The Higher

Risk General
Surgical Patient
Towards 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 Patient
2011
Contents
Contributors 2

Summary 3

Key recommendations 4

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

Actions 9
Managing the critically ill surgical patient with sepsis 9
Escalation of care 9
Urgency of source control 10
Summary timelines 11
Assessing and identifying risk 12
Why it should be done 12
How should risk be assessed? 12

Peri-operative fluid and vasoactive drug therapies 14

End of surgery bundle 15

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

Audit and outcomes 18

Conclusions 19

Figure 1. Care Pathway 20

Appendix 1: Early Warning Score (EWS) 21

Appendix 2: End of surgery bundle 22

Appendix 3: Unscheduled adult general surgical pathway 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 Consultant General and Colorectal Surgeon, Salford Royal Foundation NHS Trust
Director of Emergency Surgery, ASGBI (Chair)

J Eddleston Consultant Anaesthetist and Intensivist, Central Manchester Foundation

NHS Trust (Adult Critical Care Advisor Department of Health)

M Grocott Consultant Anaesthetist and Intensivist, Southampton, Director, NIAA

Health Services Research Centre, The Royal College of Anaesthetists

NP Lees Consultant General and Colorectal Surgeon, Salford Royal Foundation NHS Trust

D Lobo Consultant General and Upper GI Surgeon, Queens Medical Centre, Nottingham

I Loftus Consultant Vascular Surgeon, St George’s Hospital, London

NI Markham Consultant General Surgeon, North Devon District Hospital , Barnstaple

D Mitchell Consultant Vascular and Renal Transplant Surgeon. Chair, Audit and Quality
Improvement Committee. Vascular Society of Great Britain & Ireland

R Pearse Senior Lecturer and Consultant in Intensive Care Medicine, Barts and The
London School of Medicine and Dentistry

C Peden Consultant Anaesthetist and Intensivist, Royal United Hospital, Bath

RD Sayers Professor of Vascular Surgery, University of Leicester

J Wigfull Consultant Anaesthetist and Intensivist, Sheffield Teaching Hospitals

Approving organisations

This document has been reviewed and supported by:

»» Association of Anaesthetists of Great Britain and Ireland
»» Association of Coloproctology of Great Britain and Ireland
»» Association of Surgeons of Great Britain and Ireland
»» Association of Upper Gastro-intestinal Surgeons
»» Critical Care Networks
»» Faculty of Intensive Care Medicine
»» Intensive Care Society
»» Royal College of Physicians
»» Society of Academic and Research Surgeons
»» Vascular Society of Great Britain and Ireland
»» Royal College of Anaesthetists

2 Contributors
Summary
Higher risk non-cardiac general surgery is undertaken in every acute hospital. By way of comparison, the
mortality for this group, which includes most major gastro-intestinal and vascular procedures, exceeds
that for cardiac surgery by two to three fold and complication rates of 50% are not uncommon. There may
be a lack of awareness of the level of risk. Among these patients, emergency surgery and unscheduled
management of complications is common and this group of patients are one of the largest consumers of
critical care resources. The health and financial costs are considerable.

Evidence indicates that the peri-operative pathway followed by patients requiring emergency surgical
management is frequently disjointed, protracted and not always patient centred. Outcomes are known to
vary substantially and could be considerably improved. Trusts should formalise their clinical pathway for
this group of patients, ensuring that risk of further deterioration is matched with urgency of diagnostic
tests, seniority of clinician in decision making, timing of surgery and appropriate clinical location for
immediate post-operative care.

This document describes key issues and standards. It is the opinion of this expert group that the
recommendations contained within should be deliverable within two years in all acute hospitals
undertaking unscheduled general surgery in adults and that doing so would make an appreciable
difference to outcomes.

Summary 3
Key recommendations
1) Trusts should formalise their pathways for unscheduled adult general surgical care. All patients
should have a clear diagnostic and monitoring plan documented on admission. The monitoring
plan must be compliant with National Institute for Health and Clinical Excellence (NICE) CG50
guidance and match competency of the doctor to needs of the patient. The pathway should
include the timing of diagnostic tests, timing of surgery and post-operative location for patients.

