Emergency laparotomy in high risk general surgical patients: a review of perioperative care.
Emergency general surgical admissions account for the highest number of surgical admissions to UK hospitals and also account for the largest number of surgical deaths (ASGBI 2007). There is an identifiable subgroup of patients where the observed morbidity and mortality rates exceed the predicted. This is the high risk patient group which encompasses patients of advancing age, those with increasing comorbidities, and those which require urgent and major surgery. Eighty percent of surgical deaths are accounted for by this select patient population (Pearse et al 2006).
The driving force for this review came from two recently published documents which focused primarily on the management of these high risk patients. The higher risk general surgical patient is a document from the Royal College of Surgeons of England which highlights evolving concerns that this subgroup of patients receive suboptimal care when, ironically, they are the group most in need (RCSEng 2011). Knowing the risk is a combined document from the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) and the Department of Health, which was based upon a perioperative review of the care received by high risk surgical patients across all surgical disciplines in UK, over one week, in both elective and emergency surgery (NCEPOD 2011). This document highlighted that in less than half of patients was the care they received good, and demonstrated that care was more likely to be of poorer standard when patients were managed for emergencies rather than elective surgery.
The aim of this review was to compare current practice with results observed nationally by the NCEPOD report, and to highlight measures that could be implemented to improve the care received by our high risk patients.
All patients undergoing an emergency laparotomy over a six month period were identified from theatre records. Patients with a Portsmouth Physiologic and Operative Severity Score (P-POSSUM) mortality score less than 5% were excluded from the study. Notes available on file for 50 patients were reviewed retrospectively. Seven criteria were used, each of which were recommendations from either the NCEPOD or Royal College documents:
1. High risk patients should be identified as being at high risk of death and complications.
There are a number of ways of identifying what constitutes a high risk patient. The Royal College document suggested a variety of ways of identifying the high risk patient, taking into account: ASA scoring, physiological derangement, grade of surgery (i.e. major, major+), and NCEPOD classification of intervention (i.e. urgent, immediate). The document also advocates the use of the P-POSSUM scoring systems as a simple and validated tool for assessment, acknowledging that the preoperative finding will need to be estimated prior to surgery as a 'best guess' to allow completion of the score. Based upon this a high risk patient was to be identified as any patient undergoing an emergency laparotomy with a P-POSSUM mortality score predicted as more than 5%. Compliance with this criteria was assessed based upon documentation either in the medical notes or on the anaesthetic clerking proforma about whether the surgeon or anaesthetist felt that this was a high risk patient or whether a mortality score of more than 5% had been recorded.
2. High risk patients should have active consultant involvement at all stages of their surgical journey, from preoperative to postoperative, both in the surgical and anaesthetic disciplines.
What defines 'active input' is debatable, but for purposes of the review active involvement was defined as either a consultant review of the patient preoperatively or a documented conversation with a consultant regarding the preoperative patient. Compliance was assessed based upon information recorded in the medical notes or anaesthetic clerking proforma. Also documented was the grade of the most senior surgeon and anaesthetist present in theatre at the time of surgery, i.e. whether this was a consultant or registrar.
3. Mortality rates for high risk patients should be estimated, documented and then communicated to the patient in order for the patient to make informed choices.
Compliance was assessed based upon the information recorded on the consent form and whether the patient had been given an actual mortality rate figure, consented for death as a complication of their surgery, or whether there was no evidence that this conversation had occurred with the patient. The actual mortality figure recorded wasn't scrutinised for accuracy since it was the recognition of a higher mortality and resultant patient counselling that was being assessed.
4. High risk patients should have their risk of death reassessed at the end of surgery.
This purpose of this reassessment was to take into account any intraoperative events which may have had adverse outcomes in terms of morbidity and mortality rates, and ultimately may affect the postoperative care that patients receive. This was assessed based upon documentation recorded on the operation notes, medical notes, nursing notes or anaesthetic proforma which indicated that this reassessment had occurred.
5. All high risk patients should be considered for a higher level of care.
This was assessed based upon the documentation of where the patient was admitted postoperatively. It was expected that, if the patient was admitted straight to the ward from recovery, that it be documented as to why they had not been considered for a higher level of care. Length of stay on the ICU and HDU was recorded, and any readmission back to these units post discharge to the ward were also documented.
