HDU and ITU provision continues to give cause for concern with evidence
of inadequate provision and premature discharge. There is a need for a national
evaluation of the current status of provision and a clear step by step policy
for improvement.SCOTTISH AUDIT OF SURGICAL MORTALITY
1996 Annual Report
CONCLUSIONS
HDU and ITU provision continues to give cause for concern with evidence
of inadequate provision and premature discharge. There is a need for a national
evaluation of the current status of provision and a clear step by step policy
for improvement.
There
are examples of patients undergoing gastrointestinal endoscopy where death follows
excessive sedation, lack of adequate monitoring during the procedure and failure
to recognise serious complications and to implement appropriate treatment. As
many endoscopic procedures are performed by physicians, there is concern that
our Audit may not reflect the total morbidity and mortality associated with these
procedures.
Serious
complications following operations, some considered minor, eg haemorrhage after
liver needle biopsy, peritonitis after PEG insertion, and some more major, eg
bile leak after laparoscopic cholecystectomy, often lead to mortality due to delay
in recognition and institution of appropriate treatment, even though clear signs
are present at an early stage.
The risk of surgery in unfit patients undergoing emergency operations of moderate
complexity may be underestimated by surgeons and anaesthetists in training. This
particularly applies to emergency surgery for obstructed abdominal herniae.
Documentation shows no signs of improvement although the need for progress is
urgent with reduced junior doctor hours of work and increased cross-cover. Assessors
suggest that inadequate documentation of events must contribute to delays and
poor management.
Failed
gastrointestinal anastomoses continue to lead to serious morbidity, mortality
and high costs. Scotland is in a unique position to investigate this problem more
fully both from a scientific and audit perspective.
Avoidable
deaths from DVT and pulmonary embolus still occur and SIGN guidelines, although
widely adopted, are not always implemented through local protocols.
There
are rapid advances being made in the management of vascular disease. There are
patient populations in Scotland who do not have ready access to a specialised
vascular service including 24 hour availability of diagnostic and interventional
radiology and endovascular surgical techniques.
RECOMMENDATIONS
All
Trusts in Scotland, where major surgical interventions are performed in unfit
patients, should establish that their provision of high dependency care is sufficient
to meet expected needs. It is clearly not only the responsibility
of surgeons and anaesthetists but also senior management to ensure adequate facilities.
It
is the responsibility of the endoscopist to ensure adherence to nationally agreed
guidelines of management (eg British Society of Gastroenterology). In unfit patients
there should be increased consultation with an anaesthetist whose presence may
be required to reduce the risk of over-sedation. Clear guidelines should also
be available to help identify and manage well known specific complications such
as oesophageal perforation and post-ERCP pancreatitis. There is a need for a multi-disciplinary
national audit of the morbidity/mortality of endoscopy.
In
the design of protocols for post-operative management, the symptoms and signs
of well-known serious complications should be clearly stated, structured documentation
should be designed to ensure that such complications have been excluded and a
plan of immediate investigation and management should be available should a complication
be suspected.
Surgeons and anaesthetists in training should discuss with their consultations
the resuscitation and management of all unfit patients undergoing emergency surgery
even when the operation is considered to be of only minor to moderate difficulty.
Following the successful publication of guidelines on the design of a hospital
discharge document by the combined Royal Colleges there is a clear need for the
development of a range of documents promoted by the Royal Colleges, supported
nationally and linked to IT developments which accurately reflect a patient’s
physical and mental status, diagnoses, major therapeutic interventions, complications
and outcomes. Sufficient urgency to this project can only be achieved by close
collaboration between SHHD and the Royal Colleges.
Research
funding bodies in Scotland (eg National Projects Committee at the Chief Scientist’s
Office) should give high priority to further research into gastrointestinal anastomotic
leakage which continues to cause significant morbidity and mortality to patients
and high cost to the NHS.
The
care of all patients who develop a DVT or pulmonary embolus in Scottish hospitals
should be subject to a detailed in-hospital audit to identify failures in the
application of locally derived guidelines for prophylaxis. Any necessary
remedial action should be instituted.
Purchasers of health care should ensure that their population has access at all
times to a full range of vascular services, including a specialist emergency service
and interventional radiology. In view of rapid developments in vascular techniques,
a continuing national review of this field is recommended