2) Prompt recognition and treatment of emergencies and complications is essential to improve

outcomes and reduce costs. Surgical patients often require complex management and delay
worsens outcomes. The adoption of an escalation strategy which incorporates defined time-points
and the early involvement of senior staff when necessary are strongly advised. One such strategy is
defined.

3) Trusts should ensure emergency theatre access matches need and ensure prioritisation of access is
given to emergency surgical patients ahead of elective patients whenever necessary as signficant
delays are common and affect outcomes. The necessary timescale of intervention is defined.

4) Each patient should have his or her expected risk of death estimated and documented prior to
intervention and due adjustments made in urgency of care and seniority of staff involved.

5) High risk patients are defined by a predicted hospital mortality ≥5%: they should have active
consultant input in the diagnostic, surgical, anaesthetic and critical care elements of their pathway.

6) Surgical procedures with a predicted mortality of ≥10% should be conducted under the direct
supervision of a consultant surgeon and consultant anaesthetist unless the responsible consultants
have satisfied themselves that their delegated staff have adequate competency, experience,
manpower and are adequately free of competing responsibilities.

7) Each patient should have their risk of death re-assessed by the surgical and anaesthetic teams at
the end of surgery, using an ‘end of surgery bundle’ to determine optimal location for immediate
post-operative care.

8) All high risk patients should be considered for critical care and as a minimum, patients with
an estimated risk of death of ≥10% should be admitted to a critical care location. Trusts should
examine their spectrum of critical care provision and consider options for patients with lower
risks of death which will further enhance surgical outcomes and limit costs overall.

9) A national audit of outcome should be conducted for adult patients undergoing unscheduled
general surgery, utilising the standards proposed in the document and incorporating measures
of cost effectiveness. Local assessment of outcome is fundamental in improving care and results
should be shared appropriately.

4 Key recommendations
Background
Introduction

The adult higher risk non-cardiac surgical population represents a major healthcare challenge to every
acute hospital. Surgery remains a common and effective treatment option for a diverse range of diseases
and far from being replaced by drug therapies, surgery is now more frequently deemed a viable option
for elderly patients and those with co-morbidities or advanced disease. The standard of patient care
during surgery itself can now be extremely high and even complex elective surgery can be made relatively
safe.1,2 However, successful surgery also depends on good peri-operative care and here lie challenges.
While we may have made some progress towards improving surgical outcomes, the available evidence
suggests that post-operative adverse events may be much more frequent than many appreciate and that
the consequences of these complications are considerable.

In the UK, the focus has fallen previously on cardiac surgery where specialist units carry out a modest
range of predominantly elective procedures with routine intensive care support. Audit now shows
good results which continue to improve with 2–3% mortality typical.3 The established and transparent
measurement of outcomes in cardiac surgery facilitate improvement by identifying centres of good
practice and centres where change may be required.

By contrast, major general surgery is carried out in every acute hospital, encompassing a wide range of
conditions which are, hence, more difficult to audit and conducted with limited critical care support.
The mortality of elective major gastro-intestinal or vascular surgery substantially exceeds that of cardiac
surgery. A much higher proportion of non-cardiac surgical patients are treated on an emergency basis and
at present the service for such patients lacks focus despite much higher mortality and complication rates.

There is growing concern that this group of higher risk general surgical patients receive sub-optimal care
which has important implications for patients and the healthcare economy. In the UK, 170,000 patients
undergo higher risk non-cardiac surgery each year.4 Of these patients, 100,000 will develop significant
complications resulting in over 25,000 deaths. General surgical emergency admissions are the largest
group of all surgical admissions to UK hospitals and account for a large percentage of all surgical deaths.5
Emergency cases alone presently account for 14,000 admissions to intensive care in England and Wales
annually.6 The mortality of these cases is over 25% and the intensive care unit (ICU) cost alone is at least
£88 million.