6. All high risk patients should have a nutritional plan postoperatively documented to improve their nutritional status.
What defines a nutritional plan is again subject to debate. It was felt that a nutritional plan to 'keep the patient nil by mouth until further notice' was inadequate and therefore defined a nutritional plan to be any plan which aimed to correct a preoperative nutritional deficit and to meet ongoing needs, explicitly mentioning enteral or parenteral feeding. Compliance to this criteria was assessed regarding information recorded on the operation note plan.
7. High risk patients should have blood gas analysis and their temperature recorded intraoperatively.
This was assessed based upon information recorded on the anaesthetic chart.
Fifty patients' case notes were reviewed retrospectively and the data anonymised. The majority of patients were elderly and there was a mean age in the group of 70 years (range 48-90 years). The main indication for an emergency laparotomy was bowel obstruction (40%). Of these 20 patients, 12 patients were undergoing surgery as a result of a new presentation of malignant disease (Figure 1).
Post op complication 6% Perforation of viscus 24% Obstruction 40% Complicated hernla 12% Ischaemic bowel 8% Other - Anastomotic leak, toxic megacolon, bleeding 12% Ulcer Figure 1: Indication for emergency laparotomy Note: Table made from pie chart.
Identification of risk
The POSSUM and P-POSSUM predicted morbidity and mortality scores were calculated retrospectively and were generally high values for these patients, with a mean POSSUM morbidity rate of 85% (range 56-100%), mean POSSUM mortality rate of 42% (range 12-95%) and mean P-POSSUM mortality rate of 27% (range 5-94%). The mean P-POSSUM score in the deceased group was 45% (range 12-94%) and the mean score in the survival group was 21% (range 5-77%). The T-Test was used to compare the observed mortality with P-POSSUM predicted (p value >0.05). As expected, these patients had high ASA scores, usually ASA 3 (52%) and ASA 4 (20%), reflecting their premorbid state.
The observed mortality in the group was 26% (compared with a P-POSSIUM predicted morality of 27%). Eighteen percent (9) of patients experienced wound complications; of these 9 patients, 44% (4) of them required further surgery. Two patients died as a result of complications. Patients had prolonged stays on the ICU and HDU, but also on the ward. The mean length of stay was 6 days (range 1-17 days) for patients admitted to ITU, 7 days (range 1-22 days) for patients admitted to HDU, and 20 days (range 1-83 days) for patients admitted to the ward. There was a readmission rate of 8% to the HDU or ITU post discharge to the ward.
In 20% (10) of cases the patient was identified to be high risk by the anaesthetist and surgeon; in 24% (12) of cases the patient was documented to be high risk only by the anaesthetist, and in 56% (28) of cases there was no evidence documented that this was a high risk patient.
Active consultant involvement
In 56% (28) of patients there was a consultant surgical review documented preoperatively; in 28% (14) of patients there was a documented conversation with a consultant surgeon regarding the patient preoperatively, but in 16% (8) of patients there was no evidence that a consultant surgeon had been involved with the patient preoperatively. In 70% (35) of cases the most senior surgeon present in theatre at the time of surgery was a consultant.
In 36% (18) of cases there was a consultant anaesthetic review documented preoperatively; in 8% (4) of cases there was a documented conversation with a consultant anaesthetist regarding the patient preoperatively, but in 56% (28) of cases there was no evidence that a consultant anaesthetist had been involved with the patient preoperatively. In 74% (27) of cases the most senior anaesthetist present in theatre at the time of surgery was a consultant. There is clearly a discrepancy in the figures for consultant preoperative involvement and figures of consultant anaesthetists in theatre. The only explanation that can be offered for this is poor documentation preoperatively rather than consultant staff not being involved with patients' care preoperatively.
Communication of mortality risk
In 12% (6) patients there was a mortality figure documented on the consent form signed by the patient, and in 38% (19) of cases the patient was consented for 'death' as a complication of their surgery. In 50% (25) of cases there was no evidence that this discussion had taken place with the patient, and this is concerning when we remember that the observed mortality in the group was 26%. It could be argued that a patient cannot make an informed decision about their treatment without truly knowing the complications including mortality rates.
