Wide variation in death rates after emergency general surgery

DEATH rates among patients undergoing emergency general surgery are almost 12 times higher at some Trusts compared to others, according to a report by the Nuffield Trust.

The report – commissioned by the Royal College of Surgeons – concludes that the quickest way to overcome this variation would be for all hospitals offering emergency general surgery to systematically implement existing evidence-based guidelines – some of which have been shown to reduce the risk of death by a third.

Emergency general surgery typically includes abdominal procedures such as gall bladder removal or to treat a perforated gut or obstructed hernia. Patients undergoing these procedures tend to be older and more frail, frequently with other co-existing conditions. As a result, the risk of death from such surgery tends to be high, with more than one in 10 patients dying within 30 days of major emergency general surgery.

The authors of the report looked at outcomes for patients undergoing high-risk emergency general surgery and found significant variation between different hospitals – for example mortality for emergency laparotomy ranges from 3.6 per cent to 41.7 per cent in 35 NHS hospitals.

The report also identified an increasing trend towards greater specialisation in surgery leading to fewer surgeons with the skills to carry out general procedures, particularly in emergency situations. This means that surgical units can find it difficult to provide round-the-clock emergency consultant cover. A rapidly ageing population will only add to future challenges.

The authors recommend that the quickest way to improve outcomes would be the systematic use of all protocols and pathways drawn up by experts in this field and the development of managed clinical networks, such as those already set up in the NHS for patients who suffer strokes or trauma. Other professional roles – such as advanced nurse practitioners or physician associates – should be developed to address potential gaps in staffing in terms of both numbers and skills.

The report also concludes that centralisation of services in "fewer, bigger, better" units will not necessarily improve outcomes. An analysis of all major emergency general surgery across 154 sites in England over four years demonstrated that centres carrying out a high volume of procedures did not have lower death rates than those undertaking a smaller number of operations.

Report author Candace Imison, Nuffield Trust Director of Policy, commented: "The fact that there are such big differences in what happens to patients undergoing this type of surgery is very worrying.

"Our report examines various solutions to the problem, but finds that the quickest gains could be achieved simply by systematically implementing all the evidence-based guidelines that already exist. This should be the top priority for all hospitals offering emergency general surgery”.