NHS must follow protocols to address uneven death rates from emergency general surgery

There are currently unacceptable differences between hospitals in outcomes for patients undergoing emergency general surgery, with death rates for major operations in this field almost 12 times higher at some Trusts than others. Every hospital offering such surgery should systematically implement all the guidelines drawn up by experts in this area, some of which have been shown to reduce the risk of death by a third.

These are the main conclusions of a new report on emergency general surgery drawn up by experts at the Nuffield Trust health think tank (see note 2). The Trust was commissioned by the Royal College of Surgeons (RCS) both to identify the problems facing this area of surgery, and to try and find solutions to them (see note 3).

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 

Candace Imison, Director of Policy, Nuffield Trust

The procedures performed in emergency general surgery are typically abdominal, to treat conditions such as gall bladder removal, perforated gut, obstructed hernia and so on. 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 looked at outcomes for patients undergoing high-risk emergency general surgery. The main problems involving this type of surgery identified by the report are:

• Significant variation in outcomes between different hospitals – for example, a previous study found that mortality for emergency laparotomy (an incision in the abdomen to carry out major surgery) ranges from 3.6% to 41.7% in 35 NHS hospitals.
• An increasing trend towards great specialisation among surgeons means that there are fewer surgeons with the skills to carry out general surgery, particularly in emergency situations. Because of this, units can find it difficult to provide round-the-clock emergency consultant cover.
• Demographic and epidemiological trends, with a rapidly ageing population, mean that demand for this type of surgery will continue to increase.

The report’s main recommendations are:

• The quickest way to improve outcomes would be the systematic use of all protocols and pathways drawn up by experts in this field (see note 4).
• The most comprehensive way to address the challenges faced by emergency general surgery would therefore be to develop 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 practitioner or physician associates – should be developed to address potential gaps in staffing in the discipline, in terms of both numbers and skills.
• Centralisation of services in ‘fewer, bigger, better’ units will not necessarily improve outcomes. The report contains an analysis of all major emergency general surgery across 154 sites in England over four years, and demonstrates that centres that carried out a high volume of procedures did not have lower death rates than those carrying out a smaller number of operations, and vice versa (see note 5).

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”.

Mr John Abercrombie, RCS Council member for general surgery, said:

“Patients who face life-threatening injuries and major trauma are generally treated well by the NHS. However, the standard of care of other emergency and critically-ill patients needing urgent treatment is highly variable across hospitals and has fallen behind other Western countries.

“Over the last few decades the NHS has rightly spent a lot of time and money improving planned care for patients. Today’s important report from the Nuffield Trust demonstrates we now need the same determination and priority given to improving the care of some of the sickest patients in the NHS.

“The Royal College of Surgeons and others are pursuing a number of initiatives to improve emergency general surgery including the collection and publication of data, working with hospitals to improve patient pathways, and proposals to improve training. We urge the Government and local hospitals to help support us to make this area a higher priority for the NHS”.