the higher risk general surgical patient...consultant input in the diagnostic, surgical, anaesthetic...

The Higher Risk General Surgical PatientTowards Improved Care for a Forgotten Group

The Royal College of Surgeons of England and Department of Health

Report on the Peri-operative Care of the Higher Risk General Surgical Patient2011

ContentsContributors 2

Summary 3

Keyrecommendations 4

Background 5Introduction 5Variation in current outcomes 6How do adverse outcomes occur for the higher risk general surgery patient? 7Sepsis 8

Actions 9Managing the critically ill surgical patient with sepsis 9

Escalation of care 9Urgency of source control 10Summary timelines 11

Assessing and identifying risk 12Why it should be done 12How should risk be assessed? 12

Peri-operativefluidandvasoactivedrugtherapies 14

Endofsurgerybundle 15

Postoperativecare 16Structured care on the PACU 16Co-location of medium risk patients 17

Auditandoutcomes 18

Conclusions 19

Figure1.CarePathway 20

Appendix1:EarlyWarningScore(EWS) 21

Appendix2:Endofsurgerybundle 22

Appendix3:Unscheduledadultgeneralsurgicalpathway 23

References 28

1

Contributors

The Royal College of Surgeons of England and Department of Health Working Group on Peri-operative Care of the Higher Risk General Surgical Patient

ID Anderson ConsultantGeneralandColorectalSurgeon,SalfordRoyalFoundationNHSTrust DirectorofEmergencySurgery,ASGBI(Chair)

J Eddleston ConsultantAnaesthetistandIntensivist,CentralManchesterFoundation NHSTrust(AdultCriticalCareAdvisorDepartmentofHealth)

M Grocott ConsultantAnaesthetistandIntensivist,Southampton,Director,NIAA HealthServicesResearchCentre,TheRoyalCollegeofAnaesthetists

NP Lees ConsultantGeneralandColorectalSurgeon,SalfordRoyalFoundationNHSTrust

D Lobo ConsultantGeneralandUpperGISurgeon,QueensMedicalCentre,Nottingham

I Loftus ConsultantVascularSurgeon,StGeorge’sHospital,London

NI Markham ConsultantGeneralSurgeon,NorthDevonDistrictHospital,Barnstaple

D Mitchell ConsultantVascularandRenalTransplantSurgeon.Chair,AuditandQuality ImprovementCommittee.VascularSocietyofGreatBritain&Ireland

R Pearse SeniorLecturerandConsultantinIntensiveCareMedicine,BartsandThe LondonSchoolofMedicineandDentistry

C Peden ConsultantAnaesthetistandIntensivist,RoyalUnitedHospital,Bath

RD Sayers ProfessorofVascularSurgery,UniversityofLeicester

J Wigfull ConsultantAnaesthetistandIntensivist,SheffieldTeachingHospitals

Approving organisations

Thisdocumenthasbeenreviewedandsupportedby:» AssociationofAnaesthetistsofGreatBritainandIreland» AssociationofColoproctologyofGreatBritainandIreland» AssociationofSurgeonsofGreatBritainandIreland» AssociationofUpperGastro-intestinalSurgeons» CriticalCareNetworks» FacultyofIntensiveCareMedicine» IntensiveCareSociety» RoyalCollegeofPhysicians» SocietyofAcademicandResearchSurgeons» VascularSocietyofGreatBritainandIreland» RoyalCollegeofAnaesthetists

Contributors2

Summary

Higherrisknon-cardiacgeneralsurgeryisundertakenineveryacutehospital.Bywayofcomparison,themortalityforthisgroup,whichincludesmostmajorgastro-intestinalandvascularprocedures,exceedsthatforcardiacsurgerybytwotothreefoldandcomplicationratesof50%arenotuncommon.Theremaybealackofawarenessofthelevelofrisk.Amongthesepatients,emergencysurgeryandunscheduledmanagementofcomplicationsiscommonandthisgroupofpatientsareoneofthelargestconsumersofcriticalcareresources.Thehealthandfinancialcostsareconsiderable.

Evidenceindicatesthattheperi-operativepathwayfollowedbypatientsrequiringemergencysurgicalmanagementisfrequentlydisjointed,protractedandnotalwayspatientcentred.Outcomesareknowntovarysubstantiallyandcouldbeconsiderablyimproved.Trustsshouldformalisetheirclinicalpathwayforthisgroupofpatients,ensuringthatriskoffurtherdeteriorationismatchedwithurgencyofdiagnostictests,seniorityofclinicianindecisionmaking,timingofsurgeryandappropriateclinicallocationforimmediatepost-operativecare.

This document describes key issues and standards. It is the opinion of this expert group that therecommendations contained within should be deliverable within two years in all acute hospitalsundertaking unscheduled general surgery in adults and that doing so would make an appreciabledifferencetooutcomes.

Summary 3

Key recommendations

1) Trustsshouldformalisetheirpathwaysforunscheduledadultgeneralsurgicalcare.Allpatientsshouldhaveacleardiagnosticandmonitoringplandocumentedonadmission.ThemonitoringplanmustbecompliantwithNationalInstituteforHealthandClinicalExcellence(NICE)CG50guidanceandmatchcompetencyofthedoctortoneedsofthepatient.Thepathwayshouldincludethetimingofdiagnostictests,timingofsurgeryandpost-operativelocationforpatients.

2) Promptrecognitionandtreatmentofemergenciesandcomplicationsisessentialtoimproveoutcomesandreducecosts.Surgicalpatientsoftenrequirecomplexmanagementanddelayworsensoutcomes.Theadoptionofanescalationstrategywhichincorporatesdefinedtime-pointsandtheearlyinvolvementofseniorstaffwhennecessaryarestronglyadvised.Onesuchstrategyisdefined.

3) Trustsshouldensureemergencytheatreaccessmatchesneedandensureprioritisationofaccessisgiventoemergencysurgicalpatientsaheadofelectivepatientswhenevernecessaryassignficantdelaysarecommonandaffectoutcomes.Thenecessarytimescaleofinterventionisdefined.

4) Eachpatientshouldhavehisorherexpectedriskofdeathestimatedanddocumentedpriortointerventionanddueadjustmentsmadeinurgencyofcareandseniorityofstaffinvolved.

5) Highriskpatientsaredefinedbyapredictedhospitalmortality≥5%:theyshouldhaveactiveconsultantinputinthediagnostic,surgical,anaestheticandcriticalcareelementsoftheirpathway.

6) Surgicalprocedureswithapredictedmortalityof≥10%shouldbeconductedunderthedirectsupervisionofaconsultantsurgeonandconsultantanaesthetistunlesstheresponsibleconsultantshavesatisfiedthemselvesthattheirdelegatedstaffhaveadequatecompetency,experience,manpowerandareadequatelyfreeofcompetingresponsibilities.

7) Eachpatientshouldhavetheirriskofdeathre-assessedbythesurgicalandanaestheticteamsattheendofsurgery,usingan‘endofsurgerybundle’todetermineoptimallocationforimmediatepost-operativecare.

8) Allhighriskpatientsshouldbeconsideredforcriticalcareandasaminimum,patientswithanestimatedriskofdeathof≥10%shouldbeadmittedtoacriticalcarelocation.Trustsshouldexaminetheirspectrumofcriticalcareprovisionandconsideroptionsforpatientswithlowerrisksofdeathwhichwillfurtherenhancesurgicaloutcomesandlimitcostsoverall.

9) Anationalauditofoutcomeshouldbeconductedforadultpatientsundergoingunscheduledgeneralsurgery,utilisingthestandardsproposedinthedocumentandincorporatingmeasuresofcosteffectiveness.Localassessmentofoutcomeisfundamentalinimprovingcareandresultsshouldbesharedappropriately.

Key recommendations4

Background

Introduction

Theadulthigherrisknon-cardiacsurgicalpopulationrepresentsamajorhealthcarechallengetoeveryacutehospital.Surgeryremainsacommonandeffectivetreatmentoptionforadiverserangeofdiseasesandfarfrombeingreplacedbydrugtherapies,surgeryisnowmorefrequentlydeemedaviableoptionfor elderly patients and those with co-morbidities or advanced disease. The standard of patient careduringsurgeryitselfcannowbeextremelyhighandevencomplexelectivesurgerycanbemaderelativelysafe.1,2However, successful surgeryalsodependsongoodperi-operativecareandhere liechallenges.Whilewemayhavemadesomeprogresstowardsimprovingsurgicaloutcomes,theavailableevidencesuggeststhatpost-operativeadverseeventsmaybemuchmorefrequentthanmanyappreciateandthattheconsequencesofthesecomplicationsareconsiderable.

