Modernising Care for Patients Undergoing Major Surgery

Jun 27 2005

Hospitals could improve survival rates following major surgery by streamlining their critical care units, according to a new report launched recently at a London conference. As well as saving lives, hospitals could save an estimated £2 million each by implementing some of the report's key recommendations to help reduce hospital stay times.

The report, "Modernising Care for Patients Undergoing Major Surgery", argues that a simple set of measures could reduce the number of complications following surgery along with the average length of hospital stay. Measures such as 'fast-tracking' more patients through intensive care units (ICU) and using exercise to assess and improve patients' fitness could also improve overall mortality rates, currently around 20,000 deaths per year out of the 3 million surgical operations performed.

The Improving Surgical Outcomes Group behind the report, led by consultants from University College London (UCL), St George's Hospital, Ipswich Hospital, University College London Hospital and Lewisham Hospital, says that at present an estimated one per cent of NHS patients undergoing major surgery go on to ICU or high dependency units (HDU), where evidence suggests that around 35 per cent of patients would benefit from a HDU setting and around 15 per cent require an ICU. The report recommends introducing post-surgery overnight recovery units into more hospitals.

The report also recommends the adoption of methods like cardio-pulmonary exercise testing (CPX), not commonly used at present within the NHS, as more reliable methods of assessing a patient's fitness and associated risks for surgery. For some patients, the risk of death following surgery is greater than the risk of death from the underlying condition.

Some patients who suffer from dehydration go on to develop complications. The report argues that this can be avoided with fluid and electrolyte replacement procedures and a process known as haemodynamic optimisation, where the anaesthetist administers a mix of fluids guided by monitored cardiac output. At present, while these procedures are standard in some hospitals, many others do not make use of them. Nutritional supplements can also improve patients' outcome along with exercise.

Overall the report recommends:

• Assessing patient fitness at a much earlier stage prior to surgery with greater involvement from the anaesthetist

• More use of exercise and nutritional supplements to prepare a patient for surgery

• Better fluid administration before, during and after surgery

• Introducing overnight intensive recovery areas to provide critical care for up to 24 hours following surgery for all patients

• Breaking the 'silo' budgeting approach that currently inhibits clinical teams from spending small amounts on technology that will make greater savings elsewhere

The costs of implementing these measures would be marginal compared with the potential savings, argues the report. For example, CPX testing is no more expensive than many current tests which are poor at predicting actual risk. For haemodynamic optimisation, the potential savings in terms of reduced hospital stays are estimated for an average NHS trust to be over £2 million. Recent studies conducted at York Hospital and St George's Hospital showed that these interventions reduced the number of hospital bed days by up to 40 per cent.

A handful of hospitals already operate post-surgery units, such as St Thomas's Hospital where over 12,000 patients have had overnight post-surgery critical care. The new University College London Hospital just opened on Euston Road will house another such facility, combining an Extended Recovery Area with a Post-Anaesthesia Care Unit.

The UK has a lower proportion of hospital beds dedicated to critical care compared to many other countries, although the number of ICU beds is increasing in the UK. On average, there are 0.6 critical care beds per 10,000 population in England compared with 4.4 per 10,000 in the US. One study comparing a UK and US hospital found a four-fold higher level of observed mortality in the UK following surgery.

Monty Mythen, Professor of Anaesthesia and Critical Care at UCL, says: "The recommendations of our report can be delivered with existing resources and involve mainly a shift in priorities over how budgets related to surgery are allocated.

"The effect of major surgery on the energy reserves of a patient is equivalent to running a half-marathon for a fit person, which is why it is crucial to assess a patient's fitness for surgery. We're proposing, for example, that instead of running complicated body scans, doctors can use much simpler, more reliable fitness tests at no extra cost."