Elderly and frail emergency bowel surgery patients not receiving recommended levels of care
Almost 80% of patients with sepsis not receiving antibiotics within the recommended one hour
Other improvements of care are saving hundreds of lives and more patients going home early after emergency bowel surgery
Annual research led by the Royal College of Anaesthetists (RCoA) focusing on the care of over 24,800 NHS patients before, during and after emergency bowel surgery, has shown that enhanced patient care has successfully reduced the 30 day mortality rate from 11.8% in 2013 to 9.3% in 2019. But problems with other elements of patient care do still remain.
Also known as an emergency laparotomy1, this type of surgery is one of the highest risk operations a patient can undergo – at almost 10 times greater than that of major elective gastrointestinal surgery2.
The 2020 National Emergency Laparotomy Audit (NELA) report has shown that while there have been improvements in key areas of patient care, these are masking significant concerns, especially in care for elderly patients. Despite an increase in patients over the age of 65, who now make up 56% of all emergency bowel surgeries, only 28.8% of those in the frail category received care from a geriatrician.
Frailty is a known risk factor for postoperative morbidity and mortality regardless of age, however frail patients over 65 are most at risk of increased adverse outcomes and complications after surgery, with a 30 day mortality rate of 18%. The audit’s recommendation is that all clinicians who assess patients over the age of 65 must formally assess and document frailty. Frailty scoring must be considered an integral part of a formal risk assessment. However, the lack of consistent geriatrician input for elderly patients shows this is not happening across many hospitals.
The audit’s findings into the care being provided for elderly and frail emergency bowel surgery patients increases the calls for geriatricians to be embedded with anaesthetists, surgeons and other specialities within general surgery – a call the RCoA supports.
Key audit findings:
- in 2019 only 28.8% of patients in the frail category received care from a geriatrician
- only 30% of patients aged 80 were assessed by a geriatrician
- 18% of frail patients over 65 years old died within 30 days of surgery
- only 20.3% of audited patients with sepsis received antibiotics within the recommended one hour – a figure which has remained static since 2019
- over 25% of patients needing the most urgent surgery did not get to the operating theatre in the recommended time. This has stagnated since 2017
- 84% of emergency laparotomy patients received an assessment of risk (up from 77% last year)
- 94% of high risk patients saw a consultant anaesthetist before their surgery (up from 88% in 2016/17 and 90% in year 2017/18)
- 85% of patients with sepsis reached the theatre in the appropriate time
- the ‘time of day’ effect remains an issue, with 88.5%, of patients undergoing the procedure during the day seeing both anaesthetic and surgeon consultants but only 77.4% seeing them out of hours
- average number of days spent in hospital has reduced significantly from 19.2 days in 2013 to 15.4 days in 2019.
Commissioned by the Healthcare Quality Improvement Partnership as part of the National Clinical Audit Programme, the sixth annual National Emergency Laparotomy Audit report analyses the care received by approximately 24,800 emergency bowel surgery patients treated in NHS hospitals in England and Wales between December 2018 and November 2019. It is based on data collected by teams at 176 NHS hospitals in England and Wales.
Professor Ravi Mahajan, President of the Royal College of Anaesthetists, said:
“It is heartening to see sustained improvements in 30 day mortality rates and length of hospital stay. These results demonstrate that clinicians are taking heed of the NELA data and continuing to implement the recommendations locally.
“However we cannot ignore the concerning results in the on-going care of elderly and frail patients. Clinicians such as geriatricians are already working across increasingly pressured environments, and they are critical to the successful implementation of effective perioperative care pathways. Without the formal integration of geriatric care into general surgery, thousands of frail and elderly patients every year will continue to be denied vital checks, which could mean the difference between life and death when undergoing an emergency laparotomy.
“The recommendations in this report must be shared across the NHS, with hospitals, health Boards and Trusts taking on the need to reassess their care pathways for elderly patients, focusing on systematic improvements to ensure improved consistency of care. We must see organisational change before further improvements can be realised.”
Dr Arturo Vilches-Moraga, Consultant Physician and Geriatrician and British Geriatrics Society representative to NELA Clinical Research Group, said:
“There is growing clinical evidence supporting comprehensive geriatric assessment, multidisciplinary collaborative working and timely discharge planning for patients admitted to general surgical wards.
“Whilst most NHS Trusts have geriatricians embedded within orthopaedic departments, few hospitals provide geriatrician-led liaison services into general surgery. Furthermore, until recently there was no agreement amongst geriatricians of what constituted our target population in surgery. Traditionally these factors impacted negatively in the care of frail older people undergoing an emergency laparotomy.
“I expect future greater participation by geriatric teams across the UK and, as a result, improvements in clinical outcomes for older patients undergoing 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