Improving outcomes after surgery
BMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b5173 (Published 11 December 2009) Cite this as: BMJ 2009;339:b5173
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The technical complexity of the operation is ranked a mere eleventh
among twelve factors found to be predictive of fatal outcomes from surgery
in the Department of Veterans Affairs' NSQIP(1). "The most important
determinant of decreased postoperative survival was the occurrence, within
30 days postoperatively, of any one of 22 types of complications collected
in the NSQIP (2), and yet, in the study sponsored by the American College
of Surgeons, rates of individual complications did not vary significantly
across a quintile of hospitals ranked according to their risk-adjusted
overall rate of death (3). "In contrast, mortality in patients with
major complications was almost twice as high in hospitals with very high
overall mortality as in those with very low overall mortality (21.4% vs.
12.5%, P<0.001)".
Does that not mean that surgical outcomes today have little if
anything to do with operative technique, the complexity of surgery being
performed and/or the quality of anaesthetic support intraoperatively? if
so it must be the quality of postoperative care that is the most important
determinant of fatal outcomes. Can this be true?.
As one of Professor Mythen's earliest studies showed anaesthetic
management of fluid administrations is of vital importance in the
determination of fatal outcomes, an observation has since been confirmed
in Leeds. What is more it is a very well established surgical principle
that keeping out of trouble during surgery is the best way of avoiding
adverse outcomes. Indeed from the many reoperations I have done most have
been the product of operations naively, inexpertly or wrongly performed as
established by the success of revisional surgery.
Might the difference be that the former depends in most US hospitals
upon the skills of professionals other than surgeons and anaesthetists and
the latter solely upon the the skills of the surgeon and his/her
anaesthetist? In other words might soneone have been cooking the books
with political intent?
1. S F Khuri, J Daley, W Henderson, K Hur, J Demakis, J B Aust, V
Chong, P J Fabri, J O Gibbs, F Grover, K Hammermeister, G Irvin, 3rd, G
McDonald, E Passaro, Jr, L Phillips, F Scamman, J Spencer, and J F
Stremple. The Department of Veterans Affairs' NSQIP: the first national,
validated, outcome-based, risk-adjusted, and peer-controlled program for
the measurement and enhancement of the quality of surgical care. National
VA Surgical Quality Improvement Program. Ann Surg. 1998 October; 228(4):
491–507
2. Shukri F. Khuri, MD, William G. Henderson, PhD, Ralph G. DePalma,
MD, Cecilia Mosca, MSPH, Nancy A. Healey, BS, Dharam J. Kumbhani, MD, SM,
and the Participants in the VA National Surgical Quality Improvement
Program. Determinants of Long-Term Survival After Major Surgery and the
Adverse Effect of Postoperative Complications Ann Surg. 2005 September;
242(3): 326–343.
3. Amir A. Ghaferi, John D. Birkmeyer, and Justin B. Dimick.
Variation in Hospital Mortality Associated with Inpatient Surgery. New Eng
Med, 2009;361:1368-1375.
Competing interests:
None declared
Competing interests: No competing interests
The critical point in this editorial was the difference in mortality
due to complications in the post-operative period.
With introduction of EWTD and shifts there has been a loss of
continuity of care. This makes it much more likely that impending
complications will not be recognised in time. As yet this is much less
likely to occur in the USA where junior doctor hours are still nearer 80
per week.
Without following a patient upon whom they have operated through the
full post operative course it is very difficult for junior surgeons to
learn the warning signals of complications.
For this reason alone the Royal College of Surgeons campaign to
increase hours for surgeons in training should be endorsed.
Competing interests:
None declared
Competing interests: No competing interests
Call me old-fashioned...
As a surgeon with a long-standing interest in surgical outcomes and
surgical audit. I applaud Mr Grocott’s article ‘Improving outcomes after
surgery, BMJ v. 340 p 62-3. Since my early days of training I have
believed that outcomes for our patients could be improved most effectively
by examining how surgical treatment could do done better rather than by
‘original’ research.
Surgical outcomes can be improved by recognising early those surgical
patients at increased risk and then providing proper preparation and
postoperative care. Outcomes can also be improved by teaching clinicians
how to recognise when a patient is ‘going off’. For this, nursing
observations are vital, perhaps aided by monitoring equipment; however the
latter should not be a substitute for bedside interaction with the patient
by clinicians able to provide continuity of care. This is not easy with
shortened training and reduced hours but can be mitigated by proper
handover arrangements. Of course clinicians in training need to gain
enough bedside experience under the tutelage of experienced seniors to
learn to recognise when something might be wrong (the early signs are
subtle) and how to investigate by clinical examination and only later by
investigation.
I believe another factor in improving surgical outcomes is for
surgeons to be trained thoroughly to carry out operations in the lab and
under a wide range of clinical scenarios with impeccable technique. This
involves far longer apprenticeships that our current truncated training
allows.
In summary, surgeons need to be trained well and for long enough.
They need to be able to operate well; to provide continuity of care and
carry out frequent bedside review especially of high risk patients; to
recognise very early when things are going wrong and to perform early
intervention such as reoperation (which can radically reduce the risk of
sepsis and a fatal downhill path). Finally, of course results need
auditing. However I have found that the system is often let down by
failure to implement evident changes needed to improve quality of care.
Clive R Quick MS FDS FRCS
Consultant surgeon
Competing interests:
None declared
Competing interests: No competing interests