Reducing mortality for high risk surgical patients in the UK.
Abstract: Over 40 million surgical procedures are performed per annum in the USA and Europe, including several million patients who are considered to be high risk (Bennett-Guerrero et al 2003). Overall, the risk of death or major complications after surgery in the general surgical patient population is low, with a post-operative mortality rate of less than 1% during the same hospital admission (Niskanen et al 2001).

KEYWORDS Mortality / High risk / NCEPOD
Article Type: Report
Subject: Hospital patients (Patient outcomes)
Hospital patients (Health aspects)
Mortality (Research)
Mortality (United Kingdom)
Surgery (Health aspects)
Authors: Rogers, Benedict A.
Carrothers, Andrew D.
Jones Chris
Pub Date: 07/01/2012
Publication: Name: Journal of Perioperative Practice Publisher: Association for Perioperative Practice Audience: Academic Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2012 Association for Perioperative Practice ISSN: 1750-4589
Issue: Date: July, 2012 Source Volume: 22 Source Issue: 7
Topic: Event Code: 310 Science & research
Product: Product Code: 8000410 Surgical Procedures NAICS Code: 62 Health Care and Social Assistance
Geographic: Geographic Scope: United Kingdom Geographic Code: 4EUUK United Kingdom
Accession Number: 300545547
Full Text: Concerns have existed regarding the surgical outcomes of high-risk patient in the UK compared to similar sized hospitals and populations in North America (see Figure 1) (Feachem et al 2002, Bennett-Guerrero et al 2003). However, in December 2011 the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) published a report 'Knowing the Risk: A review of the perioperative care of surgical patients' (NCEPOD 2011). The report highlighted that nearly 80% of postoperative deaths occurred in 'high risk' surgical patients. An expert panel considered that less than 50% of high-risk patients received good quality care.

This review considers some of the important issues and recommendations highlighted in the report.

The 2011 NCEPOD report

It is estimated that high-risk surgical patients make up approximately 10% of the inpatient surgical workload, whilst accounting for 80% of deaths after a surgical procedure. The hospital mortality rate for this cohort is approximately 10-15% and the figure is undoubtedly affected by the provision of perioperative care (Pearse et al 2006).

The recent NCEPOD report suggested that improvements are necessary in the care of high-risk surgical patients. The evidence for this is that the reported 30 day mortality of this group is almost 7%, which represents over 75% of all postoperative deaths (NCEPOD 2011).

The data collection by NCEPOD showed substantial methodological improvement compared with previous reports which attracted criticism. In particular, it was a prospective study that provided denominator data. This method was preferable to considering perioperative deaths in isolation which would lead to a degree of selection bias and therefore difficulties in extrapolating recommendations. In addition, the use of peer review of medical notes by an expert panel of advisors ensured qualitative data in support of the quantitative evidence.

Enhancing perioperative care can be split into the separate stages of a patient's care pathway, namely:

Identification of high-risk groups

There are frequently difficulties in identifying what constitutes 'high-risk'. The report highlighted that 20% of surgical caseload was deemed high risk and that 79% of deaths occurred in this group. Further, half of the high-risk patients were undergoing elective procedures; therefore the urgency of the surgery is a poor predictor. A substantial number of high-risk patients were ASA grade 1 - 2. There was a lack of consensus as to what defined high perioperative risk.

Pre-operative assessment, triage and preparation

The report highlighted that nearly 20% of elective high-risk patients failed to be seen in a pre-assessment clinic. These had a significantly higher 30-day mortality than patients who were seen in a pre-assessment clinic. Pre-operative weight loss can lead to increased post-operative morbidity and mortality and therefore an assessment of nutritional status is beneficial (Heys & Gardener 1999).

Systematic preoperative assessment can identify patients at high risk of cardiac complications and can guide the application of appropriate risk reduction strategies (Bakker et al 2011).

The optimisation of oxygen delivery to tissue prior to major surgery has been shown to be a significant and cost effective improvement in perioperative care (Boyd et al 1993, Wilson et al 1999). It has been shown to be especially important for elderly patients (Hamel et al 2005, Tingle 2010).

