07 April 2011
Emergency patients account for half the NHS surgical workload but mortality and complication rates vary widely; these are the problems identified in new standards for emergency surgery care published today by the Royal College of Surgeons [RCS]. The RCS estimates that the care of emergency surgery patients comprises 40-50 per cent of surgical work and in general surgery alone account for 14,000 admissions a year to intensive care in England and Wales, at a costs of at least £88m* and mortality rates of 25 per cent. The report demonstrates that there is a lack of detailed outcome measurement for emergency surgery patients – which is preventing hospitals from understanding how they can improve.
Surgeons believe that dedicated operating theatre time for emergency cases; better care for highrisk patients before and after surgery; and greater availability of consultants would save lives and shorten hospital stays for emergency patients.
The standards, entitled Emergency Surgery: Standards for unscheduled surgical care, offer the new GP commissioning consortia detailed specialty-by-specialty advice on the clinical standards for emergency surgical care that should be met by hospitals they send patients to. This practical guidance is vital if hospitals are to meet the aims of the new NHS Outcomes Framework, which demands improvements in patient recovery from episodes of ill-health and injury. All critically-ill patients would benefit from these standards being followed, but surgeons believe elderly and frail patients would do so most of all.
Among the key points raised by the standards are:
- The need for improved timeliness of surgery and better access to theatres – Access to theatres is inadequate with priority often given to elective cases in order to meet arbitrary targets. This results in delays to vital surgery, resulting in poor outcomes for patients. A 2010 survey of general surgeons** indicated only half felt able to care well for their emergency patients. While detailed performance statistics are gathered for elective procedures, there is currently little gathered on timeliness of emergency operations. The standards call for this to be reversed.
- Better access to consultant care – following the lead of the College of Emergency Medicine, consultant surgeon job plans need more time allocated for the initial assessment and treatment of emergency cases.
- Better monitoring of emergency patients – because data are not being gathered, emergency patients are too often treated on an ad hoc basis. The standards call for hospitals to develop clear, defined diagnostic and monitoring plans for patients as they are admitted. Routine and on-going risk assessment of patients must occur, with those deemed high risk automatically flagged for closer levels of monitoring and attention from senior doctors.
- Dedicated wards and access to critical care – purely time-based targets, established by the previous government, for getting all patients out of Emergency Departments in four hours (which have since been scrapped) have left a legacy of patients being admitted to ‘any available bed’. The practice of emergency surgical patients being allocated to non-surgical wards leads to inefficiencies and increases risks of delays and poor outcomes – the standards call for high-risk emergency surgical patients to be located in the same ward, where surgical expertise and critical care teams can be efficiently deployed.
- Influence of European Working Time Regulation – the removal of tiers of cover within rotas and increased handovers that have resulted from the introduction of the EWTR are exacerbating problems. There are currently simply not enough doctors in the hospital at any one time to provide acutely ill patients with the comprehensive care they require.
Richard Collins, Vice-President of the Royal College of Surgeons and chair of the working group who produced the standards, said:
“In recent decades, UK hospitals have been encouraged and financially rewarded to reduce waiting times for planned operations. This has come at a cost as care for emergency patients has been institutionally neglected. These patients are often left languishing while they wait for an operation, suffer from a lack of access to senior doctors and receive suboptimal post-operative care. They deserve better. We have to put this right and GPs are now in a strong position to support hospital colleagues in achieving these standards by voting with their feet and putting resources to hospitals which provide the right care.”
Sue Woodward, Chair of the Patient Liaison Group of the Royal College of Surgeons, said:
“The PLG welcome the standards which will address the trend that, so long as the patient is somewhere in the system meeting a target then they are being adequately treated. Greater consistency of treatment from an appropriate team can only improve patient care.”
Vice President of the College of Emergency Medicine, Don MacKechnie said:
“The Royal College of Surgeons and the College of Emergency Medicine are setting the standards for early consultant-delivered emergency care. Patients presenting to hospital with acute, potentially life-threatening problems, are entitled to receive the best possible treatment, from the start of their hospital stay. This should be provided by the recognised expert, who is the consultant. All the available evidence tells us that the earlier a consultant is involved in patient care, the better the outcome.”
Dr Carol Peden and Dr Bob Winter of the Intensive Care Society said:
“If we are to operate on high risk patients then it is essential that we provide the right level of care for them after their surgery. There must be an appropriate number of critical care beds to manage these patients in the most cost effective and efficient way. Only by doing this will we be able to reduce the postoperative mortality. All age groups of critically ill patients would benefit from these standards being followed, but the most high-risk elderly and frail patients will do so most of all.”
Notes to Editors:
- * Royal College of Surgeons/ Department of Health working group; The higher risk surgical patient: towards improved care for a forgotten group; 2010
- **Anderson I, Krystopik R, Cripps N; Emergency General Surgery Survey; ASGBI; 2010.
- The report ‘Emergency Surgery: standards for unscheduled surgical care’ is published by the Royal college of Surgeons with the support of the specialty surgical associations. The working group included representatives from: Royal College of Pathologists; Association of Surgeons of Great Britain & Ireland; RCS Patient Liaison Group; British Association of Paediatric Surgeons; Royal College of Physicians; Society for Cardiothoracic Surgery; ENT UK; British Orthopaedic Association; College of Emergency Medicine; British Association of Oral & Maxillofacial Surgeons; Royal College of Radiologists; Society for British Neurological Surgeons; British Association of Plastic, Reconstructive and Aesthetic Surgeons; Intensive Care Society; Royal College of GPs; Great Western Ambulance Service NHS Trust; British Association of Urological Surgeons; Royal College of Anaesthetists; Care Quality Commission.
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