What’s the surgical mortality rate at your hospital? You probably don’t know what it is. And if you do know what it is you probably don’t know what it means. Is it good? Is it bad? It is extremely difficult to use surgical mortality rates across hospitals (or even within hospitals across time). That’s because we don’t have any universally accepted methods of risk-adjusting surgical patients. Some methods of risk adjustment have been developed for specific surgical procedures (eg. coronary artery bypass, percutaneous coronary interventions, etc.) but these obviously apply to small subsets of the entire surgical population.
But there has been a renewed interest in identifying and improving on mortality rates in high-risk patients. An article earlier this year (Moonesinghe 2011) focused on the epidemiology and outcomes of high-risk surgical patients discussed many of the risk assessment tools that have been used in determining surgical risk and outlined the many methodological issues that have hampered more widespread use. Another article in that same issue (Lobo 2011) found that multiple organ failure was the main cause of death in high-risk patients undergoing non-cardiac surgery and identified some of the factors associated with death.
In our June 2010 What’s New in the Patient Safety World colum “The Frailty Index and Surgical Outcomes” we noted a study (Makary et al 2010) demonstrating use of the frailty index greatly improved the ability to predict post-surgical outcomes (post-op complications, LOS, and discharge to an SNF or assisted living setting) much better than existing methods. And in our August 9, 2011 Patient Safety Tip of the Week “Frailty and the Surgical Patient” we noted two studies by Robinson and colleagues (Robinson 2009, Robinson 2011) looked at outcomes in (mostly male) patients age 65 and older who were undergoing major elective surgical procedures in the VA medical system and correlated them with measures of frailty, disability, and comorbidity. Using a group of markers that were easy to use in a surgeon’s office setting they were able to predict 6-month postoperative mortality and post-discharge institutionalization.
A recently released report from the Royal College of Surgeons of England (Royal College 2011) is a call for action to address high rates of mortality and morbidity in high-risk general surgery patients, especially patients undergoing emergency or unscheduled general surgery procedures. Cardiac surgery, which is closely measured and audited and highly protocolized, typically has mortality rates of 2-3% in England. Compare high-risk general surgery to that and you find much higher rates of both mortality and complications. They note that 15% of surgical cases account for 80% of the deaths they see annually. And the frequent complications lead to long lengths of stay and considerable costs to the healthcare system.
And they are quick to point out that the problem is not just with surgeons and operating rooms. Rather all levels of the perioperative experience contribute to the excess mortality and morbidity in the high-risk patient. That includes making sure there is appropriate access to the operating room, appropriate staffing, accessible radiology and interventional services and adequate critical care. Though this work comes out of the UK, where critical care beds are far fewer than in the US, the importance of getting the high-risk patient to the appropriate level of care is important.
The report has 9 main recommendations:
1. Formalize pathways for unscheduled adult general surgery
2. Prompt recognition of emergencies and complications is essential
3. Ensure OR access matches need
4. Estimate risk of each patient
5. Hi-risk (= 5%+ mortality) patients should have active involvement from multiple disciplines in their care pathways
6. If risk is >10% ensure senior staff involvement
7. Reassess risk near end of surgery using the “end of surgery bundle” or other tool
8. Consider critical care for high-risk patients
9. Audit nationally and locally
Postoperative complications, in fact, account for most of the morbidity and mortality in general surgery but they readily identify opportunities for improvement before, during and after surgery.
They focus, in particular, on rapid identification of complications so that rescue interventions can be performed on a timely basis. There should be a special focus on identifying sepsis and recognizing severe sepsis and septic shock. For severe sepsis they note two important steps. First consists of early resuscitative measures (lactate levels and blood cultures followed by broad-spectrum antibiotics within the first hour and optimal fluid resuscitation). The second critical step is dealing with the source of sepsis, which often means a surgical procedure or interventional radiology procedure is needed. Timing of the source control is crucial.
The British system often relies on the MEWS early warning system to help identify sepsis and other complications early. They provide algorithms for escalation of response to the patient with developing sepsis that includes getting the most experienced personnel involved, getting the patient to the appropriate level of care, expediting imaging or other necessary diagnostic studies, initiating the sepsis protocol and doing source control. They note that delay in source control more than 12 hours after onset of hypotension raises the mortality rate from 25% to 60% compared to patients with delays of less than 3 hours. For patients with full-blown sepsis (evidence of end-organ damage) surgery or radiologic drainage should be carried out within 6 hours of onset of deterioration.
