Patients who have emergency surgery, especially those with comorbidities, have a high risk of adverse outcomes. Of 20 000 reported surgical deaths, most occurred within days of emergency or major surgery.1 Pneumonia was the most common cause of death (www.ncepod.org.uk/pdf/200304DeathData.pdf), and suggests that organ (lung) failure can progress rapidly in susceptible people.

Recent initiatives, such as the National Confidential Enquiry into Patient Outcomes and Deaths (under the auspices of the Patients Safety Agency), aim to reduce morbidity and mortality after emergency surgery. The multidisciplinary Improving Surgical Outcomes Group has also released a document with the same aims.2 It describes system changes (such as better preoperative assessment) and interventions (such as non-invasive monitoring of cardiac output3) that will help patients reach the far end of their “surgical journey” alive and well.

Current systems for assessing risk preoperatively are of variable effectiveness. Traditional clerking often fails to prioritise resuscitation and physiological stabilisation (correction of organ dysfunction and biochemical …