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Risk stratification, management and outcomes in emergency general surgical patients in the UK
Insights
Adherence to 2011 Royal College of Surgeons guidelines for emergency surgery patients was incomplete. However, this lack of adherence did not appear to negatively impact postoperative mortality rates in the study cohort.
Area of Science:
- Surgical Outcomes Research
- Healthcare Quality Improvement
- Patient Safety in Emergency Surgery
Background:
- The Royal College of Surgeons (RCS) issued guidelines in 2011 to reduce surgical mortality in emergency patients.
- These standards recommended consultant surgeon and anesthetist presence and higher-level postoperative care for high-risk individuals.
Purpose of the Study:
- To prospectively evaluate the association between adherence to RCS guidelines and postoperative mortality.
- To assess the impact of consultant presence and postoperative care levels on patient outcomes.
Main Methods:
- Prospective data collection on emergency general surgery operations over 30 days in Merseyside, UK.
- Patient risk stratification using P-POSSUM (Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity).
- Classification of high-risk patients (P-POSSUM predicted mortality ≥10%).
Main Results:
- 494 procedures were analyzed; 5% of patients died within 30 days.
- For high-risk patients (n=65), mortality was 27%. Consultant surgeon present in 71%, consultant anesthetist in 66%, and 71% received higher-level care.
- No significant association found between guideline adherence and mortality in the overall or high-risk groups.
Conclusions:
- Adherence to national emergency surgical guidelines is currently incomplete.
- Incomplete adherence to these specific guidelines did not demonstrate an adverse impact on postoperative mortality in this study.
- Further research may be needed to understand the nuances of guideline implementation and patient outcomes.
Introduction:
The Royal College of Surgeons of England (RCS) published guidance in 2011 setting standards for the management of emergency surgical patients with the aim of reducing surgical mortality. These suggested the presence of a consultant surgeon and anaesthetist, and transfer to a higher level of care postoperatively for all patients deemed high risk.
Objective:
This prospective multi-institutional study sought to evaluate whether adherence to these standards was associated with reduced mortality.
Design:
Data were prospectively collected on all emergency general surgery operations performed in emergency theatres across Merseyside, UK, during a 30-day period in September-October 2011. Patients were risk assessed using P-POSSUM (Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity). High-risk patients were classified as those with a P-POSSUM predicted mortality of ≥10 %, and moderate-risk patients as those with a P-POSSUM predicted mortality of 5-10 %.
Results:
Some 494 procedures were performed on 471 patients. Twenty-four patients (5 %) died within 30 days of surgery. Mortality in the 65 patients identified as high risk was 27 % (14 patients undergoing 17 procedures), with a consultant surgeon present in 46 of 65 high-risk cases (71 %), a consultant anaesthetist in 43 (66 %), and 46 (71 %) cases were admitted to level 2 or 3 care postoperatively. There was no association between adherence to standards and postoperative mortality in either the whole cohort or specifically the high-risk group.
Conclusions:
There is currently incomplete adherence to the national guidelines, but this does not seem to adversely impact postoperative mortality.
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