IntheUK,thefocushasfallenpreviouslyoncardiacsurgerywherespecialistunitscarryoutamodestrange of predominantly elective procedures with routine intensive care support. Audit now showsgoodresultswhichcontinuetoimprovewith2–3%mortalitytypical.3Theestablishedandtransparentmeasurement of outcomes in cardiac surgery facilitate improvement by identifying centres of goodpracticeandcentreswherechangemayberequired.

Bycontrast,majorgeneralsurgeryiscarriedoutineveryacutehospital,encompassingawiderangeofconditions which are, hence, more difficult to audit and conducted with limited critical care support.Themortalityofelectivemajorgastro-intestinalorvascularsurgerysubstantiallyexceedsthatofcardiacsurgery.Amuchhigherproportionofnon-cardiacsurgicalpatientsaretreatedonanemergencybasisandatpresenttheserviceforsuchpatientslacksfocusdespitemuchhighermortalityandcomplicationrates.

Thereisgrowingconcernthatthisgroupofhigherriskgeneralsurgicalpatientsreceivesub-optimalcarewhichhasimportantimplicationsforpatientsandthehealthcareeconomy.IntheUK,170,000patientsundergohigherrisknon-cardiacsurgeryeachyear.4Ofthesepatients,100,000willdevelopsignificantcomplicationsresulting inover25,000deaths.General surgicalemergencyadmissionsare the largestgroupofallsurgicaladmissionstoUKhospitalsandaccountforalargepercentageofallsurgicaldeaths.5Emergencycasesalonepresentlyaccountfor14,000admissionstointensivecareinEnglandandWalesannually.6Themortalityofthesecasesisover25%andtheintensivecareunit(ICU)costaloneisatleast£88million.

Complicationsoccurinasmanyas50%ofpatientsundergoingsomecommonprocedures,andtheseresult in dramatic increases in length of stay and cost. Many of the patients undergoing this type ofsurgeryareelderlywithmultipleco-morbidities7–10andindeedtheover80saremorelikelytopresentforemergencysurgerythanelective,11,12wheretherisksmultiply.Despitethesefindings,thereissurprisinglylittleresearchintohowtoimprovethesepatientsoutcomesbutstructuresofcarewhichfacilitateattentiontothedetailofperi-operativecaremayhelp.13

StudiesfromtheUKsuggest thatareadily identifiedhigherrisksub-groupaccountsforover80%ofpost-operativedeathsbutlessthan15%ofin-patientprocedures.4,7Advancedage,co-morbiddisease,and major and urgent surgery are the key factors associated with increased risk. Within this group,emergencymajorgastrointestinal(GI)surgeryhasoneofthehighestmortalities,whichcanreach50%intheover80s.8Presently,thistypeofsurgeryiscarriedoutineveryacutehospital,butnotalwayswithconsultantstaffpresentandnotalwayswithroutineadmissiontoacriticalcarebedaftersurgery.ManyoftheseissueswerehighlightedinthemostrecentNationalConfidentialEnquiryintoPatientOutcomeandDeath(NCEPOD)report.14

Background 5

IntheUK,fewerthanonethirdofhighrisknon-cardiacsurgicalpatientsmaybeadmittedtocriticalcarefollowingsurgery.4,7Inaddition,thosepatientswhodoreceivethislevelofcarearedischargedafteramedianstayofonly24hours,despitegoingontohaveprolongedhospitalstays.Prematuredischargefromcriticalcarehasbeenidentifiedasanimportantriskfactorforpost-operativedeath,ashasdelayedadmissiontocriticalcare.15Internationalcomparisonssuggestthatcriticalcarebedsmayrunat50%ofcomparablelevelselsewhereandindeedrankamongstthelowestinthedevelopedworld.16

Toidentifyandadviseonhowthesepatientscouldbebettermanaged,ajointworkinggroupwassetupbetweenTheRoyalCollegeofSurgeonsofEnglandandtheDepartmentofHealth(DH)toaddresstheseissuesastheyrelatetotheperi-operativecareofgeneralandvascularsurgeryinthefirstinstance.

Thefollowingdocumentseekstoexplaintothenatureoftheproblemtocommissioners,chiefexecutivesandmedicaldirectors,andtolayoutlogicalstepswhichshouldbetakeninordertoachievethegreatestbenefitinthemosteffectiveway.

Variation in current outcomes

ThereareseveralindicatorsthattheoutcomesfromhigherrisksurgeryintheUKarenotasgoodastheyshouldbe.Reviewof2008/9hospitalepisodestatistics(HES)datafromDrFosterrevealagreaterthantwo-foldvariationinrelativeriskof30-daymortality(risk-adjusted)afternon-electivelowerGIproceduresbetweentrustsintheNorthWestSHA(strategichealthauthority).ItisknownthatthechanceofapatientdyinginaUKhospitalis10%higherifheorsheisadmittedataweekendratherthanduringtheweek.17Therearenoevidentreasonsforthesedifferencesotherthanthatcare,attimes,isofvariablequality: a conclusion which fits with the available evidence and professional opinion. Internationalstudies have reached similar conclusions and local audit data confirm that outcomes deteriorate ifpatientsareadmittedtowardstheendofdutyperiodsandatweekends.TworecentNCEPODreportsshowed significant deficiencies in the active care of patients who ultimately died.14, 18 These includeddelaysinassessment,decisionmakingandtreatment.Therewereshortfallsinaccesstotheatre,radiologyandcriticalcare;surgerywassuboptimallysupervisedin30%ofcasesandtherewasafailureforjuniorstocallforhelpin21%ofcases.Timelysurgerywasnotcarriedoutin22%ofpatientswhodied.Therewasalsothefailuretoreliablyadministertherapyknowntobeofbenefitsuchasantibioticandvenousthrombo-embolismprophylaxis.TherearefewdatawhichcompareouroutcomesintheUKtoothercountriesbutonestudyreportedthatrisk-adjustedmortalityrateswereasmuchasfourtimeshigherin the UK than in the US.19 A large percentage of the patients that survive have prolonged hospitalstayswithsignificantcostimplications,bothphysicalandemotionaltothepatientandtheirfamily,andfinancialtothehospital.20

Together, these data show that these higher risk patients are a significant clinical burden in everyhospital,usesubstantialcriticalcarefacilitieswithcorrespondinghighcostbuthaveoutcomeswhichvary considerably between sites and within sites at weekends. These observations represent a poorlydefinedcarepathwaywithstandardsthatareeithernotdeterminedornotimplemented.TheconsequentimpactonbothpatientoutcomesanduseofNHSresourcesisconsiderable.Thescopeforimprovementis difficult to document given the very limited nature of current audit methods and the diversity ofproceduresundertaken.However,thefindingsarewellrecognisedbymanyworkinginthefieldandnoraretheysurprising.Provisionofservices,particularlyoftheatreaccess,criticalcareandinterventionalradiology, is often incomplete and the correct location of patients after surgery is often not givensufficientpriority.Furthermore,theclinicalresponseforpatientswhodeteriorateisoftenpoorlythoughtthroughand,attimes,adhoc.Aligningpatients’needsandsubsequentriskofdeteriorationtothemostappropriatepreandpost-operativeclinicalarearequiresactiveearlyassessmentofriskofdeathandclearobjectivesforclinicalcaretobeidentified.

Background6

How do adverse outcomes occur for the higher risk general surgery patient?

Whileoccasionalpatientsdie fromhaemorrhagicorcardiaccomplicationsduringsurgery, it ispost-operativecomplicationsthataccountforthebulkofmorbidityandmortalityingeneralsurgery.Someoftheseresultfromsuboptimalsurgicalperi-operativecare–perhapsonaccountofpoorpre-operativepreparationorinexpertordelayedsurgeryoranaesthesia.Forothers,post-operativecomplicationsarechanceoccurrencesbutneverthelessoneswhichcanoftenbereadilyanticipatedandmitigatedthroughconsiderationofco-existentdiseasesandthesurgeryperformed.Intheelderly,frailtyisariskfactorandshouldbeformallyassessedinadditiontonutritionalandmentalstate.14Complicationscanbegreatlyreducedbyoptimalperi-operativecare.

