICU beds are scarce and the number of qualified intensivists is limited. Under such circumstances the recommendation of admitting more patients into intensive care facilities will be difficult to implement and many patients undergoing major emergency surgery are deprived the right of been treated in the ICU. It is no surprise therefore that emergency surgery in rural hospitals is associated with higher morbidity and mortality. Other important factors which may influence the outcome of major emergency surgery and which were not mentioned by the authors are the experience and the rank of the surgeon performing the operation & also that of the anaesthetist administering the anaesthesia. References: (1) Morris C, Russel C. Morbidity and mortality after emergency surgery. BMJ 2006;333:713-4. Competing interests: None declared |
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Frank Carlos Alvarez-Li, MD, MsC Gustavo Aldereguía Lima University Hospital, Moisés A. Santos-Peña, Roberto Pérez-García, Reinaldo Jiménez-Prendes and Susana García-Buchaca
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After reading the Editorial “Morbidity and mortality after emergency surgery” published by BMJ1. We would like to comment on our experiences in this field. Cienfuegos is an approximately 400 000 inhabitant province situated to the southern central region of the island (Cuba). For the emergency surgical assistance there is an Emergency Center located at Gustavo Aldereguía Lima University Hospital which has an assistance model based on 1. high specialization, being specialists devoted exclusively to the urgent assistance; 2. priority classification according to the colour international code: red, yellow, green or black, used not only for the patients care at the hospital arrival but also for the surgical intervention decision2; 3. observance and intervention of the lasting time occurring from the symptoms onset until the surgical operation3; 4. implementation of Clinical Practice Guides as well as the assessment of their strict fulfillment4; 5. accessibility to the intensive care unit for the immediate post operatory observance period whenever the patient’s clinical-surgical conditions demand them; and 6. short hospital stay with home follow up of the mediate postoperative period since there is a well structured primary health assistance system available. From January 2003 to September 2006, 10 420 patients have been intervened due to different kinds of major emergent surgical pathologies like acute appendicitis (39,7%)5, polytrauma (22,4%), hip fracture (11,8%), intestinal occlusion (10,5%), ectopic pregnancy (6,8%) and others (8,9%). Among them, 3 292 (31,6%) presented with comorbilities such as arterial hypertension, diabetes mellitus, chronic obstructive pulmonary disease, and malignant neoplasias. Only 122 patients died (1,2%) in our series. Severity of the disease which caused the intervention (66,4%), lesion severity of poly-traumatized patients (23,7% and malignant neoplasias presence (7,3%) were the death cause found, all confirmed by autopsy. In the year 2006 according to the Improving Surgical Outcomes Group’s recommendations, 498 people out of 1 899 patients have been surgically intervened urgently, representing 26,2% and have been benefited by the immediate postoperative intensive care. References. 1. Morris C, Russell C. Morbidity and mortality after emergency surgery. BMJ 2006;333: 713-4. 2. Rojas O, Hernández E, Molina M, Ojeda JJ. Estratificación de prioridades para la urgencia quirúrgica. Resultados de la aplicación de un método diferente. Rev Cubana Anest Reanim. 2004; 5: 95-109. 3. Pérez R, Alvarez FC, Chepe L, Bernal JL. Tiempos de demora en la atención a la paciente con embarazo ectópico. Rev Calidad Asistencial.. 2006; 21(3): 153-58. 4. Aguila-Melero O, Olivera-Fajardo D. Apendicitis aguda. www.gal.sld.cu/GBP/Cirugia/Cirugía_General/Apendictis_Aguda.htm 5. Alvarez-Li FC, Jiménez-Prendes R, Pérez-García RM, Becerra-Terón G, Santos-Peña M. Acute apendicitis, an experience in Cienfuegos, Cuba. BMJ 2006;333 Rapid Response 24 Sept 2006. Disponible en [http://bmj.bmjjournals.com/cgi/eletters/333/7567/530#142538] Competing interests: None declared |
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Paul Frost, Consultant in Intensive Care Medicine Critical Care Directorate, University Hospital of Wales, Cardiff, CF14 4XW, Matthew Wise, Consultant in Intensive Care Medicine, University Hospital of Wales