Complications occur in as many as 50% of patients undergoing some common procedures, and these
result in dramatic increases in length of stay and cost. Many of the patients undergoing this type of
surgery are elderly with multiple co-morbidities7–10 and indeed the over 80s are more likely to present for
emergency surgery than elective,11,12 where the risks multiply. Despite these findings, there is surprisingly
little research into how to improve these patients outcomes but structures of care which facilitate attention
to the detail of peri-operative care may help.13

Studies from the UK suggest that a readily identified higher risk sub-group accounts for over 80% of
post-operative deaths but less than 15% of in-patient procedures.4,7 Advanced age, co-morbid disease,
and major and urgent surgery are the key factors associated with increased risk. Within this group,
emergency major gastrointestinal (GI) surgery has one of the highest mortalities, which can reach 50%
in the over 80s.8 Presently, this type of surgery is carried out in every acute hospital, but not always with
consultant staff present and not always with routine admission to a critical care bed after surgery. Many
of these issues were highlighted in the most recent National Confidential Enquiry into Patient Outcome
and Death (NCEPOD) report.14

Background 5
In the UK, fewer than one third of high risk non-cardiac surgical patients may be admitted to critical
care following surgery.4,7 In addition, those patients who do receive this level of care are discharged after
a median stay of only 24 hours, despite going on to have prolonged hospital stays. Premature discharge
from critical care has been identified as an important risk factor for post-operative death, as has delayed
admission to critical care.15 International comparisons suggest that critical care beds may run at 50% of
comparable levels elsewhere and indeed rank amongst the lowest in the developed world.16

To identify and advise on how these patients could be better managed, a joint working group was set up
between The Royal College of Surgeons of England and the Department of Health (DH) to address these
issues as they relate to the peri-operative care of general and vascular surgery in the first instance.

The following document seeks to explain to the nature of the problem to commissioners, chief executives
and medical directors, and to lay out logical steps which should be taken in order to achieve the greatest
benefit in the most effective way.

Variation in current outcomes

There are several indicators that the outcomes from higher risk surgery in the UK are not as good as
they should be. Review of 2008/9 hospital episode statistics (HES) data from Dr Foster reveal a greater
than two-fold variation in relative risk of 30-day mortality (risk-adjusted) after non-elective lower GI
procedures between trusts in the North West SHA (strategic health authority). It is known that the chance
of a patient dying in a UK hospital is 10% higher if he or she is admitted at a weekend rather than during
the week.17 There are no evident reasons for these differences other than that care, at times, is of variable
quality: a conclusion which fits with the available evidence and professional opinion. International
studies have reached similar conclusions and local audit data confirm that outcomes deteriorate if
patients are admitted towards the end of duty periods and at weekends . Two recent NCEPOD reports
showed significant deficiencies in the active care of patients who ultimately died.14, 18 These included
delays in assessment, decision making and treatment. There were shortfalls in access to theatre, radiology
and critical care; surgery was suboptimally supervised in 30% of cases and there was a failure for juniors
to call for help in 21% of cases. Timely surgery was not carried out in 22% of patients who died. There
was also the failure to reliably administer therapy known to be of benefit such as antibiotic and venous
thrombo-embolism prophylaxis. There are few data which compare our outcomes in the UK to other
countries but one study reported that risk-adjusted mortality rates were as much as four times higher
in the UK than in the US.19 A large percentage of the patients that survive have prolonged hospital
stays with significant cost implications, both physical and emotional to the patient and their family, and
financial to the hospital.20

Together, these data show that these higher risk patients are a significant clinical burden in every
hospital, use substantial critical care facilities with corresponding high cost but have outcomes which
vary considerably between sites and within sites at weekends. These observations represent a poorly
defined care pathway with standards that are either not determined or not implemented. The consequent
impact on both patient outcomes and use of NHS resources is considerable. The scope for improvement
is difficult to document given the very limited nature of current audit methods and the diversity of
procedures undertaken. However, the findings are well recognised by many working in the field and nor
are they surprising. Provision of services, particularly of theatre access, critical care and interventional
radiology, is often incomplete and the correct location of patients after surgery is often not given
sufficient priority. Furthermore, the clinical response for patients who deteriorate is often poorly thought
through and, at times, ad hoc. Aligning patients’ needs and subsequent risk of deterioration to the most
appropriate pre and post-operative clinical area requires active early assessment of risk of death and clear
objectives for clinical care to be identified.