Postoperative reassessment of mortality risk
In only 2% (1) of cases was there evidence of a reassessment of mortality rates at the end of surgery to take into account intraoperative events. This occurred in one patient where it was documented that, at the time of surgery, they were found to have an unsurvivable ischaemic injury to their bowel and as a result they were to be transferred to the ward for end of life care.
Thirty six percent (18) of patients were managed postoperatively on the ITU and 48% (24) were managed on the HDU. Sixteen percent (8) of patients were transferred directly from recovery to the ward; in two of these patients it was documented that they were not admitted to HDU or ITU because of unsurvivable disease, however in the remaining 75% it was not documented why they had not been considered for a higher level or care. Presumably these were young and otherwise healthy patients who had an uneventful intraoperative course and were anticipated to have an uncomplicated recovery.
Nutritional planning was poor for these patients. In only 40% (20) patients was there a documented nutritional plan to be followed postoperatively; in 60% (30) there was no evidence of any nutritional planning. It could be argued that this is unlikely to cause harm as the majority of patients were reviewed by dieticians and parent teams the next day when nutritional plans could be made. However planning was less likely to occur when surgery took place over a weekend. Also, it could be questioned whether the responsibility for nutritional planning lies with the surgical team assuming responsibility for the surgery.
Blood gas analysis and temperature assessment
Blood gas analysis and temperature assessment occurred in 80% (40) of patients, and in 20% (10) only a temperature was documented. Rates of intraoperative monitoring were generally high with the majority of patients being monitored with arterial lines (96%) and central venous lines (72%). However, cardiac output monitoring with oesophageal doppler probe was used infrequently (10%). Four percent (2) of patients had no invasive circulatory monitoring documented as being used. Lack of intraoperative monitoring of the high risk patient was criticised by the NCEPOD document as it was found to be carried out only in a minority of patients, despite evidence that it is effective (Pearse et al 2005, NICE 2011).
This report highlights a number of strengths in the service provided by this hospital, especially regarding intraoperative monitoring with arterial and central venous lines, ensuring postoperative management on a higher level care facility, and the involvement of consultant staff both preoperatively and intraoperatively. It could be argued that the high risk patient undergoing an emergency laparotomy on the surgical take is the most in-need patient of week, and the requirement for the most experienced surgeon to be involved in the operation, is the greatest. This is reflected in the understanding of the surgical teams, with the large majority of operations being performed by the consultant surgeon.
However, the report also emphasises a number of areas for improvement which are unlikely to be isolated to this hospital and as a result can benefit many other trusts. Simple measures, such as adequate documentation, are a key aspect in the management of these patients. The finding that in 16% (8) of patients there was no evidence that a consultant surgeon was involved in a patients care is unlikely to be true and is more likely to be a oversight with regards documentation. However as the frequently repeated message goes: 'if it is not written down, it didn't happen'. Although ineffective documentation may seem insignificant, it is important to remember that a significant number of these patients will die and, as a postoperative surgical death, the entries in the notes may be scrutinised as part of an inquest or complaint. But more importantly, effective documentation helps to ensure that we deliver high quality care for our patients.
We need to be more effective at identifying high risk patients; without identifying them, we have no hope of better caring for them. Therefore we need an agreed method of identification. It should be suggested that any patient undergoing an emergency laparotomy should be considered high risk, unless there are obvious factors in the clinical setting which would suggest against this. Preoperative scoring systems should be used to aid assessment of high risk patients and both POSSUM and P-POSSUM are good predictors of morbidity and mortality in patients undergoing emergency laparotomy (Mohil et al 2004). The importance of correlating these scoring systems with clinical judgment should not be underestimated (Hobson et al 2007).
The report also highlights that we need to take more responsibility for patient counselling and ensuring that we help our patients to make informed choices by means of communicating predicated mortality rates. This appears to be something we shy away from, perhaps because of issues such as time constraints or lack of privacy, or perhaps for fear of causing further distress, although there is little evidence to support the latter (Kerrigan et al 1993). Either way, patients need to be fully informed before they can legally and ethically sign a consent form.
From the results of the study, a 'time out' session at the end of surgery is recommended to take account of intraoperative events which may impact our patients' post operative management and recovery. This is a simple tool which would take minutes, but which may help to predict potential postoperative problems.