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Editor - We share Morris and Russell’s concern at the alarming level of adverse outcomes following emergency surgery in the United Kingdom [1]. Patients requiring emergency surgery often have limited physiological reserve and little tolerance for error in their management. It is entirely appropriate that these patients are managed directly by consultants or by closely supervised trainees. In our opinion such supervision is most likely to ensure that the trainee becomes competent to care for these patients. However as the authors point out, the European Working Time Directive has limited the interaction between trainees, who may be working after hours and consultants, who work mainly during the day. We were surprised therefore, that amongst the recommendations that the authors have made to improve outcomes from emergency surgery in the future, no consideration is given to the possibility that consultants should change their working practices to increase their after-hours presence. This suggestion is not new the Academy of Medical Royal Colleges has suggested that Trusts may wish to contract consultants to stay in the hospital for emergency work in the evenings and during the daytime at weekends [2]. In our institution in Cardiff, there has been a resident consultant shift system since Sept 2004 [3]. Consequently critically ill patients are managed from the outset by a consultant Intensivist, this has obvious benefits for training and patient care. Consultants from other acute specialities may wish to give consideration to a similar change in working practice. References [1] Morris C, Russell C. Morbidity and mortality after emergency surgery. BMJ 2006;333:713-4 [2] Academy of Medical Royal Colleges. Implementing the European Working Time Directive. Available at http://www.aomrc.org.uk [3] Frost P, Wise M. Resident consultants in large intensive care units? Critical Care and Resuscitation 2006;8:50-51 Competing interests: None declared |
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Dr Raghesh varot kangath, lecturer Dr SMCSI Medical College Hospital, Karakonam
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The increase in time spend for the initital evaluation of the patient will be at the cost of delay in providing essential surgical care. Ethical issues are also included like comatose patients without a relative in which case, the past medical and surgical history of the patient is unavailable. Competing interests: None declared |
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Mr H Hashimi, Senior Consultant Surgeon Medical City Teaching Hospital, Baghdad, Iraq, Dr H Hashimi, Dr W Dhahiri
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The authors Morris and Russel deserve to be congratulated on attempting to tackle the problem of morbidity and mortality after emergency surgery (1). This problem is too big and elaborate to be addressed merely by throwing more money at it in the form of more ICU beds and intensivists. Indeed if prevention were to be better than cure, steps should be taken much earlier in the management pathway and far before the postoperative patient arrives to his/her bed in ICU under the capable care of our awaiting intensivist. At the outset, the need for surgery and the abandonment of the conservative approach (if any) has to be critically examined. Some patients have obviously far less chance of surviving surgery and may even do better with the conservative approach, where that is an option (2). Once the need to carry out surgery is deemed the best solution, the magnitude and extent of surgery must be determined. An obstructed patient may have a better chance of meaningful survival with a simple colostomy rather than a full blown lengthy resection procedure that may stress further already depleted reserves (3). The pros and cons of preoperative invasive resuscitation have to be balanced. Central and arterial lines as well as nasogastric tubes for example have their definite, albeit rare, complications. A temporary nasogastric tube placed during a straight forward laparoscopic cholecystectomy, leading to a perforated oesophagus and ending with a thoracotomy is not totally unheard of (personal communication Mr M Ani). Similar cases have been cited (4). While invasive monitoring and resuscitation are desirable, their potential detrimental effects may tip the scales unfavourably against the patient, should he be unable to withstand these complications or the treatment thereof. The question of investigations is an important one in emergency surgery. Over-investigating a patient may be unfruitful. Under- investigation may simply reduce the available information which can adversely impact the decision making process. Judicious investigations may provide information that may preclude surgery as a therapeutic option altogether and direct therapy more appropriately (5). Surgeons relenting to unreasonable, macho personal, or peer, pressure may spell doom for the patient. On the other hand appropriate timely consultation with trustworthy colleagues should be the norm as well as a cohesive and coherent multidisciplinary team approach, if patient survival rates are to be improved. Aviation experts teach that flying a precise accurate approach is always a prerequisite to a good safe landing. To achieve a better outcome in surgery, there is no substitute for accurate preoperative assessment and management planning by experienced clinicians. Mr H Hashimi Senior Consultant Surgeon