Consent

n only 7% of cases was there any documentation of the risk of death. This was concerning particularly as the GMC requires doctors to have a clear discussion with patients regarding surgical risks (GMC 2006, RCS 2008).

Improve antra-ones care

In those patients considered to have inadequate fluid management, the 30-day mortality rate was nearly five times that of patients receiving adequate fluid therapy (20.5% v 4.7%). Arterial lines, central lines and cardiac output monitoring were only used in 27%, 14% and 5% respectively, for high-risk patients.

Cardiac monitoring was rarely used, though good evidence exists for its benefits, and suboptimal intra-operative monitoring correlated with a three-fold increase in mortality. For example, intraoperative monitoring, using continuous 12-lead ECG assessment and transesophageal echocardiography, may identify treatable myocardial ischemia and arrhythmias in a timely manner (Bakker et al 2011).

[FIGURE 1 OMITTED]

Improved postoperative resource use

Of the patients who died, over 50% were never admitted to critical care departments and 48% of the high-risk patients who died never went to critical care.

Detailed clinical guidelines for the monitoring of high risk and acutely ill patients have been published by NICE (2007). Though beyond the remit of this review, the NCEPOD report clearly demonstrates that the guidelines developed by NICE are not being fully implemented.

There is a substantial evidence base for the importance of physiological monitoring. A multicentre, prospective, observational study found that the majority (60%) of primary events (deaths, cardiac arrests and unplanned ICU admissions) were preceded by documented abnormal physiology, the most common being hypotension and a fall in Glasgow coma scale (Kause et al 2004). Box 1 Principle recommendations Reprinted from: NCEPOD 2011 'Knowing the risk-A review of the perioperative care of surgical patients'

Another study found that mortality increased with the number of physiological abnormalities (p<0.001), being 0.7% with no abnormalities, 4.4% with one, 9.2% with two and 21 3% with three or more (Goldhill 2005, Goldhill et al 2005).

Recommendations

The need for improved care of high-risk surgical patients has been clearly demonstrated. Previously published data from the Intensive Care National Audit & Research Centre, collating the outcomes of over 4 million surgical procedures, highlighted deficiencies in the use of critical care resources for high risk surgical patients (Pearse et al 2006).

The NCEPOD report details significant areas for clinical improvement within the UK (NCEPOD 2011). In addition there are several, recently published, reports that provide evidence-based guidelines for perioperative management of high-risk surgical patients, that are beyond the scope of this editorial.

They include:

* The Royal College of Surgeons of England/Department of Health 2011 The higher risk general surgical patient: Towards improved care for a forgotten group London, RCSEng/DH Available from: www.rcseng.ac.uk/publications/docs/higher-risk-surgical-patient/ [Accessed April 2012]

* The Association of Anaesthetists of Great Britain and Ireland 2007 Recommendations for standards of monitoring during anaesthesia and recovery London, AAGBI Available from: www.aagbi.org/sites/default/files/standardsofmonitoring07.pdf [Accessed April 2012]

* National Institute for Health & Clinical Excellence 2007 Acutely ill patients in hospital. Recognition of and response to acute illness in adults in hospital CG50 London, NICE Available from: www.nice.org.uk/CG50 [Accessed April 2012]

It is now the challenge of clinicians, hospital managers and allied healthcare professionals to implement these standards and protocols with continual auditing at both a local and national level.

Conclusions

Based on the findings of the 2011 NCEPOD report some key organisation recommendations are proposed (see Box 1). Each of these recommendations requires a varying amount of resources, both in clinical and financial terms. However, the long term cost benefits of optimal care is likely to far exceed the current expenditure for this patient cohort. The re-structuring of resources, at a local, regional and national, may be essential in order to achieve this.

* A national system must allow the rapid and easy identification of patients at high risk of postoperative mortality and morbidity.

* The decision to operate on high-risk patients should be made at a consultant level jointly between surgeon and clinical care clinicians.

* All elective and more urgent high-risk surgical patients should be seen and fully investigated in pre-assessment clinics. Arrangements should exist to ensure urgent surgical patients have the same robust work up.

* The consent form should clearly state the mortality risk.

* Improved intra-operative monitoring for high risk patients.