Thereareopportunitiestoimproveoutcomesbefore,duringandaftersurgery.Manyofthesehigherriskpatientsareemergencieswherethetimeforpre-operativeassessmentislessandsurgeryisoftenunavoidable.In thesecases,optimal resuscitation is importantbutdelay isdetrimental.However, for thosepatientsundergoingelectivehigh-risksurgery,optimalmultidisciplinarypre-operativeplanningistheideal.

Complicationsarecommonandraisecosts,oftenseveral-fold.Theirdevelopmentreducessurvival(bothshortandlongterm)independentlyofpre-operativeriskandcomplexityofsurgery.21Thosethatoccuraremanagedvariablyandadverseoutcomesareestimatedtobeduetoerrorsintheprocessofcareormedicalmanagement,eachinabout20%ofcases.22

Minor complications are extremely common after complex procedures and slow or suboptimalmanagement of these, particularly in patients with other medical diseases can trigger a subsequentcascadeofmoreseriouscomplications.Manyofthelifethreateningproblemsinvolvesystemicinfection(sepsis).Onceapatientdevelopsmajorcomplications,theyareatriskofmajororgandysfunctionorfailure. Typically, patients at risk or with organ dysfunction are managed in high dependency units(level2),where themortality is at least5%.Onceorgan failuredevelops, full intensivecare (level3)is required and the mortality rises to 30% or more, often after prolonged treatment. The health andfinancialadvantagesofmanagingcomplexpatientswithadequatecriticalcaresupportfromthetimeofsurgeryareselfevident.

Complicationsmaybeinevitableafterthismagnitudeofsurgerybuttheirnumberandseveritycanbemitigatedbyrapidandsuccessfultreatment.Itiswellestablishedthatthisrequiresthefollowingsteps:

1) Rapididentification2) Adequateresuscitation3) Investigationtodefinetheunderlyingproblem4) Rapiddefinitivetreatmentofthatproblem5) Appropriatecriticalcareprovisiontopreventfurthercomplications

Toooftenthewholeprocessissloworinaccurateasitiscomplex,requiresmultidisciplinaryinput,oftenoccursoutofhoursandisinitiatedbyjuniorstaff.Suboptimalcareongeneralwardspriortocriticalcareadmissionhasbeenrecognisedasacauseofavoidablemortality14whichhasresultedinthepublicationof a clinical guideline document from NICE23 and of a competency framework from DH.24 Thesedocuments outline a graded response strategy that each acute hospital should establish to recogniseandrespondtothedeterioratingpatient.Escalationofcareforthosethatrequiresurgicalintervention,includingradiologicalintervention,hasnotbeenthesubjectofspecificguidancetodate.CertainlyintheUS,theabilityofdifferenthospitalstomanagecomplicationsdifferedsignificantlyandthis(ratherthantheinitialfrequencyofcomplications)accountedforlargevariationsinoutcomes.25Promptinterventionisfundamentaltothesuccessfultreatmentofthepatientwhodeterioratesaftersurgery.

Background 7

Sepsis

Sepsis (the body’s generalised response to infection) requires special consideration because it is theprincipalreasonforprolongedadmissiontocriticalcareanddeath inthesepatientsandbecausetheexistingguidelinesdonottakeintoaccountcurrentunderstandingofthetimelinessofintervention.

Theprocessistimecriticalandtwostepsareofparticularimportanceinsurgicalpatients.Thefirst,asdefinedintheSurvivingSepsisCampaign,istoadministerbroad-spectrumantimicrobialsasearlyaspossible,andalwayswithinthefirsthourofrecognisingseveresepsisandsepticshock26togetherwithotherappropriatemeasuresshowninBox1.

The second is to deal with the source of sepsis which, in surgical practice, often means a complexoperationorradiologicaldrainage.Previousguidancewithregardtotheurgencyofemergencysurgeryistoonon-specificanddoesnottakeaccountofnewevidencewhichsuggeststhatpatientswithsepticshockrequiringsourcecontrolhaveaprogressivedeteriorationinoutcomeassociatedwithincreasingdelaytosourcecontrol.27Delayofmorethantwelvehoursaftertheonsetofsepticshockmayincreasemortalitybyafactorof2.5timeswhencomparedwithpatientswhoreceivedsourcecontrolwithinthreehours.GatheringdataonthesepatientsisdifficultbutthisexpertgroupbelievesthereisenoughevidenceatpresenttoestablishpragmaticguidanceconsistentwithNICECG50.Namely,thatagradedresponsebeestablishedthatrequiresincreasinglyrapidinterventionforpatientswithincreasingseverityofillnessandthatthedegreeofurgencyshouldbeconsiderablygreaterthanthatpreviouslyaccepted.

Itisanticipatedthattheeffectsofthiswillbetoreduceseverityofillness,theneedforhigherlevelsofcriticalcareanditsassociatedcostandimproveoutcomes.

Box 1. Early resuscitative measures in sepsisMeasureserumlactate.Takebloodcultures(preferablybeforeantibioticadministration).Administerbroadspectrumantimicrobialswithin1hour.Treathypotension,hypovolaemiaorelevatedlactatewithappropriateintravenousfluids.

Background8

Actions

Managing the critically ill surgical patient with sepsis

Surgicalpatientsmaybecomecriticallyillfortworeasons.Theymaypresentasanemergencywithanacute surgical illnessor theymaydevelopcomplications following surgeryorduring surgical illness.Somecomplicationshavewelldefinedtreatmentprotocolsandothersaresocatastrophicthattheneedfor immediate summoning of the cardiac arrest team is obvious. However, the graded response foridentificationandtreatmentofsepsis,themostfrequentseriouscomplicationisnotwelldefined.Thisdeficitleadstoavoidableadverseoutcomes.

Escalation of careFundamental to prompt definitive treatment of sepsis and indeed, all complications, is the need toidentify critically ill patients at an early stage. This escalation guideline is written with reference toexisting documents; NICE CG5023 and Competencies for Recognising and Responding to Acutely Ill Patients in Hospital.24Thegradedresponsetoearlywarningscoreswillbedescribedasathreepointscaleofresponsetolow,mediumandhighscoringpatients.Furtherexplanationofthecurrentstatusofearlywarningscores(EWS)isgiveninAppendix1.

Surgical patients frequently differ from non-surgical ones in two ways. Firstly, the conditions whichdevelop often demand greater urgency and secondly, they more often require complex operativeinterventionsfollowingadvancedimaging.Thesedifferencesbringopportunityfordelay.

Foramedium-scorepatientNICECG50requires:‘Urgentcalltoteamwithprimarymedicalresponsibilityandsimultaneouscalltostaffwithcorecompetenciesincareofacuteillness.’Inthecaseofasurgicalpatientthathasdeterioratedonthewardthememberofstaffwith‘corecompetencies’isasurgicaltrainee,whowillusuallyhavepassedMRCS.Atypical‘mediumscore’patientwouldbeonethatisdevelopingseveresepsisoronewithlesssevereacutepathologybutwithsignificantco-morbidities.

Thistrainee,heredenotedMRCS,isthesecondaryresponderinthechainofresponsedescribed.23TheMRCSplaysakeyroleindiagnosisandcommunicationbetweentertiaryresponsegroups;cruciallytheconsultantsurgeonalthoughmicrobiologist,radiologist,anaesthetistandintensivistmayallneedtobeinvolvedwithinashortspaceoftime.Staffingarrangementsbetweenhospitalswillvary.Responsibilityforensuringthat theMRCSisable toreviewapatient that triggersamediumscorewithoutdelay isfundamentalandwillrestwithindividualdepartments.

Fortheescalationstructure,below,toworkforthepatient’sbenefit,theMRCSmustbecompetentinrecognisingwhetheradeterioratingpatienthassepsisornotandwhetherthecauseofsepsis ismostappropriately treated with antibiotics alone or with source control. The MRCS must also be able todifferentiate between the different levels of severity of sepsis. Successful attendance at a Care of theCriticallyIllSurgicalPatient®(CCrISP®)course28orequivalentwouldprovidethis,andthisisa‘stronglyrecommended’facetofbasicsurgicaltrainingintheUK.

