Peri- and post-operative management of the “high-risk” surgical patient. an audit of practice in a large district general hospital

Intr

In 2011, the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) published a report, “Knowing the Risk,” [1] which reviewed data regarding peri-operative management of the high risk surgical population and subsequently produced recommendations in aim to improve outcomes in this patient population.

Of particular focus, recommendations included; clear documentation of operative mortality risk, to use peri-operative cardiac output monitoring with CardioQ technology, as supported by NICE Medical Technology guidance 3 [2] and to provide higher-level care, with Critical Care input, post-operatively.

Aim

This study aimed to audit clinical anaesthetic practice at a large district general hospital (DGH) against those recommendations outlined in the NCEPOD 2011 report, regarding the management of high risk surgical patients.

Methods

Case notes were used for retrospective data collection. Patients undergoing emergency surgery between January-March 2013 and January-March 2014 were identified. From these, high-risk patients were selected for inclusion in the audit. For the purpose of this audit, high-risk patients were defined as those older than 65 years and undergoing emergency laparotomy. Data included demographic details, documentation of risk, peri-operative haemodynamic monitoring used, 30-day survival and involvement of Critical Care post-operatively. These data were collated and compared between 2013 and 2014, identifying any interval improvement, and with the national prospective data outlined in the NCEPOD report.

Results

33 and 23 patients were identified as undergoing high-risk surgery in 2013 and 2014, respectively.

NCEPOD data identified arterial lines; central lines and cardiac output monitoring were used in 27%, 14% and 5%, in high-risk patients, respectively. In this audit, these figures were 50%, 36.1% and 2.8%, in 2013, and 60.9%, 26.1% and 34.8%, in 2014, respectively.

In this audit, 69% and 65% of “high-risk” patients were referred to higher-level care in 2013 and 2014, respectively. Of these, 85% (2013) and 90% (2014) had a clearly documented plan from higher-level care, whether that be admission to HDU or outreach plan. The overall admission rates to higher level care were 47.2% and 65.2% in 2013 and 2014, respectively. This is comparable to the 22.1% seen in the NCEPOD data.

Conclusions

Comparison between 2013 and 2014 data suggests peri-operative care is improving year-on-year after publication of this NCEPOD report. However, there is a need for further improvement in peri-operative care to fully comply with NCEPOD recommendations.