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

While occasional patients die from haemorrhagic or cardiac complications during surgery, it is post-
operative complications that account for the bulk of morbidity and mortality in general surgery. Some
of these result from suboptimal surgical peri-operative care – perhaps on account of poor pre-operative
preparation or inexpert or delayed surgery or anaesthesia. For others, post-operative complications are
chance occurrences but nevertheless ones which can often be readily anticipated and mitigated through
consideration of co-existent diseases and the surgery performed. In the elderly, frailty is a risk factor and
should be formally assessed in addition to nutritional and mental state.14 Complications can be greatly
reduced by optimal peri-operative care.

There are opportunities to improve outcomes before, during and after surgery. Many of these higher risk
patients are emergencies where the time for pre-operative assessment is less and surgery is often unavoidable.
In these cases, optimal resuscitation is important but delay is detrimental. However, for those patients
undergoing elective high-risk surgery, optimal multidisciplinary pre-operative planning is the ideal.

Complications are common and raise costs, often several-fold. Their development reduces survival (both
short and long term) independently of pre-operative risk and complexity of surgery.21 Those that occur
are managed variably and adverse outcomes are estimated to be due to errors in the process of care or
medical management, each in about 20% of cases.22

Minor complications are extremely common after complex procedures and slow or suboptimal
management of these, particularly in patients with other medical diseases can trigger a subsequent
cascade of more serious complications. Many of the life threatening problems involve systemic infection
(sepsis). Once a patient develops major complications, they are at risk of major organ dysfunction or
failure. Typically, patients at risk or with organ dysfunction are managed in high dependency units
(level 2), where the mortality is at least 5%. Once organ failure develops, full intensive care (level 3)
is required and the mortality rises to 30% or more, often after prolonged treatment. The health and
financial advantages of managing complex patients with adequate critical care support from the time of
surgery are self evident.

Complications may be inevitable after this magnitude of surgery but their number and severity can be
mitigated by rapid and successful treatment. It is well established that this requires the following steps:

1) Rapid identification
2) Adequate resuscitation
3) Investigation to define the underlying problem
4) Rapid definitive treatment of that problem
5) Appropriate critical care provision to prevent further complications

Too often the whole process is slow or inaccurate as it is complex, requires multidisciplinary input, often
occurs out of hours and is initiated by junior staff. Suboptimal care on general wards prior to critical care
admission has been recognised as a cause of avoidable mortality14 which has resulted in the publication
of a clinical guideline document from NICE23 and of a competency framework from DH.24 These
documents outline a graded response strategy that each acute hospital should establish to recognise
and respond to the deteriorating patient. Escalation of care for those that require surgical intervention,
including radiological intervention, has not been the subject of specific guidance to date. Certainly in the
US, the ability of different hospitals to manage complications differed significantly and this (rather than
the initial frequency of complications) accounted for large variations in outcomes.25 Prompt intervention
is fundamental to the successful treatment of the patient who deteriorates after surgery.

Background 7
Sepsis

Sepsis (the body’s generalised response to infection) requires special consideration because it is the
principal reason for prolonged admission to critical care and death in these patients and because the
existing guidelines do not take into account current understanding of the timeliness of intervention.

The process is time critical and two steps are of particular importance in surgical patients. The first, as
defined in the Surviving Sepsis Campaign, is to administer broad-spectrum antimicrobials as early as
possible, and always within the first hour of recognising severe sepsis and septic shock26 together with
other appropriate measures shown in Box 1.

Box 1. Early resuscitative measures in sepsis

Measure serum lactate.
Take blood cultures (preferably before antibiotic administration).
Administer broad spectrum antimicrobials within 1 hour.
Treat hypotension, hypovolaemia or elevated lactate with appropriate intravenous fluids.