SuggestedpathwaysforescalationareshowninFigure1.TheupperpartofFigure1utilisestheearlystages of the generic pathway described in NICE CG50 up to the point of referral to the secondaryresponder.However,notethat12-hourlyobservationsistooinfrequentforthisgroup:hourlyobservationswouldbemoreusualuntilmedicalreview,andwouldlikelybetriggeredbytheEWS.Therefollowstherecommendedpathwayforthesurgicalpatient.

Actions 9

Thesummarytimelines forassessmentof theunstablepatientandfor interventionareshownbelow.Fordefinitivetreatmenttooccurwithintherecommendedtimeframe,itwillbeclearthateachphaseoftreatmentmustbeexpeditious.Thesephasesoftenincludeinitialrecognition,initialassessment,MRCSassessment,investigation(mostcommonlyCTscan)andseniordecisionmaking.Hospitalsshouldauditthestagesofthepathwaytominimisetheavoidabledelayswhicharecurrentlyrecognised.Whenstaffshiftschange,effectivehandoveratasufficientlyseniorlevelisessentialtomaintainmomentum.

Urgency of source controlPatientswithsepsisrequireimmediatebroad-spectrumantibioticswithfluidresuscitationandsourcecontrol.

a) Thosewithsepticshockrequireimmediatebroad-spectrumantibioticswithfluidresuscitationandsourcecontrol.Delaytosourcecontrolofmorethantwelvehoursafteronsetofhypotensionwhencomparedwithadelayoflessthanthreehourscouldbeexpectedtoincreasemortalityfrom25%tomorethan60%.27Rapidinvolvementofseniorstaffisimportant.Controlofthesourceofsepsisbysurgeryorothermeansshouldbeimmediateandunderwaywithinthreehours.

b) Patientswithseveresepsis(sepsiswithorgandysfunction)areatgreatestriskofdevelopingsepticshock.Thereisnodirectevidencetoconfirmthatdelayedsourcecontrolworsensoutcomebutthereareobviousadvantagestooperatingbeforeprogressiontosepticshockoccurs29-31giventheassociated5to10-foldriseinmortalitywhichoccursasthepatientdeteriorates.Surgeryorequivalent(egradiologicaldrainage)shouldbecarriedoutwithinsixhoursfromtheonsetofdeterioration.Thesepatientsrequireimmediatebroad-spectrumantibioticswithfluidresuscitation,urgentbutnotimmediatesurgery,frequentmonitoring(asperNICECG50)inanappropriateenvironmentduringtheinterimtopromptlyidentifydevelopmentofhypotension.Whereitiselectedtoobserveandresuscitatethepatientforafewhoursuntilmorning,surgeryshouldassumepriorityoverelectiveprocedures.Neitherobservationnorresuscitationshoulddelaysourcecontrolformorethansixhours.Evidencesuggeststhatfurtherdelaysatthispointarecommon.14,32

c) Sourcecontrolforpatientswithsepsisbutwithoutorgandysfunctionshouldalwaysbecarriedoutwithin18hours.Immediatebroad-spectrumantibioticsarerequiredbutsurgerycanbedelayedovernightoruntilthenexttheatrebecomesavailable.Sourcecontrolisneededbeforeprogressiontoseveresepsiswhichcarriesagreateroverallmortalityandanincreasedfrequencyofobservationsisneededintheinterimtoidentifyanyclinicaldeteriorationwhichshouldtriggerarevisedmanagementplan.

d) PatientsthatrequiresourcecontrolbuthavenotmountedasystemicinflammatoryresponseareclinicallyappropriateforNCEPODclassification‘expedited’.

Doctors should be aware of these timescales when determining the urgency of assessment andintervention. As the acute management pathway for many of these patients is tortuous (assessment,seniorassessment,investigation,anaestheticreview,criticalcarereview,theatrescheduling,operation)theneedforurgencyateachstageisemphasised.

Thesetimescalesshownarethemaximum.Somepatientswillhavesurgicalconsiderationsmandatingmoreurgentintervention.

Actions10

Hospitals should provide adequate emergency theatre access free from predictable obstruction orrestrictioncausedbyover-runningelectiveworkormanpowershortage.Thisisnotinfrequentlyseenatlateafternoon/earlyevening.

Hospitals should also ensure that there are clear arrangements in place for interventional radiology,especiallyoutofhours.Formany,thiswillbeviaanetworkofcoveracrossmultiplehospitals.

Movingapatienttocriticalcaredoesnottreatthesourceofsepsisandthefocusmustremainontimelydefinitivecare.Thisneedstobebalancedwithappropriatebutrapidpre-operativeresuscitation.Ifthepatientbecomeshypotensive,failstorespondtoresuscitationorotherwisedeterioratesthenimmediatetreatmentisnecessaryasina).

RecentCollegestandards,fromamulti-professionalgroupwithlayinput,definetheneedforconsultantavailabilityforemergencycare24-hoursaday,7-daysaweek,locationofat-riskemergenciesinasinglesite, genuine availability of emergency theatre and defined rotas for interventional radiology.33 Theseprinciplesarefundamentaltomodern,safeandreliableunscheduledcareandarestronglysupported.Manyhospitalshavemovedsubstantiallyinthisdirectionbutremainingonesshouldfollowandadjustjobplansaccordingly.32

Summary timelines

Surgical Response (level 2 / secondary)

EWS Gradeofstaff Time

Low Foundation / ST 1–2 1 hour

Medium MRCS within 30 mins

High MRCS and critical care / anaesthetic staff immediate

Ifthereisanincompleteresponsetoresuscitationwithinonehour,particularlyifthepatientremainshypotensiveorwithorgandysfunction,then:inform/involveseniorstaffandmovetocriticalcareareaoroperatingroomasappropriate.

IfMRCSisnotavailablebecauseheorsheisoperating,theICUoranaestheticspecialregistrar(SpR)shouldbecalleddirectlytothepatientaccordingtoa localtieredescalationpolicyand,typically,theconsultantsurgeonshouldbeinvolved.Ateachstage,allmembersofthemultidiscplinaryteamshouldbeencouragedtoinvolvemoreseniorstaffifthereisadelayedorincompleteresponsebythemedicalteamorthepatient.

Intervention to control source of sepsis

Severityofsepsis Timetointervention(maximum)

Septic shock Immediate

Severe sepsis / organ dysfunction as soon as possible and within 6 hours of onset

Sepsis as soon as possible and within 18 hours (7am–10pm start)

Infected source, no SIRS as soon as possible (7am–10pm start)

Figure1,below,combinesinitialgenericassessmenttakenfromNICECG50(upperpartoffigure)withasurgeryspecificpathway(lowerpartoffigure).Initialroutinemonitoringforthisgroupofpatientswillbehourly.

Actions 11

Assessing and identifying risk

Why it should be doneStudiesfromtheUKsuggest thatareadily identifiedhigherrisksub-groupaccountsforover80%ofpost-operativedeathsbutlessthan15%ofin-patientprocedures.4,7Advancedage,co-morbiddisease,majorandurgentsurgery,primarydiagnosisandacutephysiologicaldeteriorationarethekeyfactorsassociated with increased risk. Routine identification of patients most at risk would permit care andresourcestobebetterdirected.

How should risk be assessed?Presently,clinicians’assessmentofperi-operativeriskmaybeomitted, inaccurateormaynot lead toaneffectivechange inclinicalmanagement.Objectiveassessmentof riskmustbecomeroutine.Mostimportantly,identificationofhigherriskneedstotriggerjointadvanceplanningspecifictothatcase.

1) Werecommendthatobjectiveriskassessmentbecomeamandatorypartofthepre-operativechecklisttobediscussedbetweensurgeonandanaesthetistforallpatients.ThismustbemoredetailedthansimplynotingtheAmericanSocietyofAnesthesiologists(ASA)score.

2) Forelectivepatients,riskshouldbeassessedatpre-operativeassessmentandthoseathighriskshouldideallyseetheanaesthetistwhowillanaesthetisethem.Beingseenbyacolleaguewithappropriatecompetenciesfromaspecialistteamthatadoptscommonacceptedprotocolswouldbeacceptable.Arangeofriskscoresandtestsofexercisecapacityareavailableandshouldbeadopted.Closeworkingarrangements,advancecommunicationandsub-specialisationareadvocatedforhigherriskcasesthatshouldbeoptimisedaccordingtocurrentlocalandnationalguidelinespriortosurgery.Thereliabilityofthisprocessshouldbeaudited.