Healthcare facilities must therefore be capable of adjusting elective surgical schedules, prioritizing these patients as critical, and ensuring access to OR’s that are appropriately staffed and equipped to facilitate source control.
Though they start the report focusing on the postoperative complications, they then go back and focus on the need to assess and identify the risk in all patients at several points in time. They make a case for objective assessment of risk and note several tools available to help assess that risk, such as the simple but validated P-POSSUM score or a scoring tool they developed in their report. Yet others use modifications of the ASA class or use data from the types of procedures being considered.
So the patient should have his risk identified prior to surgery. But they also recommend a second determination of risk should be undertaken near the end of the surgical procedure. The latter facilitates disposition on completion of the surgery and such decisions should be made jointly by the surgeon and anesthesiologist. They suggest use of the surgical Apgar score (Gawande 2007, Reynolds 2011) or the “end of surgey bundle” described in their report. Note that in addition to the more general risk assessment tools, some have developed risk prediction tools for specific procedures, such as one recently validated for emergency colon surgery in the very elderly (Kwok 2011). Those with predicted mortality risks equal to or above 10% should be admitted to high-capability post-anesthesia care units (PACU’s) or critical care units.
Like everything we do in quality improvement, measurement and audit are critical activities. They make a case for such auditing on a national level but also identify those outcomes and process parameters that should be audited and measured on a local level, including:
· Outcome such as death and LOS in the high-risk general surgery group
· Frequency of observations in the high-risk group
· Accuracy of the risk estimate prior to surgery
· Accuracy of the risk estimate at the end of surgery
· Time to CT scan from emergency admission or deterioration
· Time from deterioration to surgery/procedure for the high-risk group
· Compliance with involvement of senior staff intraoperatively
· Compliance with use of post-surgery pathways or protocols for high-risk patients
· Unplanned surgical readmissions to critical care within 48 hours of discharge back to ward
The report appendices have some good algorithms and care pathways, and information about the MEWS scoring and the ‘end of surgery bundle” plus a comprehensive bibliography.
Expect to see a lot more in the coming year about managing high-risk general surgery patients.
Moonesinghe SR, Mythen MG, Grocott MPW. Review Article: High-Risk Surgery: Epidemiology and Outcomes. Anesth Analg 2011; 112: 891-901
Suzana M. Lobo SM, Rezende E, Knibel MF, et al. Early Determinants of Death Due to Multiple Organ Failure After Noncardiac Surgery in High-Risk Patients. Anesth Analg 2011; 112: 877-883
The Royal College of Surgeons of England / Department of Health. The Higher Risk General Surgical Patient: Towards Improved Care for a Forgotten Group. 2011
Gawande AA, Kwaan MR, Regenbogen SE. An Apgar Score for Surgery. J Am Coll Surg 2007; 204: 201–208
Reynolds PQ, Sanders NW, Schildcrout JS, et al. Expansion of the Surgical Apgar Score across All Surgical Subspecialties as a Means to Predict Postoperative Mortality. Anesthesiology 2011; 114(6):1305-1312
Kwok AC, Lipsitz SR, Bader AM, Gawande AA. Are Targeted Preoperative Risk Prediction Tools More Powerful? A Test of Models for Emergency Colon Surgery in the Very Elderly. J Am Coll Surg 2011; 213(2): 220-225
Makary MA, Segeve DL, Pronovost PJ, et al. Frailty as a Predictor of Surgical Outcomes in Older Patients. Journal of the American College of Surgeons 2010;
Robinson TN, Eiseman B, Wallace JI, et al. Redefining Geriatric Preoperative Assessment Using Frailty, Disability and Co-Morbidity. Annals of Surgery 2009; 250(3): 449-455, September 2009
Robinson TN, Wallace JI, Wu DS, et al. Accumulated Frailty Characteristics Predict Postoperative Discharge Institutionalization in the Geriatric Patient. J Am Coll Surg 2011; 213(1): 37-42, July 2011