SASM Annual Report 1996: Conclusions and Recommendations

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