An 'emergency laparotomy proforma' is recommended to ensure that we are meeting all aspects of high risk patients' preoperative and intraoperative management. A check list on the proforma would also ensure that key elements such as nutritional planning or mortality rate estimations don't get overlooked during stressful, fast paced, high volume surgical take. It is also likely that a structured proforma would help improve documentation (O'Connor et al 2001).
Table 1 compares the outcomes observed at this hospital with results seen nationally as documented by the NCEPOD report take into account all surgical disciplines, all grades of surgical risk from low to high, and all grades of surgical urgency from elective to emergency. Only 22.5% of patients in the NCEPOD report underwent urgent or immediate surgery, 21.9% of patients underwent abdominal surgery and only 20.1% of the total number were felt to be high risk. Therefore the group that would be a direct comparison would only be a small contribution to the total sample population. In the high risk group undergoing intra-abdominal surgery on a non-elective basis (i.e. immediate, urgent and expedited), the mortality rate was 13.2%. However, this also takes into account expedited surgery which wasn't applicable to our patients, and by including this group it is likely to lower the overall mortality rate as patients undergoing expedited surgery would be anticipated to be a fitter cohort of patients.
Large district general National results hospital results % of patients admitted 84% 22% to HDU / ITU post operatively % of patients having 96% 27% arterial line monitoring % of patients 72% 14% having central venous line monitoring % of patients having 10% 5% cardiac output monitoring % of patients having 80% 61% Intraoperative temperature assessment % of patients having 40% 6% nutritional planning % of patients with a 12% 8% mortality figure on the consent form % of patients with 56% 50% consultant surgical preoperative involvement Table 1: Comparison of data observed at this hospital compared With national data from the NCEPOO report (NCEPOO 2011)
Implementation of these changes and a further prospective review is intended.
Association of Surgeons of Great Britain and Ireland 2007 Emergency general surgery: the future. A consensus statement. Available from: http://asgbi.org.uk/en/publications/consensus_statements.cfm [Accessed September 2012]
Hobson SA, Sutton CD, Garcea G et al 2007 Prospective comparison of POSSUM and P-POSSUM with clinical assessment of mortality following emergency surgery Acta Anaesthesiologica Scandinavica 51 (1) 94-100
Kerrigan D, Thevasagayam R, Woods T et al 1993 Who's afraid of informed consent? British Medical Journal 306 298-300
Mohil R, Bhatnagar D, Bahadur L et al 2004 POSSUM and P-POSSUM for risk-adjusted audit of patients undergoing emergency laparotomy British Journal of Surgery 91 (4) 500-3
National Confidential Enquiry into Patient Outcome and Death 2011 Knowing the risk Available from: www.ncepod.org.uk/2011poc.htm [Accessed September 2012]
National Institute for Health and Clinical Excellence 2011 Medical technology guidance 3 Cardio Q-ODM (oesophageal Doppler monitor) Available from: www.nice.org.uk/guidance/MTG3 [Accessed September 2012]
O'Connor A, Finnel L, Reid J 2001 Do preformatted charts improve doctors' documentation in a rural hospital emergency department? A prospective trial New Zealand Medical Journal 114 443-4
Pearse R, Dawson D, Fawcett J 2005 Early goal-directed therapy after major surgery reduces complications and duration of hospital stay. A randomised, controlled trial Critical Care 9 (6) 687-93
Pearse RM, Harrison DA, James P 2006 Identification and characterisation of the high-risk surgical population in the United Kingdom Critical Care 10 (3) 81
Royal College of Surgeons of England 2011 Higher risk general surgical patient Available from: www.rcseng.ac.uk/publications/docs/higher-risk-surgical-patient [Accessed September 2012]
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Correspondence address: Sophy Rymaruk, SHO in Surgery, c/o AfPP, 42 Freemans Way, Harrogate, HG3 1DH. Email: firstname.lastname@example.org
About the author
SHO in Surgery, A large district general hospital, North Western Deanery
No competing interests declared
Provenance and Peer review: Unsolicited contribution; Peer reviewed; Accepted for publication July 2012.
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|Title Annotation:||CLINICAL FEATURE|
|Publication:||Journal of Perioperative Practice|
|Date:||Nov 1, 2012|
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