* The postoperative care of the high-risk surgical patient needs to be improved. Each hospital must provide sufficient critical care beds in the postoperative period.

* The annual caseload of high-risk surgical patients and their critical care requirements should be quantified and reported to hospital trust board.

References

Bakker EJ, Ravensbergen NJ, Poldermans D 2011 Perioperative cardiac evaluation, monitoring, and risk reduction strategies in noncardiac surgery patients Current Opinions in Critical Care 17 (5) 409-15

Bennett-Guerrero E, Hyam JA, Shaefi S et al 2003 Comparison of P-POSSUM risk-adjusted mortality rates after surgery between patients in the USA and the UK British Journal of Surgery 90 (12) 1593-8

Boyd 0, Grounds RM, Bennett ED 1993 A randomized clinical trial of the effect of deliberate perioperative increase of oxygen delivery on mortality in high-risk surgical patients Journal of the American Medical Association 270 (22) 2699-707

Feachem RG, Sekhri NK, White KL 2002 Getting more for their dollar: a comparison of the NHS with California's Kaiser Permanente British Medical Journal 324 (7330) 135-41

General Medical Council 2006 Good medical practice: The duties of a doctor registered with the GMC Available from: www.gmc-uk.orestatic/documents/content/GMP_0910.pdf [Accessed April 2012]

Goldhill DR 2005 Preventing surgical deaths: critical care and intensive care outreach services in the postoperative period British Journal of Anaesthesia 95 (1) 88-94

Goldhill DR, McNarry AF, Mandersloot G, McGinley A 2005 A physiologically-based early warning score for ward patients: the association between score and outcome Anaesthesia 60 (6) 547-53

Hamel MB, Henderson W, Khuri S 2005 Surgical outcomes for patients aged 80 and older: morbidity and mortality from major noncardiac surgery Journal of the American Geriatric Society 53 (3) 424-9

Heys SD, Gardner E 1999 Nutrients and the surgical patient: current and potential therapeutic applications to clinical practice Journal of the Royal College of Surgeons of Edinburgh 44 (5) 283-93

Kause J, Smith G, Prytherch D et al 2004 A comparison of antecedents to cardiac arrests, deaths and emergency intensive care admissions in Australia and New Zealand, and the United Kingdom--the ACADEMIA study Resuscitation 62 (3) 275-82

National Confidential Enquiry into Perioperative Deaths 2011 Knowing the risk. A review of the perioperative care of surgical patients London, NCEPOD

National Institute for Health and Clinical Excellence 2007 Acutely ill patients in hospital: Recognition of and response to acute illness in adults in hospital. CG50 London, NICE Available from: www.nice.org.uk/CG50 [Accessed April 2012]

Niskanen MM, Takala JA 2001 Use of resources and postoperative outcome European Journal of Surg 167 (9) 643-9

Pearse RM, Harrison DA, James P et al 2006 Identification and characterisation of the high-risk surgical population in the United Kingdom Critical. Care 10 (3) R81

Royal College of Surgeons 2008 Good surgical. practice London, RCSEng Available from: www.rcseng.ac.uk/publications/docs/good-surgical-practice-1 [Accessed April 2012]

Tingle J 2010 Report identifies defects in care for elderly surgery patients British Journal. of Nursing 19 (22) 1436-7

Wilson J, Woods I, Fawcett J et at 1999 Reducing the risk of major elective surgery: randomised controlled trial of preoperative optimisation of oxygen delivery British Medcial Journal 318 (7191) 1099-103

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Correspondence address: Benedict Rogers, Sunnybrook Health Sciences Centre, Bayview Avenue, Toronto, Ontario, Canada M4N 3M5. Email: benedictrogers@hotmail.com

About the authors

Benedict A Rogers

MA MSc DipSEM MRCGP FRCS(Orth)

Trauma Fellow, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada

Andrew D Carrothers

MBChB Dip IMC RCSEd FRCS(Orth)

Trauma Fellow, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada

Chris Jones

MBBS FRCA

Anaesthetic Research Fellow, Royal Surrey County Hospital NHS Foundation Trust, Guildford

No competing interests declared
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