In a drive to improve patient care, the Royal College of Surgeons (RCS) and the Association of Surgeons of Great Britain and Ireland (ASGBI) have set out their views on the challenges and a way forward for emergency general surgery in the NHS.
Emergency general surgery accounted for 14,000 adult admissions to intensive care in England and Wales in 2011/12, and created intensive care costs of over £88m per year. Patients requiring emergency surgical assessment or operation are among the sickest in the NHS. Often frail, elderly and with other medical problems, the risk of death or serious complication can be high. The most common complex major emergency operations in adults are those to treat abdominal infections, bowel obstructions, appendicitis and gallstones. The Royal College of Surgeons (RCS) and Association of Surgeons of Great Britain and Ireland (ASGBI) are concerned about the delivery and future viability of emergency general surgery. Systems within some hospitals are not sufficiently well designed to deal with the safe and efficient delivery of this important area of care. Several factors affect the ability to deliver a good service, from having the right workforce in place through to problems accessing operating theatres and diagnostic services when necessary. To improve the care provided to emergency general surgery patients they have produced a report Emergency General Surgery which recommends that:
• NHS England establish a strategic clinical network for emergency general surgery to oversee the delivery of safe and efficient care.
• Best practice tariffs should be developed to reward the delivery of high quality emergency general surgical services.
• Surgical treatment of acutely ill patients must take priority over planned, elective surgery when necessary.
• Services must be consultant-led and senior doctors must be involved throughout the patient’s care. The seniority of the surgeon involved in the operation must match the clinical need of the patient.
• There should be a greater focus on the outcomes of care, with improved resources for audit and review of practice. Outcomes should be in the public domain.
A recent study, published in the British Journal of Surgery revealed significant variation between hospitals in patient death rates following emergency surgical admissions in England. It also found that survival rates were higher in hospitals with better resources. Patients presenting as emergencies account for the majority of deaths associated with general surgery. There is increasing evidence that the quality of care for these high-risk patients is variable across hospitals within the NHS. Researchers at Imperial College London conducted a national study to quantify and explore variability in death rates among high-risk emergency general surgery patients. Their analysis included 367,796 patients who received care at 145 hospitals from 2000 to 2009. The researchers found significant variability in death rates within 30 days of admission among patients treated at different hospitals, with rates ranging from 9.2% to 18.2%. This may, in part, be explained by differences in hospital resources. Specifically, hospitals that had greater numbers of intensive care beds and made greater use of ultrasound and computed tomography scanning tended to have lower mortality rates. Commenting on the report, Omar Faiz, from the Department of Surgery and Cancer at Imperial, who led the study, said: “We do not yet fully understand all the reasons for variable performance, but this study strongly suggests that there is considerable scope for improving the care of emergency surgical patients. The findings may have long-term implications with regard to the provision of emergency services and the infrastructure required to support high-risk emergency patients in acute general hospitals.”
