NCEPOD: Only half of high risk surgical patients received good care in UK hospitals

9 December 2011

NCEPOD news release: National enquiry finds only half of high risk surgical patients received good care in UK hospitals

Only half (48%) of high risk surgical patients received good care in UK hospitals; this is a group of patients who are already known to be at an increased risk of death and post-operative complications. Knowing the Risk, the latest National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report, shows that 79% of the patients who died came from the high risk group.

Read the full report here >>

Read the Executive Summary here >>

Data collected at the time of surgery found that 21% of patients undergoing elective surgery had not been seen in an assessment clinic before their operation and in only 8% of patients defined as ‘high risk' was risk of death stated on the patient's consent form.

Co-report author Dr George Findlay, NCEPOD Clinical Co-ordinator and Intensive Care Consultant, said that pre and post-operative care in the UK was in a poor state across the board: "There appears to be a serious lack of awareness of the degree of mortality risk to patients, and we have to ask if the Health Service really does appreciate the level of risk that surgical patients face? If we don't identify the risks to patients, then how can we provide the best pre and postoperative care?"

Dr Findlay also expressed serious concern that many high risk patients did not understand the extent of the risks of death or serious complications they faced when they gave consent to the operation: "Clinicians must communicate this risk to patients."

Co-report author Dr Alex Goodwin, NCEPOD Clinical Co-ordinator and Consultant in Anaesthesia and Intensive Care called for a robust system of risk identification and  assessment "and strategies to mitigate risk". There needs to be the introduction of a UK-wide system that allows rapid and easy recognition of patients who are at high risk of post-operative mortality and morbidity. All high-risk patients should undergo early pre-operative assessment so that co-morbidities are recognised and managed appropriately."

He said that the decision to operate on high-risk patients should only be made at consultant level. He wishes to see care delivered by a team approach that includes case planning and identifying the facilities needed to achieve the best outcome for patients.

Following surgery only 22% of the high risk group were cared for in a critical care unit, with the remaining 78% of patients returning to the ward.

"It is essential to improve the availability of critical care services for these patients, if we are to deliver appropriate post-operative care," Dr Goodwin said. "We must give greater consideration to how critical care is used in the management of high-risk patients, and hospitals should provide adequate resources to ensure there are enough critical care beds."

Key findings

Data collected at the time of surgery on all patients

• Anaesthetists involved in the surgery identified 20% of patients as high risk.
• 21% of elective patients were not seen in pre-assessment clinics.
• Half of the high risk patients had elective procedures and 22% of those were not seen in a pre-assessment clinic.
• 79% of all deaths were in the high risk group.
• Overall mortality at 30 days was 1.6%. The mortality in the high risk group was 6.2% and in the low risk group was 0.4%.

Data from the detailed review of high risk cases

• The care of high risk surgical patients was found to be good in 48% of patients.
• Only 8% of patients, defined as high risk, had any mention of mortality made on their consent forms.

• 48% of high risk patients who died never went to a critical care unit.
• 8% of high risk patients who should have gone to a higher care level area postoperatively did not do so.
• Cardiac output monitoring was rarely used in high risk patients.

Organisational

• 16% of hospitals did not provide pre-admission anaesthetic clinics.
• 27% of hospitals did not have a critical care outreach team.
• 34% of hospitals did not have a policy to prevent peri-operative hypothermia.

Key recommendations

• Introduction of a UK-wide system for the rapid identification of patients who are at high risk of post-operative mortality and morbidity.
• All elective high risk patients should be seen in a pre-assessment clinic.
• Patients should be told of the mortality risks associated with surgery and this should be recorded on the consent form.
• Trusts must make provision for sufficient critical care resource to provide appropriate post-operative care.
• Trusts should analyse the volume of work considered to be high risk and quantify the associated critical care requirements. This should be reported to trust boards annually.

NCEPOD Chairman Mr Bertie Leigh said that this report provided a disturbing explanation for the apparently poor results achieved by the NHS: "People die because we do not give them the level of care they are entitled to expect.

"Today's patients are more challenging than those the NHS dealt with even ten years ago," he explained. "The difficulty is that the NHS does not seem to be rising to the challenge. Our report suggests that the NHS has not caught up, and that the distance between what we are achieving and what we aspire to achieve is showing no signs of getting narrower. Poor care is also leading to longer hospital stays, putting further strain on already stretched hospital budgets."

Notes to editors

-NCEPOD is an independent charitable organisation that reviews medical and surgical clinical practice and makes recommendations to improve the quality of the delivery of care. This is done by undertaking confidential surveys covering many different aspects of care and making recommendations for clinicians and management to implement.
-This study forms part of the Clinical Outcome Review Programme into Medical and Surgical Care commissioned by the Healthcare Quality Improvement Partnership on behalf of England, Wales, Northern Ireland, Isle of Man and the Channel Islands. Read more here >>
-301 hospitals performing surgery were identified. A prospective dataset was collected on 19,097 cases over a one week period and the retrospective case review was undertaken on 829 high risk patients. High risks patients make up about 10% of the patients who have surgery in the UK.
-For further information about NCEPOD visit the website on www.ncepod.org.uk. Copies of Knowing the Risk can also be downloaded here >>