National report shows inconsistent care for high-risk emergency bowel surgery
Published: 04 Jul 2016
Lack of consistent care for patients undergoing high-risk emergency bowel surgery may be negatively affecting patient outcomes and placing major strain on scarce NHS resources according to a joint national report led by the Royal College of Anaesthetists (RCoA), published today.
View full report here
View executive summary here
It highlights that the annual cost of ward care alone is in excess of £200 million, but reports that improvements in care and length of hospital stay have already led to an estimated £22 million savings1. To combat the variation in the levels of care provided across NHS hospitals, the report makes 12 recommendations to health commissioners and providers.
Commissioned by the Healthcare Quality Improvement Partnership as part of the National Clinical Audit Programme, the National Emergency Laparotomy Audit (NELA) report analyses the care received by more than 20,000 emergency bowel surgery patients treated in NHS hospitals in England and Wales between December 2014 and November 2015. Analysing patients’ short-term survival, the report found 1 in 9 patients died within 30 days of surgery, but that risk of death ranged from under five percent to over 30 percent, depending on the patient’s condition at the time of surgery. The 30-day mortality rates for individual hospitals were in the range expected given the number of patients and the range of conditions treated; however the report shows substantial variation in the delivery of care against pre-existing national standards.
Data from this report highlights that the current provision of care is falling short of that provided for adult patients undergoing other major elective surgery of comparable or lesser risk. NELA’s f ir st patient report, published in 2015, revealed that more patients die from emergency bowel surgery than from any other type of high-risk planned surgery. Office for National Statistics and NELA data indicate that emergency laparotomy carries an 11 percent mortality rate, confirming the high-risk nature of emergency bowel surgery. More than a quarter remained in hospital 20 days after surgery, with older patients more likely to remain in hospital longer.
Examples of where hospitals fall short of the standards of care referenced within the NELA report include:
- prior to surgery, 36 percent of patients do not receive a documented assessment of risk of death
- 29 percent of emergency bowel surgery patients identified as urgent do not arrive in theatre within the stipulated two hour timeframe
- 39 percent of patients are not admitted directly to a critical care unit after surgery
- 90 percent of elderly patients did not receive input from Elderly Medicine Specialists.
Though the proportion of patients receiving a formal risk assessment prior to bowel surgery has increased from 56 percent to 64 percent over the last year, there remain large differences in standards of care between hospitals. Furthermore, little improvement has occurred at an organisational level to raise standards of care such as timely access to operating theatres, critical care provision, and input from Elderly Medicine Specialists for older patients. Rectifying this will require greater engagement between clinicians, health care managers and commissioners. Investing in resources to bring about improvement and the delivery of higher quality care is also likely to be cost effective, as demonstrated by the estimated £22 million of savings to the NHS since the first NELA report of 2015.
Professor Mike Grocott, Chair of NELA and Council Member of the Royal College of Anaesthetists said: “Shortfalls in the perioperative* care of these patients before, during and after major surgery may be negatively affecting patient outcomes and use of resources. There is still much work to be done and it is vital that, clinicians, hospital managers and commissioners of healthcare examine these data to determine why standards are not always met and how improvements can be made. This will lead to better care and efficiencies that will benefit both patients and the NHS.”
The NELA report calls for improvements and makes 12 recommendations targeted at commissioners, hospital chief executives and clinicians, in a bid to reduce variation in the care of patients undergoing emergency bowel surgery. These include:
- assessing and documenting patient risk to guide allocation of resources
- providing sufficient critical care and emergency operating theatre capacity to allow emergency surgery to occur in a timely fashion
- ensuring consistent medical staffing at all times
- implementing care pathways for emergency surgical patients
- planning and reviewing essential processes of care by multi-disciplinary team working
Dr Dave Murray, NELA National Clinical Lead said: “The second phase of reporting for this important national Audit reveals that more hospitals are delivering high levels of service and are meeting the standards for more than 80 percent of patients. As continued effort is made to improve care across all hospitals, we would expect to see a reduction in mortality following an emergency laparotomy. The Audit allows us to identify the best performing hospitals so that good practice can be disseminated amongst the less well-performing hospitals. Multi-disciplinary teams of doctors from various specialties need to work together to reduce variation and deliver personalised care pathways for this highly vulnerable group of patients.”
Mr Iain Anderson, NELA Surgical Lead commented: “We are aware that many consultant surgeons and anaesthetists are putting considerable personal effort into improving local services and leading their teams so it is encouraging to see early signs of better patient care and outcomes. We would encourage all clinicians and hospitals who have not yet made the necessary changes to how they look after these sick and complex patients, to do so.”
Dr Liam Brennan, President of the RCoA, said: “While today’s report highlights significant variation in care for patients who undergo emergency bowel surgery, it has also identified several areas in which NHS clinical teams have implemented recommendations from the 2015 NELA patient report. The acceptance of these recommendations has enabled hospitals to adhere more closely to relevant standards, thereby provide better patient care – and for this they should be commended.”
The full NELA report is available online at http://nela.org.uk/reports.