Patientswithapredictedmortality≥5%shouldbemanagedas‘highrisk’.Mostmajorgeneralsurgicalemergencylaparotomyproceduresfallinthiscategory,togetherwithcomplexelectiveGIandvascularprocedures,incomorbidpatients.

Thereareanumberofmethodswithwhichtopredicthospitalmortalityrisk.Somemethodsaredescribedbelow.Eachmethodhasstrengthsandweaknessessoforpatientstobesafelydefinedaslowrisktheyshouldnotobviouslyenterthehighriskgroupbyanymethod.

Notethattheaveragemortalityofadefinedgroupcanbeexpectedtobeapproximately2–4timesthethresholdanditisanticipatedthatteamsmaywishtosetthethresholdlowerintime.a) P-POSSUM,freelyavailableontheinternet,34ispossiblythesimplestandbestvalidatedmethod

andagoodplacetostart.Itsscoringincludesoperativedetailssothesehavetobeestimatedforpre-operativeuseandcanbeupdatedattheendofsurgery.

b) Alternatively,thecriteriabelowaretakenfromanexpertclinicaltrialinthispopulationandalsofitwithexpertopinion,Box2.Thesewilldefineagroupwithapredictedmortality≥5%andanoverallmortalityof10–12%.

c) AthirdwayofidentifyingthehigherrisksurgicalpatientisbyreferencetoHESproceduregroups.Whilethisapproachshowsconsiderableconcordancewiththemethodsaboveforpopulationsofpatients,itsfailuretoincludeacuteillnessorchronicco-morbiddiseasemeansitshouldbeusedalongsideaconsiderationofpatientphysiologyforindividualpatientassessment.Withthatcaveat,HESdataanalysisshowsthatthefollowingemergencycaseshaveanaveragemortalityof≥10%intheUK;laparotomyforperitonitis,resectionofcolonorrectum,therapeutic

Actions12

operationsonsmallbowel,therapeuticupperGIendoscopy,pepticulcersurgery,gastrectomyandsplenectomy.Insuchcasespatientsarelikelytobe‘higherrisk’unlesstheyareunusuallyfit.

d) Otherphysiologicalderangements,diseasestatesandproceduresmayalsodefinehighandmediumriskpatients,includingurgentsurgeryinpatientwithASA>3plusatleastoneacuteorgandysfunction/failure,ASA4or5,dialysis-dependentpatientsorpatientswithelevatedlactate.

The identification of higher risk status should lead to certain levels of care. Staff involved should besufficient in seniority and number to permit care to proceed expeditiously. It is recognised that,whilesomemoreseniortraineesmayhavemanyoftheskillsnecessary,thisislesssothanpreviously.Furthermore, the presence of a consultant can remove organisational barriers and assist in promptdecisionmaking.Forthesurgicalteam,thispracticalassistanceisessentialgivenmoderndayoncallarrangements.Anaestheticjuniorsmaysimilarlylackexperienceandhavetomanagecallsaboutotherpatientssimultaneously,causingfurtherdelays.

Consequently,eachhigherriskcase(predictedmortality≥5%)shouldhavetheactiveinputofconsultantsurgeonandconsultantanaesthetist.Surgicalprocedureswithapredictedmortalityof≥10%shouldbeconductedunderthedirectsupervisionofaconsultantsurgeonandaconsultantanaesthetistunlesstheresponsibleconsultantshaveactivelysatisfiedthemselvesthatjuniorstaffhaveadequateexperienceandmanpowerandareadequatelyfreeofcompetingresponsibilities.

Occasionalcasesmaybeappropriatelymanagedbyunsupervisedjuniorsbutthisshouldbeanactiveandauditedseniordecision.Callingseniorstaffatalaterstageonceproblemshavedevelopedwillusuallybeassociatedwithworseoutcomesandthiseventshouldalsobeaudited.Itisalsorecognisedthatthesystemic impact of sepsis on patients undergoing major procedures is not always identified initiallyandseniorsshouldbecautiousaboutleavingbeforethecaseisfinished.Itisveryimportantthatrotaspermittraineestoworkwithconsultantswhoaredeliveringcare,inordertoensuretrainingoffutureconsultants.

Formalidentificationofriskcanhelpidentifywhensurgeryforfrailandcriticallyillpatientsmaybefutileandwhereendoflifecaremaybemoreappropriate.Thewishesofpatientandfamilyandseniorinputareimportant.Asthepopulationages,theissueoffutilecarewillincrease.Betterworkingrelationshipswithservicesprovidingcarefortheelderlyandprimarycare,althoughcurrentlydifficultinemergencysettings,canonlybeanadvantage.14

Box 2. Patients undergoing major gastro-intestinal or vascular surgery who are either:

1. Aged>50years; andundergoingurgent,emergencyorre-dosurgery orhaveacuteorchronicrenalimpairment(serumcreatinine>130µmol/l) orhavediabetesmellitus(evenifonlydietcontrolled) orhaveorarestronglysuspectedclinicallytohaveanysignificantriskfactorforcardiacor respiratorydisease.

2. Aged>65years.

3. Haveshockofanycause,anyagegroup.

Actions 13

Peri-operative fluid and vasoactive drug therapies

Fluidresuscitationoftheemergencypatientisessential.26Itshouldoccurinalocationappropriatetothedegreeofillnessandinterventionsnecessary.Itmayoftenrequireseniorinput.Theimportanceofurgentsourcecontrolhasbeenindicatedaboveandlocationandprotocolsshouldtakeaccountofthataswell,especiallyinthesickestpatientswheredeferringsourcecontrolforprolongedfluidresuscitationcouldbedetrimental.

The optimal approach to intra-operative fluid and vasoactive drug therapies remains uncertain butevidence from a number of small trials suggests that the use of cardiac output monitoring, typicallyvia oesophageal Doppler, to guide fluid therapy during major gastro-intestinal surgery may reducecomplicationratesanddurationofhospitalstay.Forthisreason,thetechnologyhasbeenrecommendedin a recent guideline issued by the NICE as being clinically and financially effective when invasivemonitoring is required.35 Several larger trialsof this treatmentare under way and will inform futurepracticerecommendations.

Bothexcessiveandinadequateintravenousfluidadministeredintheperi-operativeandpost-operativeperiod can be harmful, particularly in the elderly.14,36 A fluid plan should be agreed between theanaestheticteamandseniorsurgeon,bearinginmindcurrentevidenceandtherisksofbothexcessiveandinadequatefluidtherapy.Thisshouldincludebloodlossandreplacement.

Peri-operative fluid and vasactive drug therapies14

End of surgery bundle

Thepost-operativepathwaymustbedeterminedbytheriskofdeathandcomplicationsandreceivingareasmustpossessthecompetenciestodealwithsurgicalpatients.

Akeydecisionpointoccurs towards the endofhigher risk surgery,muchofwhich is emergency innatureandthus less thanperfectlyplanned.Atthispoint,decisionsneedtobemadeconcerningthedispositionofthepatientfollowingsurgery.Underestimatingthedegreeofexistingphysiologicalupsetorofthelikelyevolutionoforgandysfunctioncanbecatastrophic:lateadmissiontocriticalcarecarriesamuchhighermortality thanaplannedadmission from theoperating room.Staffmaybe relativelyinexperienced, tired or dealing with unfamiliar circumstances and it seems logical to conduct astructuredassessmentofrisktowardstheendofsurgery.OnemethodwouldbetousetheApgarscoreforsurgery.37Analternativewouldbetousethebundledescribedbelow38withinthelast30minutesofsurgeryinallcasesidentifiedbythepre-operativeassessmentashavingmortalityrisk≥5%andinthosewhodeteriorateduringsurgery.

1) Riskscorepatient(≥5%mortalitydefineshighrisk)2) Checkarterialbloodgasestoassesslactate,acid-basestatusandtheratioofarterialoxygen

concentrationtothefractionofinspiredoxygen(P:Fratio)3) Summarisefluidsgivenanddraftongoingfluidrequirements.4) Reversemusclerelaxant;useofnervestimulatorismandatory.5) Checkanddocumenttemperature,planfurthercorrectionasnecessary.

Basedonthebundlecriteria,thesurgeonandanaesthetistshoulddecidejointlythepreferreddestinationof the patient after surgery. All patients with predicted mortality ≥10% should be admitted to theappropriate(level2/3)criticalcareunitwithsurgicalcompetencies.Thisdecisionwillbeinfluencedbyadverseeventsduringsurgeryorahighlikelihoodofdeteriorationintheshorttomediumterm.Thebundleshouldbeusedtosupplementratherthanreplaceexistingindicatorsoftheneedforcriticalcare.DetailsofthecriteriaaregiveninAppendix3.

