New guidelines are helping organisations to ensure that most vital of services, emergency surgery, is up to standard. Richard Collins explains.
Patients requiring emergency surgical treatment are among the sickest cared for by the NHS; often frail, elderly and with significant co-morbidities. The risks are high – and these patients require access to fast, expert assessment and treatment if they are to recover well from their illness.
The requirements are clear – more consultant involvement early in the care of acutely ill patients alongside better organisation of admission, assessment and diagnostics; leading to swifter access to theatre and improved peri-operative care.
Although at present there is no detailed data available, what exists suggests that the outcomes for patients undergoing emergency surgery give cause for real concern, with great variability between comparable units and with mortality rates of 50 per cent being suggested for the over-80 age group.
It is likely that this compares unfavourably with evidence from abroad.
In these austere times, it is vital that the NHS achieves an efficient service that offers value for money.
The costs of poorly organised care to the NHS are significant in terms of increased lengths of stay, higher complication rates and, in some cases, litigation. The costs to society – in terms of lost productivity, increased reliance on social care – and most importantly to individual patients and their families can be astronomical.
The Royal College of Surgeons, working with the surgical specialty associations and other colleges and faculties involved in delivering this type of care, has published standards and guidance aimed at commissioners, service planners and providers to help them define and deliver safe and high quality emergency surgical care.
The document is set out to provide NHS clinicians and managers with practical guidance in assessing whether the organisation meets the requisite standards and points them in the right direction to make any required changes to service delivery (see the end of this article for details of how to download the full document).
Emergency surgery is often incorrectly characterised as the service that operates on patients in the out of hours period.
But this is not so, it should instead be thought of as a holistic service that has six key elements (see graph).
Key to improving patient experience and outcome are the following:
Timeliness of surgery
Emergency surgery is undertaken where the patient’s condition is life-threatening or could imminently lead to permanent physical damage or disability. Many operations are time critical – delay often results in adverse outcome.
The majority of operations should be performed during the day time but often theatre space is unavailable leading to delays and poor peri-operative care arrangements.
The NHS needs to:
- Prioritise the needs of emergency surgical patients according to their clinical need (this will often mean prioritisation above elective surgical patients).
- Ensure adequate access to emergency theatres – additional, dedicated theatres will be required for orthopaedic surgery and other specialties where required. Accurate profiling of workload will help to define the number and type of additional theatres required. Emergency theatres will need to be staffed appropriately at all times; in high specialised areas, better outcomes are achieved if the emergency theatre team is familiar with the type of surgery to be undertaken.
Outcomes and patient experience
We know that poor planning and management in the peri-operative period and a lack of consultant involvement are associated with increased complications, morbidity and mortality and length of stay. There is, however, a paucity of data to enable the development of meaningful criteria for audit in emergency surgical care. The NHS needs to:
- Prioritise and facilitate audit in this area. Surgeons should be encouraged to record and audit, at the local level, the time from decision to operate to actual time of operation. The results of such audit need to be discussed at mortality and morbidity meetings and, if necessary, at board level to push for improvements.
- Define patient experience measures that take into account those patients requiring emergency surgical intervention.
Pre- and post-operative care
The assessment, treatment and rehabilitation of an acutely ill patient are true team activities. Emergency surgery must be a consultant led activity; surgery should be managed by a team with the required skills and competencies to care for the patient. The NHS needs to:
- Ensure pathways and protocols for surgical care are agreed; all patients must have a clear diagnostic and monitoring plan on admission, including risk assessment. Discharge and rehabilitation requirements must also be considered early on.
- Ensure the immediate availability of clinicians with the right skills – this will require excellent planning. In some specialties, separation of emergency and elective workloads can help achieve this.
- Ensure consultant led teams are free of elective commitments when on call for emergencies.
- Carefully consider the level of middle grade and junior cover required. It is not acceptable for a busy unit to have a single tier of resident cover.
- Ensure there are sufficient and competent staff to deal with any of the elements detailed in the patient pathway (see diagram), which may be required simultaneously.
- If there isn’t one already, consider establishing a surgical assessment unit, which provides a centralised area for patients to be assessed and monitored prior to being admitted and/or receiving treatment. A well resourced and planned unit can provide speedy access to assessment, diagnosis and treatment and avoid unnecessary delays.
- Facilitate the co-location of patients so clinicians can find them. This is an age-old complaint from surgeons whose patients are often distributed to any available bed in the hospital. This makes ward rounds virtually impossible, is detrimental to surgical training and can be dangerous if patients are being nursed on wards with limited surgical expertise.
Elements of emergency surgery
- Undertaking emergency operations at any time (day or night)
- The provision of ongoing clinical care to post-operative patients and other inpatients who may develop complications
- Undertaking further operations for patients who have recently undergone surgery (i.e. planned or unplanned returns to theatre)
- The provision of assessment and advice for patients referred from other areas of the hospital/network
- Early, effective and continuous pain management
- Communication with patients and their supporters
Increasingly, services may need to be provided on a networked basis. If well planned, this can allow collaborative working, the adoption of national standards, the development of agreed protocols of care and permit the flexible movement of clinical staff. Expertise can be drawn from the entire network allowing patients to be treated at the most appropriate unit depending on the complexity of the case and available resources.
When considering networking arrangements:
- Involve the ambulance service early on and continue to engage with them to ensure the development of appropriate bypass arrangements, transfer and repatriation protocols. Standards for the transfer of critically ill patients must be adhered to and properly resourced.
- Ensure senior clinical and managerial endorsement; consider contractual arrangements where necessary.
- Ensure network-wide audit takes place, both of processes and outcomes, and that the results of audit are discussed and auctioned at board level.
- Ensure networks are supported financially to ensure the sustainability of services at each site.
Of vital importance is the appropriate provision of surgical opinion. All contributors to the college’s standards agreed that hospitals accepting undifferentiated patients (for example via the emergency department) must have access to 24 hour on-site surgical opinion at ST3 level or above. If this is not available, the unit should not accept undifferentiated patients
Training and education
A prime concern for the colleges is the protection and promotion of training opportunities. There must be a balance within service provision to enable trainees to achieve the required competencies in emergency surgery as defined in the surgical curriculum. Alongside this, trusts must commit to providing access to multiprofessional training (for example, advanced trauma and life support, care of the critically ill surgical patient).
Of critical importance is the consideration of clinical interdependencies. In order to operate effectively, the emergency general and orthopaedic surgical service needs 24 hour, seven day access to:
- anaesthesia, critical care and acute pain service;
- acute medicine;
- interventional and diagnostic radiology;
- elderly care and rehabilitative medicine.
If children are admitted, inpatient paediatrics and specialist children’s facilities are required. Arrangements for other surgical specialties will be required as appropriate.
Communication with patients and supporters
Patient communication is an often overlooked element of surgical care. It must be consultant led. This is a demanding and time consuming activity, but vital to ensure patients have the best experience possible when undergoing emergency surgical treatment. Surgeons need adequate time for discussion with patients factored into the schedule of work for the emergency team; this includes taking consent and making decisions about ongoing care.
We know that many strategic health authorities are now focusing on the future of acute surgery and we welcome this. The patient liaison group of the Royal College of Surgeons was instrumental in designing standards around communication – further detail of which can be found in the report.