1. Morris C. and Russell C. Morbidity and mortality after emergency surgery. Br Med J 2006;333:713-714. 2. Boey J, Choi S K, Poon A and Alagaratnam T T. Risk stratification in perforated duodenal ulcers. A prospective validation of predictive factors. Ann Surg. 1987; 205: 22–26. 3. Khuri S F, Determinants of Long-Term Survival After Major Surgery and the Adverse Effect of Postoperative Complications. Ann Surg 2005;242:326- 343. 4. Fisman D N, Ward M E. Intrapleural placement of a nasogastric tube: an unusual complication of nasotracheal intubation. Can J Anaesth. 1996;43:1252-1256. 5. Hashimi H, Hashimi H and Dhahiri W. CT Diagnosis of Clostridium difficile Colitis Recent submission by the authors to BMJ Minerva. Competing interests: None declared |
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Jeremy E Oates, Clinical Research Fellow Salford Royal Hospitals Foundation Trust, Manchester M6 8HD
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The editorial by Morris and Russell highlights some of the failings in the current system of management for critically ill surgical patients. Understandibly, the editorial emphasises the role of the anaesthetic and intensivist team in the pre-operative management, with good quality care being shown to improve outcome. For the anaesthetic team to be involved does however require that the surgical team have made a decision that emergency operation or higher level care is necessary. Sometimes this decision is obvious to all, but sometimes it is not, especially to inexperienced, junior trainees. As a result, numerous institutions I have worked at recently have tried to improve this situation by stopping the most junior members of the surgical team - the PRHO or Foundation year 1 doctor - from seeing acute admissions. Instead, all referrals, both from A&E as well as general practice are seen and assessed by the SHO of the oncall team. Whereas this may benefit admission time targets by speeding up surgical admission, the detriment to training is significant. We are rapidly encountering a whole cohort of FY1 doctors who have never dealt with an acutely ill surgical admission, and SHOs who have had extremely limited exposure. Instead they will have spent many hours on the wards filling in fluid charts and completing TTOs instead of seeing sick patients, who are dealt with by more senior doctors. In the absence of training and experience with such cases, it will be extremely difficult for juniors to make the required decisions and initiate the correct management that leads to the involvement of anesthetists and intensivists. This situation also occurs in other specialities; in many hospitals, medical admissions are assessed by registrars or even consultants to reduce unnecessary admissions and improve care. But what will happen when the medical SHOs become registrars and have never dealt with a new admission with chest pain? Under the current proposal for foundation year training, it is entirely possible for a doctor to progress through their hospital jobs having never seen an acute surgical (or indead even medical) admission. If they then go into general practice, is it fair to expect them to then make a decision as to which patient requires admission and which can be dealt with safely at home? I fully accept that we can no longer have a system where the sickest patients are dealt with by the most junior staff alone, but we must ensure that these juniors have regular exposure to such patients with support and supervision. Otherwise a time will rapidly come upon us where the senior staff do not have the experience to deal with these patients either. Competing interests: None declared |
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Kishore K Sridharan, Consultant Physician Sunderland Royal Hospital, SR4 7TP
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I agree entirely with Dr Oates's comments. I think this is a problem that is real and also discussed in informal chats but not highlighted adequately. The other group which seem to take away the experience from junior doctors are the nurse practitioners who seem to admit patients but do not have any further role in their management. If we consider the scenario where the team on call is not the actual team of the consultant it becomes too obvious why we face problems with continuity of care. The days of the entire team being on call together are long gone but definiely had major advantages. So much for modernisation of the NHS! Competing interests: None declared |
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Anthony P Morton, Consultant medical statistician Princess alexandra Hospital, Brisbane 4102 Australia