Theuseof‘bundles’hasbeenshowntoincreasethereliabilityofkeystepsofcare.39Theconceptofusingabundleattheendofhighrisksurgeryshouldbetestedinindividualinstitutions,ifnecessaryadjustedforcontext,andiffoundtoincreasethereliabilityofkeystepdelivery,incorporatedintoroutineanaestheticpaperwork.Jointearlydiscussionwiththecriticalcareteamisfundamental.

End of surgery bundle 15

Postoperative care

Accesstocriticalcareisanessentialaspectofadequateperi-operativecareforthehigh-riskgroupinordertoidentifycomplicationsearlyandminimisetheirimpact.Allpatientsshouldbemanagedaftersurgeryinalocationdeterminedbyriskandstaffcompetence.Hospitalsshouldplantheircriticalcareresourcetomatchneedinordertoavoidshortagesanddefinecriticalcareareasaccordingly.Patientsshouldmoveupanddownthroughaspectrumoflevelsofcare.Levelsofcarearedescribed40,41asshowninTable1.

Table 1. Levels of care

Level Description Patientcharacteristics

0 Ward Basic observations

1 Enhanced ward At risk of deterioration, more frequent observations, basic resuscitation

2 High dependency Needs detailed observation, intervention or single organ support

3 Intensive care Multiple organ support, complexity

Allpatientswithapredictedmortalityof≥10%shouldbeadmittedtoalevel2or3criticalcareareaaftersurgeryandallpatientsshouldhaveanupdatedmanagementplanwhichincorporateshaemodynamicandbloodgasparameters,on-goingantibiotics,nutritionandthromboembolicprophylaxis.

Importantly,trustsmaywishtoexaminetheirexistingprovisionparticularlyaroundlevels1and2.Whencomparedtolevel0care,theimpactoflevel1or2careislikelytobemuchgreaterintheunscheduledsurgicalpopulationthantheelectivepopulationduetothedynamicnatureoftheacuteillnessanditsinfluenceonorganfunction.Recognitionofanydeteriorationinorganfunctionandtimelyinterventionis essential to optimise patient benefit. Provision of this level of monitoring is frequently difficult todeliverinastandardwardenvironmentwithastaffingratiowhichisfrequently<0.20nurse-to-patient.42Defining and auditing pathways for such patients affords organisations an opportunity to addresscompetenciesofstaffandstaffingratiostodeliverareliabletieredpathwayofcare.

Considerablegainsinoutcomearelikelywithimprovedlevel1and2careandsomeorganisationshavedeveloped bespoke solutions such as the development of post-anaesthesia care unit (PACUs) or co-locatingmediumriskpatientsinpre-definedclinicalareas.

Structured care on the PACU

ApatientinappropriateforthewardcouldbeadmittedtoPACUforcontinuedmonitoring.Formaljointassessmentshouldoccurafter fourhours. If thepatient isalertandhasanormal temperature,meanarterialpressure,pH,lactateandgasexchange,andthepreviousthreeconsecutivehourlyurinevolumeswereall>0.5ml/kg, transfer to theward is acceptableunless there is specificclinical concern to thecontrary.

IftheabovecriteriaarenotmetafterfourhoursinPACU,careshouldbeformallytakenoverbythecriticalcareteamwhowillcontinuetocareforthepatientinPACUuntiltransfertoacriticalcarebedcanbearrangedorthepatientisconsideredreadyfortransfertothewardbyaseniorcriticalcarespecialist.

Todothis,hospitalswillneedtoensurethatthereisa24/7PACUserviceandthataconsultantfromanaesthesia/criticalcare/surgeryisidentifiedtotakeresponsibilityforthisprovisionandtoworkwiththePACUmanagertoensuredeliveryofappropriatecare.

Postoperative care16

OngoingauditwillallowassessmentofimpactofPACUonelectiveandemergencysurgery.HospitalswillwishtomakethedifferencebetweenPACUandtheatrerecoveryexplicitasinadequatestaffingmayresultinlossofabilitytoundertakefurtheremergencysurgeryifapatientis‘blocking’recovery.Theseeventsshouldbeauditedandclassifiedasanadverseincident.

Co-location of medium risk patients

Existingsystemsofcriticalcarecanleavealargestepbetweenhighdependencyunit(HDU)andwardcare.Incost-limitedtimes,theco-locationofmediumriskpatientsinspecialwardsorward-areas(level1)couldbeexpectedtoleadtoimmediateimprovementinstandardsevenifstaffedneargeneralsurgicalwardlevelsandwithoutsignificantinvestmentinadditionalmonitoring.

Immediatebenefitswouldbepromoted,providingtrusts:» establishlocalprotocolsdrawnupjointlybetweensurgicalandcriticalcaredepartmentstodefine

parametersofcareandtoensureseamlesstransitionofpatientsbetweenunits» establishco-operativeeducationprogrammeswithcriticalcarefornursingandmedicalstaff» establishimproveddailycommunicationbetweenunits» recommendgeographicalproximitytocriticalcarewherepossible» nameacriticalcareconsultantwithresponsibilityforbasiceducationandsupportfornursingand

juniormedicalstaff.

Postoperative care 17

Audit and outcomes

Therelativepaucityofdatainthisfieldneedstobeaddressedurgently,preferablyonanationalbasis.Giventhemortalityandmorbidityassociatedwiththisgroup,comparativerisk-adjustedoutcomesshouldbemonitoredforeachhospitalandwouldbecompletelyinlinewithnationalpolicy.Atthemoment,HESdatamaybethebestavailable.Theadoptionofadefinedbasketofhealthcareresourcegroup(HRG)codeswouldfacilitatethis.Internationalcomparisonswouldprovidethegreatestre-assurancethatcareforthisgroupisoptimal.

Localauditofoutcomesisanimportantdriverforchange.Theprocessesadvocatedinthisreportshouldbeauditedineachhospitalandkeyindicatorsinclude:» outcomes(death,lengthofstay)fromhigherriskgeneralsurgery» frequencyofobservationsinhigherriskgroup» accuracyofriskestimatepriortosurgery» accuracyofriskestimateatendofsurgery» timetoCTfromemergencyadmissionordeterioration» timefromdeteriorationtooperationforhigherriskgroup» compliancewiththestandardforintra-operativesurgicalteamseniority» compliancewithpost-surgerypathwayforhigherriskpatients.» unplannedsurgicalreadmissionstocriticalcarewithin48hoursofdischargebacktotheward.

Emergencylaparotomyisaclearlydefinedpointinthepathwayofasignificantproportionofthesepatientsandinthisgroup,manyofthefactorsdiscussedinthisreportcometogether.Thelaparotomynetworkaudit (http://www.networks.nhs.uk/nhs-networks/emergency-laparotomy-network) is beginning tolookatthesepatientsonavoluntarybasisandthisstudyshouldbesupportedandexpanded.

Audit and outcomes18

Conclusions

Peri-operative care of higher risk general surgical patients in the UK appears to have significantdeficiencies.Outcomesarevariable,appearworsethanothercountriesandgeneratealargehealthcostthroughprolongedhospitalstayanduseofintensivecare.

Whilethereareseveralspecificinitiatives(eghospital-acquiredthrombosis)andpatientpathwaysforsingleoperations(egaorticaneurysm),thereisalackofoverallrecognitionandstrategyforthecareofallpatientsathigherriskofdeathandcomplications.

Thishigherriskgroupcomprises12–15%ofcasesbutcontributes80%ormoreofpostoperativedeathsandcomplications.Thisgroupcanbeidentifiedatanearlypointanddifferentialmanagementpathwaysapplied.Identificationoftheseatriskpatientsshouldbecomeaformalpartofpatientassessmentandincludedinthepre-operativechecklist.

Standardsofcarearedescribedinthisdocument.Trustsshoulddeveloppathwaysinordertoachievethese.Theclinicalpathwayshouldidentifyriskofdeathforanindividualpatient,matchtheneedsofthepatient,basedonriskofdeathwithtimingandchoiceofdiagnostictests,seniorityofclinicianindecisionmaking,timingofsurgeryandpost-operativelocationofcare.

