COVID-19 patients 26% more likely to die after emergency bowel surgery, but mortality rates improved for COVID negative patients
Many standards of patient care maintained despite pressures faced by NHS and critical care
Research led by the Royal College of Anaesthetists (RCoA) focusing on the care of over 10,500 NHS patients before, during and after emergency bowel surgery has been released today. Results have shown that patients with COVID-19 were 26% more likely to die within 30 days of their surgery than would have been expected if they did not have COVID-19.
The Interim Report of the National Emergency Laparotomy Audit covers patients undergoing surgery between 23 March and 30 September 2020, with data being compared with the same time period in 2019. It captured the impact of the first wave of the pandemic on emergency bowel surgery. The procedure, also known as an emergency laparotomy1, is one of the highest risk operations a patient can undergo – with an almost 10 times greater risk of death than that of major elective gastrointestinal surgery even in pre-pandemic times.2
While results for patients with COVID-19 were concerning, patients who did not have COVID-19 had a lower rate of death within 30 days than in previous years. There were also positive signs for patient care with 93% of high-risk patients having a consultant anaesthetist in theatre compared with 92.5% in 2019. A total of 85.3% of patients also had a preoperative assessment of risk compared with 84.7% the previous year. Despite the enormous pressures placed on critical care, 82% of patients were still admitted compared to 86.4% in 2019.
Key audit findings:
- 10,546 patients had emergency bowel surgery compared to 13,024 for the same time period in 2019, a 20% reduction in operations
- 867 patients undergoing the surgery had a perioperative diagnosis of COVID-19
- 30-day mortality rate of COVID-positive patients was 12.5%. This is 26% higher than the predicted
- 30-day mortality rate for non-COVID patients was 7.2%. This was 15% lower than had been predicted
- 93% of high-risk patients had a consultant anaesthetist present in theatre compared to 92.5% in 2019
- 96.6% of high-risk patients had a consultant surgeon present in theatre compared to 94.6% in 2019
- 82% of all high-risk patients were admitted to critical care compared to 86.4% in 2019
- 85.3% of patients had a preoperative assessment of risk, up from 84.7% in 2019.
Commissioned by the Healthcare Quality Improvement Partnership as part of the National Clinical Audit Programme, the Interim Report of the National Emergency Laparotomy Audit analyses the care received by patients at 173 NHS hospitals in England and Wales between 23 March and 30 September 2020.
Professor Ravi Mahajan, President of the Royal College of Anaesthetists, said:
“It is heartening to see that during the first six months of the pandemic, clinicians managed to maintain and improve standards of patient care in emergency bowel surgery. The increase in consultant presence, and the number of preoperative risk assessments undertaken, demonstrates the dedication our NHS staff have to treating these high-risk patients, even during periods of unprecedented pressure.
“However, we cannot ignore the serious impact a positive COVID test has on the 30-day mortality rates for patients undergoing the surgery. With the death rate at 26% above predicted levels, it is essential that these results are analysed further, and steps be made to improve these outcomes on behalf of patients. We hope the vast NELA database will be able to answer many of the questions raised by the report.
“We also call on all clinicians to seriously consider COVID infection status when planning care and discussing treatment options with patients and their families. It is vital that everyone is fully informed before making a decision to undergo a surgery that may have devastating consequences.
“The findings of this report must be shared across the NHS in England and Wales, with hospitals, Health Boards and Trusts taking on board the need to reassess the care of their COVID positive patients undergoing an emergency laparotomy.”
- An emergency laparotomy (emergency bowel surgery) is a surgical operation for patients, often with severe abdominal pain, to find the cause of the problem and treat it. General anaesthetic is used and usually an incision made to gain access to the abdomen. Emergency bowel surgery can be carried out to clear a bowel obstruction, close a bowel perforation and stop bleeding in the abdomen, or to treat complications of previous surgery. These conditions could be life-threatening. The National Emergency Laparotomy Audit was started in 2013 because studies showed this is one of the most risky types of emergency operation and lives could be saved and quality of life for survivors enhanced by measuring and improving the care delivered.
- Mortality after surgery in Europe: a 7 day cohort study, Lancet 2012