Emergency bowel surgery patients face unacceptable delays following arrival at hospital

Patients having emergency bowel surgery are waiting up to five times longer than recommended between arriving at hospital and going into theatre, according to new data from the National Emergency Laparotomy Audit (NELA) led by the Royal College of Anaesthetists in partnership with the Royal College of Surgeons of England.  

This type of surgery is one of the highest risk operations a patient can undergo. NELA found that many aspects of patient care fall short of recommended standards, and some have deteriorated since the last annual audit, including lengthy delays in administering antibiotics to patients with suspected sepsis.  

NELA analysed care received by 27,863 patients undergoing emergency bowel surgery (laparotomy), in 173 hospitals in England and Wales from December 2021 until March 2023.  

Patients are waiting up to five times longer than recommended 

The audit classified patients according to how urgently they needed to undergo surgery and found median waiting times following arrival at hospital exceeded the recommended times.  

Patients requiring surgery within two hours of a decision to operate (by national standards) had been at hospital on average over ten hours by the time they got to theatre. Those requiring surgery within six hours had on average been in hospital for 17 hours. 

80% of suspected sepsis patients waiting hours for antibiotics 

Sepsis is a life-threatening condition which occurs when a patient’s immune system overreacts to an infection and begins to damage the body’s own tissues and organs. One in five (20%) patients included in the audit were suspected to have sepsis at time of arrival in hospital.  

Early detection and rapid treatment are critical for sepsis management, but the audit revealed that only 20% of patients suspected of having sepsis upon arriving at hospital received antibiotics within the recommended one-hour window, and 25% waited over 6.5 hours. The median delay until definitive control of the source of infection and sepsis reached 15.5 hours, well beyond the recommended three to six hours.  

Frailty and mortality 

Only one third (33%) of older patients or those living with frailty received specialist input into their care by a member of a geriatrician-led team following surgery, despite this being associated with a striking reduction in the risk of dying after surgery. 

The in-hospital mortality rate for patients undergoing emergency laparotomy was 9.3%, largely unchanged from previous years. However, this varies across hospitals and the mortality risk is greater for patients living in the most deprived areas.  

14% of high-risk patients did not receive immediate postoperative critical care contrary to published guidance. Instead, they were transferred to a normal ward following surgery; 7% of these patients subsequently died. 

Recommendations for improvement 

NELA makes a series of recommendations, including:  

• Royal Colleges should publish consensus pathways to manage patients presenting to hospital who might require emergency laparotomy. These pathways should include targets for timeliness of each phase of treatment, including during the diagnostic phase which involves radiological investigations and initial clinical management.  

• Health services commissioners should ensure that trusts/hospitals provide adequate specialist care for older patients and those with frailty following emergency laparotomy, as per guidance published by the Royal College of Surgeons of England, British Geriatrics Society and the Centre for Perioperative Care. 

• To help expand the pool of clinical staff with the requisite specialist skills, the Royal Colleges of Physicians, Surgeons and Anaesthetists should consider working together to develop common competency-based training curriculae around optimising perioperative care for older patients and those living with frailty who undergo emergency surgery. 

• NHS England and regional and local health services commissioners should ensure better matching of available services to patients from more deprived backgrounds to their greater needs.  

Dr Claire Shannon, President of the Royal College of Anaesthetists, said: 

“Emergency bowel surgery is high risk for patients and it’s concerning that some elements of care are falling short. Patients should not be waiting this long for surgery once they have arrived at hospital or to receive antibiotics to treat infection and sepsis. These delays can have a serious impact on patients, but there is potential to reduce them through multidisciplinary clinical teams implementing improvements in the care pathway.  

“The Royal College of Anaesthetists is committed to working with other Royal Colleges to enhance existing guidance and I urge health services commissioners, trusts and hospitals to act upon the recommendations too.”   

The National Emergency Laparotomy Audit is commissioned by the Healthcare Quality Improvement Partnership and led by the RCoA.