Inparticular,attentioncouldbebetter focussedonelectivecaseswhodevelopcomplicationsandonmajoremergencycases.Adefinedandescalatingpathwayofmanagement,whichcomplementsexistingguidanceforacutecare,shouldbeadopted.Thedescribedpathwaysmatchurgencytopatientneedandincludeguidanceonseniorinvolvementandtimetotreatment.

Anestimatedmortalityof≥5%definesahighriskpatient.

Highriskproceduresshouldbemanagedbyconsultantstaff.Activeinputwillalwaysberequiredandconsultantsshouldusuallybepresentforproceduresandanaesthesiawhentheriskofmortalityexceeds10%.

Thereshouldbeabriefbutstructuredreviewofriskstowardstheendofhigherriskoperations,conductedjointlybetweensurgeonandanaesthetist.Thisendofsurgerybundleshouldguidethelocationofpost-operativecare.

Higherriskpatientsshouldbemanagedaftersurgeryinalocationcapableofmeetingtheirneedforhigherlevelsofcare.Trustsshouldlookcriticallyattheirprovisionofenhancedlevelsofcareasinvestmentinbetterperioperativecarewouldrealisebenefitsforbothcostandoutcomes.

Theprincipallifethreateningcomplicationisthedevelopmentofseveresepsis.Patientsfromthisgroupaccount for the greatest use of ICU beds. Improved assessment and treatment would likely improveoutcomesandreduceICUutilisation.

Outcomesfromemergencysurgeryaredifficulttocompareduetotherangeofdiagnosesandoperations.Anationalauditofhigherriskemergencysurgeryisessential.AbasketofHEScodesisproposedandshouldbeagreedforongoingcomparison.

Conclusions 19

Figure 1. Care pathway

MRCStoattendpatientandtocoordinateresponse.MRCS will immediately leave less urgent tasks such as clinics and ward rounds and will delegate to an appropriately competent colleague if currently operating or attending another medium-high score case.

SURGICALImmediate life, limb or organ saving surgery is indicated.Resuscitation is

simultaneous with

intervention. Example;

the exsanguinating

patient.

MRCS to liaise with

consultant surgeon,

anaesthetist and theatre

staff.

The patient should be

transferred to theatre

within minutes of the

decision to operate.

The patient is septicThe need for source control must be established rapidly. Urgency of surgery

depends on severity of sepsis.

The patient has sepsisbut no organ impairment or low score risk. Establish

source control urgently and always within 18 hours. Patient should be

monitored hourly and reassessed by MRCS every 6 hours to check for

progression to severe sepsis/septic shock.

The patient has severe sepsis or medium-high score risk without

hypotension. Establish source control as soon as possible and within 6 hours

maximum. Reassess hourly for progression to septic shock and provide

appropriate interim critical care.

The patient has septic shock. The patient’s chance of survival progressively

deteriorates with increasing delay to source control. Establish source control

as soon as possible. Transfer to theatre must not be delayed for resuscitation

which should be continued in the anaesthetic room.

The patient is NOT septic and does not require immediate interventionOrganise initial treatment

and investigations, liaise

with consultant surgeon

and plan definitive

treatment.

MEDICALContinue to follow NICE CG50

Figure 1. Care pathway20

Appendix 1: Early warning score (EWS)

Thisisascoringsystemusedtotrackabnormalphysiologyandtriggerclinicalresponse.Thescoreisbasedonroutinelyrecordedphysiologicalobservationssuchasbloodpressureandheartrate.Eachobservationisgivenascoreofzeroifitisnormal,increasingto(typically)threeastheobservationdeviatesfurtherfromthenormalrange.ThesumofallparameterscoresgivesatotalEWS.Thereiscurrentlynonationalsysteminuse.Differenthospitalsusescoringsystemsthatdifferinthemethodologyforgeneratingthefinal EWS and in the response. Until a national scoring system (expected to be available in autumn2011)isestablished(andaudited)theonlygenerallyapplicableguidancecomesfromNICECG50whichstipulatesthathospitalsshouldestablishagradedresponsesystemaccordingtothefollowingsystem:

Low-score group: increasefrequencyofobservationsandinformnurseincharge.

Medium-score group: urgentcalltoteamwithprimarymedicalresponsibilityandsimultaneouscalltopersonnelwithcorecompetenciesforacuteillness.

High-score group:emergencycalltoteamwithcriticalcarecompetenciesanddiagnosticskills.

SepticShockisdefinedasseveresepsiscomplicatedbypersistenthypotension(systoliclessthan90mmHgor>40%decreasefrombaseline)thatisnotreversedbyfluidresuscitation.Anadequatevolumeoffluidisconsideredtobe20ml/kgofcrystalloidoranequivalentvolumeofcolloid.Inthisdocumenthypotensioninthecontextofseveresepsisistakentobepersistenthypotensionthatisnotfluidresponsive.

Appendix 1: Early warning score (EWS) 21

Appendix 2: End of surgery bundle

1) ThePOSSUMscoreisthemostvalidatedriskpredictionmethodforgeneralandvascularpatientsthattakesintoaccountpre-operativeandperi-operativefactors.P-POSSUMmaybeusedforallpatients.43Apredictedmortalityrisk≥10%indicatesneedforcriticalcareadmission,exceptforpatientsonend-of-lifepathwayswithappropriatepalliativecarefacilitiesavailableatwardlevel.

2) Hyperlactataemia(>4mmol/l)andsignificantmetabolicacidosisindicateunresolvedphysiologicalimpairmentthatrequiresongoinginvasivemonitoring+/-physiologicalsupport.26Serumlactatelevelsmayalsobeusedtoguidefluidtherapyandlevels>2mmol/lindicatetheneedforclosermonitoring.44P:Fratio<40kPaisconsistentwithanacutelunginjury.Aseniorcriticalcarespecialistshouldbeinvolvedinthedecisiontoextubate.AP:Fratio<26kPaisconsistentwithadiagnosisofacuterespiratorydistresssyndrome(ARDS):thepatientshouldbetransferredtoICUintubated.

3) Bothexcessiveandinadequateintravenousfluidadministeredintheperi-operativeandpost-operativeperiodcanbeharmfulparticularlyintheelderly.14Afluidplanshouldbeagreedbetweentheanaestheticteamandseniorsurgeon,bearinginmindcurrentevidenceandtherisksofbothexcessiveandinadequatefluidtherapy.36Thisshouldincludebloodlossandreplacement.

4) Partialreversalofmusclerelaxationiscommonandpoorlyrecognised.Itisariskfactorforpost-operativerespiratoryfailureandaspiration.Nervestimulationandreversalismandatoryifaneuromuscularblockerhasbeengivenregardlessoftimeinterval.Atrain-of-four(TOF)ratioof0.9isrequiredforairwayprotection.UnfortunatelyTOFratioisdifficulttoassessaccuratelybyobservationalone.45Tobeconfidantofairwayprotection,neostigmineshouldnotbegiveniftheTOFcountislessthantwoandatleastnineminutesshouldelapseafterneostigminebolusbeforeextubationisattempted.

5) Hypothermia(coretemperature<36°C)increasestheincidenceofpost-operativemyocardialevents46andwoundinfections.Drugmetabolismisreducedsuchthatdurationofneuromuscularblockerscanbedoubled47andneostigminecantake20%longertotakeeffect.48NICEclinicalguidance(Management of Inadvertent Perioperative Hypothermia,2008)shouldbefollowed.49

Appendix 2: End of surgery bundle22

Appendix 3: Unscheduled adult general surgical pathway

Thispathwayhasfouridentifiablecomponents:ClinicalAssessment,Diagnostics,Intra-Operative,andPost-Operativephases.Itwasdevelopedbyclinicalstafffromsurgery,anaesthesia,intensivecaremedicine,radiologyandemergencymedicineinCentralManchesterUniversityHospitalsNHSFoundationTrust.Thepathwaywillassistcolleaguesinmatchinganindividualpatient’sriskofdeathtoseniorityofstaffindecisionmakingandidentifyingthetimingofkeyinterventions.Theseincludethetimingandchoiceofdiagnostictestsandlocationofpost-operativecare.Thepathwaydescribesmeasurablestandardsbasedonthereport.

Clinical assessment

DiagnosticsIntra-operative phase

Post-operative care

FEAT

UR

ES

Decisionbasedon:clinicalhistory,clinicalexamination,bedsideobservations,EWSandlaboratorytests.