The second is to deal with the source of sepsis which, in surgical practice, often means a complex
operation or radiological drainage. Previous guidance with regard to the urgency of emergency surgery
is too non-specific and does not take account of new evidence which suggests that patients with septic
shock requiring source control have a progressive deterioration in outcome associated with increasing
delay to source control.27 Delay of more than twelve hours after the onset of septic shock may increase
mortality by a factor of 2.5 times when compared with patients who received source control within three
hours. Gathering data on these patients is difficult but this expert group believes there is enough evidence
at present to establish pragmatic guidance consistent with NICE CG50. Namely, that a graded response
be established that requires increasingly rapid intervention for patients with increasing severity of illness
and that the degree of urgency should be considerably greater than that previously accepted.

It is anticipated that the effects of this will be to reduce severity of illness, the need for higher levels of
critical care and its associated cost and improve outcomes.

8 Background
Actions
Managing the critically ill surgical patient with sepsis

Surgical patients may become critically ill for two reasons. They may present as an emergency with an
acute surgical illness or they may develop complications following surgery or during surgical illness.
Some complications have well defined treatment protocols and others are so catastrophic that the need
for immediate summoning of the cardiac arrest team is obvious. However, the graded response for
identification and treatment of sepsis, the most frequent serious complication is not well defined. This
deficit leads to avoidable adverse outcomes.

Escalation of care
Fundamental to prompt definitive treatment of sepsis and indeed, all complications, is the need to
identify critically ill patients at an early stage. This escalation guideline is written with reference to
existing documents; NICE CG5023 and Competencies for Recognising and Responding to Acutely Ill
Patients in Hospital.24 The graded response to early warning scores will be described as a three point scale
of response to low, medium and high scoring patients. Further explanation of the current status of early
warning scores (EWS) is given in Appendix 1.

Surgical patients frequently differ from non-surgical ones in two ways. Firstly, the conditions which
develop often demand greater urgency and secondly, they more often require complex operative
interventions following advanced imaging. These differences bring opportunity for delay.

For a medium-score patient NICE CG50 requires: ‘Urgent call to team with primary medical responsibility
and simultaneous call to staff with core competencies in care of acute illness.’ In the case of a surgical
patient that has deteriorated on the ward the member of staff with ‘core competencies’ is a surgical trainee,
who will usually have passed MRCS. A typical ‘medium score’ patient would be one that is developing
severe sepsis or one with less severe acute pathology but with significant co-morbidities.

This trainee, here denoted MRCS, is the secondary responder in the chain of response described.23 The
MRCS plays a key role in diagnosis and communication between tertiary response groups; crucially the
consultant surgeon although microbiologist, radiologist, anaesthetist and intensivist may all need to be
involved within a short space of time. Staffing arrangements between hospitals will vary. Responsibility
for ensuring that the MRCS is able to review a patient that triggers a medium score without delay is
fundamental and will rest with individual departments.

For the escalation structure, below, to work for the patient’s benefit, the MRCS must be competent in
recognising whether a deteriorating patient has sepsis or not and whether the cause of sepsis is most
appropriately treated with antibiotics alone or with source control. The MRCS must also be able to
differentiate between the different levels of severity of sepsis. Successful attendance at a Care of the
Critically Ill Surgical Patient® (CCrISP®) course28 or equivalent would provide this, and this is a ‘strongly
recommended’ facet of basic surgical training in the UK.

Suggested pathways for escalation are shown in Figure 1. The upper part of Figure 1 utilises the early
stages of the generic pathway described in NICE CG50 up to the point of referral to the secondary
responder. However, note that 12-hourly observations is too infrequent for this group: hourly observations
would be more usual until medical review, and would likely be triggered by the EWS. There follows the
recommended pathway for the surgical patient.

Actions 9
The summary timelines for assessment of the unstable patient and for intervention are shown below.
For definitive treatment to occur within the recommended timeframe, it will be clear that each phase of
treatment must be expeditious. These phases often include initial recognition, initial assessment, MRCS
assessment, investigation (most commonly CT scan) and senior decision making. Hospitals should audit
the stages of the pathway to minimise the avoidable delays which are currently recognised. When staff
shifts change, effective handover at a sufficiently senior level is essential to maintain momentum.

