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Surgical patients are not receiving the care they should, finds inquiry

BMJ 2011; 343 doi: http://dx.doi.org/10.1136/bmj.d7983 (Published 08 December 2011) Cite this as: BMJ 2011;343:d7983
  1. Zosia Kmietowicz
  1. 1London

The care of patients in the UK before and after surgery needs to be radically overhauled to identify those at high risk of complications and death, to ensure they get the appropriate care, say the authors of a nationwide audit.

The latest National Confidential Enquiry into Patient Outcome and Death (NCEPOD) shows that only half of high risk surgical patients received care that the advisers said they would accept from themselves or their own institutions.

The inquiry describes a damning list of essential services that are absent in many UK hospitals, putting patients at greater risk of death after surgery. It collected data on 19 097 patients who underwent surgery during one week in March 2010 in 301 hospitals and retrospectively reviewed data on 829 high risk patients.

It found that 16% of hospitals had no preadmission anaesthetic assessment clinic and 17% had no surgical assessment clinic. Five hospitals had neither. Overall, 21% of high risk elective patients were not seen in preassessment clinics, and 30 day mortality among those who weren’t seen was almost seven times that among those who were (4.8% versus 0.7%).

Arrangements for recovery were also poor. Four hospitals seemed to have no post-anaesthetic recovery area at all, and more than 60% of those that did could provide ventilatory support only in an emergency or for a maximum of six hours.

A third of hospitals had no critical care outreach team, and overall only 22% of high risk patients went to critical care. The 30 day mortality rate among patients who were returned to wards was four times higher than among those who went to critical care (5% versus 1.4%). In 74 cases, high risk patients who were returned to wards died there without being taken to critical care.

The inquiry also reported that one in eight hospitals (12%) had no policy for identifying acutely ill patients; a third had no policy for identifying perioperative hypothermia; and only a small proportion of high risk patients had arterial lines (9%), central lines (14%), or cardiac output monitoring (27%), despite evidence that these are beneficial.

The report concludes that “there is a long way to go in this country before we can suggest that we have reached an acceptable position.”

The overall risk of serious complications or death among surgical patients in the UK is less than 1%. But among the 10% of patients considered to be at high risk this rises to between 10% and 15%.

Post-surgical mortality among UK patients who have a predicted risk of death of up to 5% is eight times that in the United States, and mortality among those with a risk of death of 11-20% is triple the US rate.

Alex Goodwin, a coauthor of the report and a consultant in anaesthesia and intensive care, said that the decision to operate on high risk patients should be made only at consultant level. And care should be delivered through a team approach that includes case planning and identification of the facilities needed to achieve the best outcomes.

Bertie Leigh, the inquiry’s chairman, said, “People die because we do not give them the level of care they are entitled to expect.”

Surgical patients who are seen today are more challenging than those seen even 10 years ago, he said. They are generally older, two thirds are overweight, and many have major comorbidities.

“The distance between what we are achieving and what we aspire to achieve is showing no signs of getting narrower. Poor care is also leading to longer hospital stays, putting further strain on already stretched hospital budgets,” said Mr Leigh.

The inquiry found that only 37 of 496 (7.5%) high risk patients were given an estimate of mortality reflecting “the standards of benevolent paternalism that society and the GMC [General Medical Council] expected in the 1970s,” said Mr Leigh.

Another coauthor, George Findlay, an intensive care consultant, called for a robust system to assess patients and identify risk and for “strategies to mitigate risk.”

Trusts should analyse how many of their surgical patients are at high risk and provide sufficient critical care resources for all patients who need intensive postoperative care. They should also report this work to trust boards every year, says the report.

Notes

Cite this as: BMJ 2011;343:d7983

Footnotes

  • Knowing the Risk: A Review of Perioperative Care of Surgical Patients is at www.ncepod.org.uk.