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Don't drop your bundle. The subject of hospital safety continues to dominate the news.1,2 Sadly, much of the discussion misses a key issue: safety must be built into hospital systems, if cannot be inspected into them. Last year Brennan3 and colleagues reported that the data on improved hospital safety were not strong and that the way forward must be through implementing evidence-based systems. This year Berwick and colleagues4 report a huge increase in hospital safety. They carefully assembled and built into hospital systems the evidence for 6 of those systems where mortality can be high, for example the care of intravenous devices to prevent blood-stream infection. They were able to persuade the staff of a number of hospitals to implement those systems and this was clearly done with great determination. The success of the Berwick 100,000 lives saved campaign has spawned a new industry: the package of evidence-based systems in BUNDLES.5,6 Many hospital administrations are now busy on bundles. This change of emphasis from judgmental data collection and analysis to understanding and optimizing the system that produces those data is very welcome and long overdue. Eighty years ago Walter Shewhart, one of the founders of statistical process control and continuous quality improvement, pointed out that statistical analysis of industrial outcome data was meaningless unless the underlying systems had first been brought into control.7,8 He also emphasized that systems must be devised to prevent problems. Inspection without first fixing systems does not promote progressive improvement. This is not to devalue data collection and its proper analysis; sequential monitoring remains vital to ensure that evidence- based systems remain on track. However, as hospital administrations jump on the bundle bandwagon, we need to think about how effective this will be. It is being recognized increasingly that presenting people with a plan that requires behavior change and seeing that change implemented can be poles apart.9,10 We all know how difficult it is to get people to stop smoking or over-eating.11 One of the simplest and most effective things for controlling hospital-acquired infection is hand-washing between patient contacts, yet its efficient implementation has proved difficult and this has generated a good deal of research directed at finding out why this is so.12-15 We must recognize that having hospital administrations provide clinical staff with bundles will not work unless the difficult task of behavior change to effect implementation is also tackled; clinical staff will need a lot of help to implement those bundles. Unless this is understood and acted on, we will drop our bundles and they will become yet another failed effort to improve hospital safety. References 1. Medical Journal of Australia “The safety and quality of health care: where are we now?” 2006;184(10). 2. Ohlssen D, Sharples L and Spiegelhalter D “Flexible random-effects models using Bayesian semi-parametric models: Applications to institutional comparisons” Statistics in Medicine 2006 (in press). Published online in Wiley InterScience. 3. Brennan T, Gawande A, Thomas E and Studdert D “Accidental deaths, lives saved and improved quality” New England Journal of Medicine 2005;353:1405-1409. 4. Berwick D, Calkins D, McCannon C and Hackbarth A “The 100,000 lives campaign: setting a goal and a deadline for improving health care quality” JAMA 2006;295:324-7. 5. Morris C and Russell C “Morbidity and mortality after emergency surgery” BMJ 2006;313:314. 6. Friedman D, Russo P and Richards M “Surveillance of ventilator- associated pneumonia: the challenges and pitfalls” australian Infection Control 2005;10:122-125. 7. Deming W “Out of the crisis” Cambridge University Press 1986, page 88. 8. Oakland J and Morris P “Pocket Guide to TQM” Butterworth-Heinemann 1998, chapter 6, page 51. 9. Sheehan P, Saxon A and Howard A “You can't scare people into getting fit or going green” www.esrc.ac.uk. 10. Mah M and Meyers G “Towards a socioethical approach to behavior change” American Journal of Infection Control 2006;34:73-79. 11. Avenell A, Satter N and Lean M “ABC of Obesity. Management: Part 1- Behavior change, diet and activity” BMJ 2006;353:740-743. 12. Pittet D “Improving Adherence to Hand Hygiene Practice: A Multidisciplinary Approach” Emerging Infectious Diseases 2001;7:234-240. 13. Pittet D “The Lowbury Lecture: Behavior in Infection Control” Journal of Hospital Infection 2004;58:1-13. 14. Pittet D “Infection Control and Quality Health Care in the New Millenium” American Journal of Infection Control 2005;33:258-267. 15. Whitby M and McLaws M-L “Why Health Care Workers Don't Wash Their Hands: A Behavioral Explanation” Infection Control and Hospital Epidemiology 2006;27:484-492. Competing interests: None declared |
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Ajith K Siriwardena, Consultant Hepatobiliary Surgeon Manchester Royal Infirmary, Kolitha S Goonetilleke, Harsha R Hathurusinghe.