Urgency of source control

Patients with sepsis require immediate broad-spectrum antibiotics with fluid resuscitation and source
control.

a) Those with septic shock require immediate broad-spectrum antibiotics with fluid resuscitation
and source control. Delay to source control of more than twelve hours after onset of hypotension
when compared with a delay of less than three hours could be expected to increase mortality from
25% to more than 60%.27 Rapid involvement of senior staff is important. Control of the source of
sepsis by surgery or other means should be immediate and underway within three hours.

b) Patients with severe sepsis (sepsis with organ dysfunction) are at greatest risk of developing septic
shock. There is no direct evidence to confirm that delayed source control worsens outcome but
there are obvious advantages to operating before progression to septic shock occurs29-31 given
the associated 5 to 10-fold rise in mortality which occurs as the patient deteriorates. Surgery
or equivalent (eg radiological drainage) should be carried out within six hours from the onset
of deterioration. These patients require immediate broad-spectrum antibiotics with fluid
resuscitation, urgent but not immediate surgery, frequent monitoring (as per NICE CG50) in an
appropriate environment during the interim to promptly identify development of hypotension.
Where it is elected to observe and resuscitate the patient for a few hours until morning, surgery
should assume priority over elective procedures. Neither observation nor resuscitation should
delay source control for more than six hours. Evidence suggests that further delays at this point
are common.14, 32

c) Source control for patients with sepsis but without organ dysfunction should always be carried
out within 18 hours. Immediate broad-spectrum antibiotics are required but surgery can be
delayed overnight or until the next theatre becomes available. Source control is needed before
progression to severe sepsis which carries a greater overall mortality and an increased frequency
of observations is needed in the interim to identify any clinical deterioration which should trigger
a revised management plan.

d) Patients that require source control but have not mounted a systemic inflammatory response are
clinically appropriate for NCEPOD classification ‘expedited’.

Doctors should be aware of these timescales when determining the urgency of assessment and
intervention. As the acute management pathway for many of these patients is tortuous (assessment,
senior assessment, investigation, anaesthetic review, critical care review, theatre scheduling, operation)
the need for urgency at each stage is emphasised.

These timescales shown are the maximum. Some patients will have surgical considerations mandating
more urgent intervention.

10 Actions
Hospitals should provide adequate emergency theatre access free from predictable obstruction or
restriction caused by over-running elective work or manpower shortage. This is not infrequently seen at
late afternoon / early evening.

Hospitals should also ensure that there are clear arrangements in place for interventional radiology,
especially out of hours. For many, this will be via a network of cover across multiple hospitals.

Moving a patient to critical care does not treat the source of sepsis and the focus must remain on timely
definitive care. This needs to be balanced with appropriate but rapid pre-operative resuscitation. If the
patient becomes hypotensive, fails to respond to resuscitation or otherwise deteriorates then immediate
treatment is necessary as in a).

Recent College standards, from a multi-professional group with lay input, define the need for consultant
availability for emergency care 24-hours a day, 7-days a week, location of at-risk emergencies in a single
site, genuine availability of emergency theatre and defined rotas for interventional radiology.33 These
principles are fundamental to modern, safe and reliable unscheduled care and are strongly supported.
Many hospitals have moved substantially in this direction but remaining ones should follow and adjust
job plans accordingly.32

Summary timelines

Surgical Response (level 2 / secondary)

EWS Grade of staff Time
Low Foundation / ST 1–2 1 hour
Medium MRCS within 30 mins
High MRCS and critical care / anaesthetic staff immediate

If there is an incomplete response to resuscitation within one hour, particularly if the patient remains
hypotensive or with organ dysfunction, then: inform/involve senior staff and move to critical care area
or operating room as appropriate.

If MRCS is not available because he or she is operating, the ICU or anaesthetic special registrar (SpR)
should be called directly to the patient according to a local tiered escalation policy and, typically, the
consultant surgeon should be involved. At each stage, all members of the multidiscplinary team should
be encouraged to involve more senior staff if there is a delayed or incomplete response by the medical
team or the patient.