Laboratory:assessmentoforganfunction;microbiologyassessment.

Radiology:choicedeterminedbyclinicalexaminationandhistory.

Minimisesecondaryrenalmorbidity.

Assessmentofriskassociatedwithanaesthesiaandsurgerycalculatedanddocumentedinnotes.

ThesurgicalriskwillbecalculatedusingP-POSSUM.

TheriskassociatedwithanaesthesiawillbeundertakenusingtheASAgrade.

Antibioticswithin30minspriortoskinincision.

Optimisationofperi-operativefluidadministration,cardiovascularandrespiratoryfunction.

Monitoringofotherorganfunction

Patientswillbelocatedinaclinicalareadependentonendofsurgerybundleassessment.

Principlesofcare:»Post-operativeplan

determinedbydiagnosis/surgery/clinicalcondition.

»Earlydetectionofnewonsetacuteorgandysfunction.

»Mobilisationattheearliestopportunity.

DE

CIS

ION

MA

KIN

G

MRCSandseniorhelpasindicatedbycondition.

MRCS. MRCSandFRCAnaes. MRCSforlowandmediumriskpopulations.

Appendix 3: Unscheduled adult general surgical pathway 23

Clinical assessment

DiagnosticsIntraoperative phase

Postoperative care

INTE

RVE

NTI

ON

S

MonitoringEWSplanset.Minimumof4hrlyobservations.

GradedresponsebasedonEWSandclinicalprogress.

Diagnosticplanidentified.

Seniorreviewwithin12hrs(ConsultantorMRCStraineeshouldnotbemovedfromESUornorshouldtheybehandedofftoanotherteamuntilreviewhasoccurred).

lfreferredtoanothersurgicalteamseniorreviewwithin12hrs.

Organdysfunctionquantified.

AntibioticsasperTrustSurvivingSepsisguidelines.

USS

CT;selectionofcontrastdeterminedbyrenalfunction.

CTwithangiography.

Discussionaboutneedforinterventional/otherproceduresbeforeleavingtheradiologydept.

lntra-operative:» Invasivemonitoringto

optimiseintravascularfluidtherapyandorganperfusion.

»Measurementofarterialbloodgasesandlactate.

»Minimiseriskofsecondaryorgandysfunctionegatrialfibrillation,basalatelectasis,renaldysfunction.

EndofSurgery:»Assessmentof

postsurgeryorgansupportneeds,basedonoperativefindings,clinicalstateandriskoffurtherdeterioration.

»DevelopmentofBundletoidentifylow,mediumandHighRiskGroupsanddeterminepostsurgerypathways

Maintainminimumof1hrlyobservationsfollowingsurgeryuntilseniorreview.

Antibioticregimedependentonsurgicaldiagnosis.

ChestphysiotherapyandMobilisationregime.

Nutritionalregime.

DVTprophylaxis.

Useofcontinuousfluidbalancemonitoring.

DailybiochemistryandHaematologyuntilsteppeddowninfrequencybyseniorreview.

Post-operativepainreliefregimeaccordingtoprotocolisedcare.


Clinical assessment


Postoperative care

HIG

HR

ISK

CR

ITE

RIA

Patientswithapredictedmortality>10%(usingP-POSSUMorotherscoringsystem).

2SIRScriteria+lacuteorgandysfunction.

Age>65.

Dialysisdependentpatients.

ASA>3+1organdysfunctionASA4&5.

Ptientswhoareimmunosuppressede.g.transplantpatients,IVDA.

IDDMpatients.

PatientsonlongtermsteroidsorBetablockade.

Evidenceofluminalperforation.

Suspectedischaemia/infarction/intra-abdominalbleeding.

Pre-Surgery:»ASA3+atleast

1acuteorgandysfunction/failure.

»ASA4or5.»Dialysisdependent

patients.»Patientswithelevated

lactate>4mmol/L.

EndofSurgery:»ElevatedLactate

>4mmol/L.»PatientswithP/F

ratio<40kPa.»Patientsatriskof

intra-abdominalhypertensionandabdominalcompartmentsyndrome.

»Patientswithmassivetransfusion:riskofTRALI.

»Hypothermia(coretemp<36°Catendofprocedure).

Patientswithincriticalcare.

Patientswithnewonsetorgandysfunction/failureadmissiontocriticalcarebasedoncurrentEWSprotocol.

DE

CIS

ION

MA

kIN

GF

OR

HIG

HR

ISK

GR

OU

P

Consultant-ledprocess–identifiedandcommunicatedtogeneralconsultantoncallwithinhour

Consultant-leveldecisionmaking:surgeryandradiology.

Consultantanaesthetist,surgeonandcriticalcarediscussion.

Consultantsurgeonandconsultantincriticalcare.


Clinical assessment


Postoperative care

INTE

RVE

NTI

ON

S

Arterialbloodgases.

Expediteddiagnosticinvestigations(CTwithin6hrs).

Goaldirectedresuscitation.

Communicationofresultsofinvestigationstoconsultantsurgeonandgeneralanaestheticteam(FRCAnaes)includingemergencytheatrewithin1hour.

Definitivesurgerywithin2hrstooperate.

Criticalcareneedsdiscussedwithanaesthesiaandcriticalcare.

Avoidfurtherorgandysfunctionbyadoptionofsupportingclinicalinitiatives,egAcuteKidneyInjuryprotocol.

lntra-operativeperiod:» Targetedoptimisation

ofcardiovascularandrespiratoryfunctionusinginvasivetechniques.

»Anaesthesiatoexpand.

EndofSurgery:»Consultantsurgeon

andanaesthetisttoassessriskoffurtherdeteriorationandultimatemortality:usingbundle,clinicalfindings(ischaemia,evidenceofperforation,ongoingbleeding,newonsetrhythm,needforvasoactivedrugs,evidenceofALl,elevatedlactate,renaldysfunction).

»Highriskgroupwillrequirelevel2or3criticalcarepost-surgeryandshouldbeadmittedtocriticalcareattheendofsurgery.

»Patientsrequiringlevel1criticalcareshouldreturntoawardareawithincreasedmonitoringfrequency(initialmonitoringevery30minsfor2hrsfollowedbyhourlyuntilnextseniorreview(MRCS)).

»Consultantincriticalcareinvolvedinpost-surgerypathwayforlevel2and3patients.

Timetoadmissiontocriticalcarewithin4hrsofdecisiontoadmittocriticalcare.


Clinical assessment


Postoperative care

CLI

NIC

AL

STA

ND

AR

DS

ConsultantSurgeoninvolvedindecisionmakingforhighriskgroupwithin1hrofidentificationashighrisk.

DefinitivediagnosticCTasearlyaspossiblebutshouldbewithin4hrsofidentificationashighrisk.

Patientsadmittedwithsepticshockshouldhaveanoperationtotreatthesourceofsepsiswithin3hrsofadmission.

Patientswithanintraabdominalpathologyandorgandysfunctionshouldbeoperatedonwithin6hrsofonsetoforgandysfunction.

Consultantreviewwithin12hrsofemergencyadmissionforallotherpatients.

CTfornon-highriskgroupwithin24hrsofdecisiontoundertakeaCT.

Consultantdecisionmakingforhighriskgroup.

Timetooperatewithin2hrsofdecisiontooperateforhighriskgroup.

Fornon-high-riskgroupdefinitiveoperationwithinsameworkingdayfromtimeofdecisiontooperate.

Useofendofsurgerybundle.

Decisionmakingteamforhighriskpatientsinvolvesconsultantsurgeon,intensivistandanaesthetist.

Allhighriskpatientsadmittedtocriticalcarewithin4hrsofdecisiontoadmit.

Nounplannedreadmissionstocriticalcarewithin48hrsofdischargebacktotheward.

AU

DIT

CTwithin4hrsforhighriskGroup.

Definitivedecisionwithin1hourofCT.

Timetooperateforbothhighandnon-high-riskgroups.

CompliancewithdocumentingtheriskofsurgeryandanaesthesiausingP-POSSUMandASAgrading.

Compliancewithendofsurgerybundle.

Unplannedsurgicalreadmissionstocriticalcarewithin48hrsofdischargebacktotheward.

Timeofadmissiontocriticalcareforhighriskgroup.


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heartsurgery.cqc.org.uk/Survival.aspx.4. JhanjiS,ThomasB,ElyAet al.Mortalityandutilisationofcriticalcareresourcesamongsthigh-

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