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Editor – The editorial on outcome after emergency surgery addresses an important area of clinical practice (1). There is clearly a challenge to improve outcome. It seems reasonable that the creation of care bundles and management protocols will improve outcome. However, it is probably incorrect that surgical trainees spend less time interacting with their consultants who “work mainly during the day” as current surgical practice is heavily consultant-led. The statement that “making a diagnosis can come at the price of delay”, whilst correct is illogical as the crux of management depends on knowing whether surgery is required or not. However, Morris and Russell’s article does not address what is probably the root cause that makes improvement of outcome in emergency surgery difficult, namely that out-of-hours General Surgical work often appears unattractive and sits outwith current specialised practice patterns. Although still regarded as a single specialty for training purposes, gastrointestinal (GI) surgery is sharply defined into colorectal, oesophago-gastric and Hepatobiliary practice. The emphasis for trainees and for appointment committees is to ensure procedure-based competency in these specialist areas. Whilst there is some overlap between the skill sets required in elective surgery and emergency surgery, there is at present a dearth of incentive for surgical trainees to gain mastery of emergency gastrointestinal surgery. How then can a high- quality emergency surgery service be provided within this setting? The potential solution of training specialist “emergency GI Surgeons” is unfeasible as a breadth of competence is required and these skills are properly taught in their respective specialties. Separation of “General” surgery into specialty-based rotas is also unfeasible as it would result in overlap of service and would be costly. Practical solutions require greater emphasis on the importance of emergency surgical cover in consultant job plans, ensuring that “on-call” time is free of elective work and close co-operation between specialties so that patients requiring specialty skills are appropriately resuscitated and channelled. Kolitha S Goonetilleke Harsha R Hathurusinghe Ajith K Siriwardena Hepatobiliary Surgical Unit,
Manchester Royal Infirmary,
Oxford Road,
Manchester M13 9WL, UK
Competing interest: none declared. Reference: 1. Morris C, Russell C. Morbidity and mortality after emergency surgery. BMJ 2006;333:713-4. Competing interests: None declared |
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Richard D Seigne, Specialist Anaesthetist Christchurch Hospital, Private Bag 4710, Christchurch, 8001. New Zealand
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The authors refer to the POSSUM scoring system as "a simple" way of guaging pre-operative risk. In my view there are 3 problems with POSSUM. Firstly it can not be used pre-operatively. It relies on the collection of 12 pre operative physiological variables followed by 5 operative variables which can not be scored until after surgery has been completed. Secondly it is not simple, 17 variables are required. Thirdly it is designed for audit and comparision of the performances of multiple surgeons or institutions or an individual surgeon/institution over time. It suffers the weakness of all similar risk assessmnet tools, individualised patient risk can not be accurately obtained. The only method that can approach this ideal is cardio-pulmonary exercise testing which is not possible in the acute setting. Two models that overcome 2 of the problems with POSSUM are the Surgical Risk Scale (SRS)(1) and a model published by Donati (2). The SRS is a simple risk assessment tool that can be used pre-operatively, relying on 3 variables. It's performance is at least as acaurate as POSSUM regarding predicting post-operative mortality. Doanti's model requires 4 variables which are available pre-operativley. Currently Donati, in collusion with myself and surgical colleagues are investigating this model on database of over 10,000 general surgical patients. Preliminary workings appear to confirm the model's published results with narrower confidence intervals for predicted mortality. Neither of these models can predict post-operative morbidity (POSSUM does) or an individual's risk death. References 1. Sutton, R. Bann, S. Brooks, M. Sarin, S. The Surgical Risk Scale as an improved tool for risk-adjusted analysis in comparative surgical audit. British Journal of Surgery. 2002; 89: 763-68. 2. Donati, A. Ruzzi, M. Adrario, E. Pelaia, P. et al. A new and feasible model for predicting operative risk. British Journal of Anaesthesia. 2004; 93(3): 393-9. Competing interests: Co-author of a manuscript describing a model for assessing post-operative mortality risk, to be submitted for publication |
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