PERIOPERATIVE  MEDICINE  IN  ACTION  

UNIVERSITY  COLLEGE  LONDON  

 
 
WEEK  1  THE  SURGICAL  EPIDEMIC  
STEP  1.7  Right  person,  right  place,  right  time  
 
In  2011,  a  joint  working  party  was  set  up  between  the  Royal  College  of  
Surgeons  of  England  and  the  Department  of  Health,  UK  to  set  out  how  
care  for  the  higher  risk  surgical  patient  was  failing  and  provide  a  list  of  
recommendations  as  to  how  care  can  be  improved.  In  this  article  Dr  
Philip  Sherrard,  a  London  anaesthetic  registrar,  provides  a  summary  of  
the  report,  which  can  be  found  in  full  in  the  ‘See  Also’  section.  
 
Whilst  this  document  refers  only  to  the  situation  in  the  UK,  the  problem  of  poor  
outcomes  after  surgery  is  not  unique  to  this  country,  as  we  find  out  later  when  we  
explore  the  so  called  EuSOS  and  ISOS  studies.  The  learning  here  is  relevant  to  all.  
 
The  problem  
 
Surgery  is  a  common  and  effective  treatment  for  a  diverse  range  of  diseases.  
However,  it  is  now  more  frequently  being  performed  on  elderly  patients  and  those  
with  co-­‐morbidities  and  advanced  disease.  
 
In  the  UK  170  000  patients  undergo  higher-­‐risk  non-­‐cardiac  surgery  each  year  (2011  
figures).  Of  these  100  000  will  develop  complications  resulting  in  25  000  deaths.  
Advanced  age  and  co-­‐morbid  disease  combined  with  major  and  urgent  surgery  are  
associated  with  a  higher  risk  group  that  accounts  for  less  than  15%  of  in-­‐patient  
procedures,  but  over  80%  of  post-­‐operative  deaths  [1].  
 
This  report  recommends  that  all  patients  with  a  predicted  mortality  of  >5%  should  
be  identified  as  “high-­‐risk”  for  major  complications  and  death  in  the  perioperative  
period.  We  will  look  at  risk  assessment  more  extensively  in  week  2,  but  in  general  
this  would  cover  most  co-­‐morbid  patients  having  emergency  laparotomy  procedures  
or  complex  elective  general  and  vascular  surgery.  
 
Variations  in  outcomes  
 
There  is  mounting  evidence  that  there  is  significant  variation  in  the  perioperative  
pathway  for  the  higher  risk  general  surgical  patient.  Management  of  their  care  is  
frequently  disjointed  and  not  always  patient  centred.  Reviews  of  2008/9  hospital  
episode  statistics  show  a  ≥  2-­‐fold  variation  in  relative  risk  of  30-­‐day  mortality  after  
non-­‐elective  general  surgery  between  trusts.  

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Major  shortfalls  identified  in  NCEPOD  (National  Confidential  Enquiry  into  Patient  
Outcome  and  Death)  reports  included  delays  in  assessment,  decision  making,  access  
to  theatre,  radiology  and  critical  care  [2].  In  the  UK  less  than  1/3  of  the  high-­‐risk  
patients  are  admitted  to  critical  care  following  surgery  with  a  median  stay  of  only  24  
hours  [1],[3].  There  were  also  delays  in  administration  of  medical  therapy  such  as  
fluids,  antibiotics  and  venous  thrombo-­‐embolism  prophylaxis  [4].  
 
The  vast  majority  of  poor  outcomes  come  not  from  deaths  on  the  operating  table  
but  from  post-­‐operative  complications.  Minor  complications  are  extremely  common  
but  delays  or  sub-­‐optimal  management  of  these  can  result  in  more  serious  
complications.  Most  of  the  life-­‐threatening  problems  involve  sepsis  resulting  in  
organ  failure.  
 
Key  recommendations  for  change  
 
The  working  party  made  a  list  of  recommendations  to  help  improve  the  care  of  the  
higher  risk  surgical  patient.  The  aim  was  to  streamline  the  perioperative  pathway  to  
deliver  consistent,  continuous  and  well  communicated  high  level  multidisciplinary  
care  that  should  improve  outcomes.  The  document  states  that  “complications  can  be  
greatly  reduced  by  optimal  perioperative  care.”  
 
These  recommendations  are  summarised  below:  
 
1. All  hospitals  should  have  a  pathway  for  unscheduled  adult  general  surgical  
care.  A  monitoring  plan  must  be  in  place  that  is  compliant  with  the  national  
standards  (NICE  Guidelines  CG50).  The  pathway  should  also  include  timing  of  
diagnostic  tests,  timing  of  surgery  and  post-­‐operative  destinations  for  patients.  
2. Prompt  recognition  and  treatment  of  emergencies  and  complications.  
Adoption  of  an  escalation  strategy  is  strongly  advised.  
3. Emergency  theatre  access  should  match  need  and  ensure  prioritisation  of  
access  is  given  to  emergency  surgical  patients  ahead  of  elective  patients.  
4. Each  patient  should  have  his  or  her  expected  risk  of  death  estimated  and  
documented  prior  to  surgery  with  due  adjustments  made  in  urgency  of  care  
and  seniority  of  staff  
5. High  risk  patients  are  defined  by  a  predictive  mortality  of  ≥  5%.  They  should  
have  active  consultant  input  in  the  diagnostic,  surgical,  anaesthetic  and  critical  
care  elements  of  their  pathway.  
6. Surgical  procedures  with  a  predicted  mortality  of  ≥  10%  should  be  conducted  
under  direct  supervision  of  a  consultant  surgeon  and  consultant  anaesthetist  
unless  they  are  confident  their  juniors  can  perform  the  case  without  them.  
7. Each  patient  should  have  their  risk  of  death  re-­‐assessed  by  the  surgical  and  
anaesthetic  teams  at  the  end  of  surgery.  Their  optimal  location  for  immediate  
post-­‐operative  care  should  be  determined.  
8. All  high-­‐risk  patients  should  be  considered  for  critical  care.  At  a  minimum,  all  
patients  with  an  estimated  risk  of  death  ≥  10%  should  be  admitted  to  critical  
care.  

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9. A  national  audit  of  outcomes  should  be  conducted  for  adult  patients  
undergoing  unscheduled  general  surgery.  Local  assessment  of  outcome  is  
fundamental  in  improving  care  and  results  should  be  shared  appropriately.  
 
Consider  these  key  recommendations  published  in  2011.  Which  of  them  has  been  
applied  in  your  place  of  work  and  which  do  you  consider  to  be  sup-­‐optimally  
performed?  
 
If  you  choose  to  reference  your  own  place  of  work,  please  ensure  that  any  detailed,  
identifying,  or  confidential  information  is  removed  from  your  response.  
 
Further  calls  for  improved  perioperative  care  
 
This  call  for  improved  perioperative  care  for  the  high  risk  surgical  patient  was  
reflected  in  the  2011  NCEPOD  (National  Confidential  Enquiry  into  Patient  Outcome  
and  Death)  Report  ‘Knowing  the  Risk’.  This  report  used  prospective  data  to  robustly  
investigate  care  of  the  high  risk  surgical  patient.  Its  conclusion  was  that  less  than  half  
of  the  patients  were  receiving  the  care  they  should.  It  recommended  a  defined  
package  of  care,  or  pathway,  for  the  high  risk  surgical  patient.  The  full  report  makes  
for  very  interesting  reading  and  can  be  accessed  in  the  See  Also  section.  

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