Intervention to control source of sepsis

Severity of sepsis Time to intervention (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)

Figure 1, below, combines initial generic assessment taken from NICE CG50 (upper part of figure) with
a surgery specific pathway (lower part of figure). Initial routine monitoring for this group of patients will
be hourly.

Actions 11
Assessing and identifying risk

Why it should be done

Studies from the UK suggest that a readily identified higher risk sub-group accounts for over 80% of
post-operative deaths but less than 15% of in-patient procedures.4,7 Advanced age, co-morbid disease,
major and urgent surgery, primary diagnosis and acute physiological deterioration are the key factors
associated with increased risk. Routine identification of patients most at risk would permit care and
resources to be better directed.

How should risk be assessed?

Presently, clinicians’ assessment of peri-operative risk may be omitted, inaccurate or may not lead to
an effective change in clinical management. Objective assessment of risk must become routine. Most
importantly, identification of higher risk needs to trigger joint advance planning specific to that case.

1) We recommend that objective risk assessment become a mandatory part of the pre-operative
checklist to be discussed between surgeon and anaesthetist for all patients. This must be more
detailed than simply noting the American Society of Anesthesiologists (ASA) score.

2) For elective patients, risk should be assessed at pre-operative assessment and those at high risk
should ideally see the anaesthetist who will anaesthetise them. Being seen by a colleague with
appropriate competencies from a specialist team that adopts common accepted protocols would
be acceptable. A range of risk scores and tests of exercise capacity are available and should be
adopted. Close working arrangements, advance communication and sub-specialisation are
advocated for higher risk cases that should be optimised according to current local and national
guidelines prior to surgery. The reliability of this process should be audited.

Patients with a predicted mortality ≥5% should be managed as ‘high risk’. Most major general surgical
emergency laparotomy procedures fall in this category, together with complex elective GI and vascular
procedures, in comorbid patients.

There are a number of methods with which to predict hospital mortality risk. Some methods are described
below. Each method has strengths and weaknesses so for patients to be safely defined as low risk they
should not obviously enter the high risk group by any method.

Note that the average mortality of a defined group can be expected to be approximately 2–4 times the
threshold and it is anticipated that teams may wish to set the threshold lower in time.
a) P-POSSUM, freely available on the internet,34 is possibly the simplest and best validated method
and a good place to start. Its scoring includes operative details so these have to be estimated for
pre-operative use and can be updated at the end of surgery.

b) Alternatively, the criteria below are taken from an expert clinical trial in this population and also
fit with expert opinion, Box 2. These will define a group with a predicted mortality ≥5% and an
overall mortality of 10–12%.

c) A third way of identifying the higher risk surgical patient is by reference to HES procedure
groups. While this approach shows considerable concordance with the methods above for
populations of patients, its failure to include acute illness or chronic co-morbid disease means it
should be used alongside a consideration of patient physiology for individual patient assessment.
With that caveat, HES data analysis shows that the following emergency cases have an average
mortality of ≥10% in the UK; laparotomy for peritonitis, resection of colon or rectum, therapeutic

12 Actions
 operations on small bowel, therapeutic upper GI endoscopy, peptic ulcer surgery, gastrectomy and
splenectomy. In such cases patients are likely to be ‘higher risk’ unless they are unusually fit.

d) Other physiological derangements, disease states and procedures may also define high and
medium risk patients, including urgent surgery in patient with ASA >3 plus at least one acute
organ dysfunction/failure, ASA 4 or 5, dialysis-dependent patients or patients with elevated
lactate.

Box 2. Patients undergoing major gastro-intestinal or vascular surgery

who are either:

1. Aged >50 years;

and undergoing urgent, emergency or re-do surgery
or have acute or chronic renal impairment (serum creatinine >130 µmol/l)
or have diabetes mellitus (even if only diet controlled)
or have or are strongly suspected clinically to have any significant risk factor for cardiac or
respiratory disease.

2. Aged >65 years.

3. Have shock of any cause, any age group.

The identification of higher risk status should lead to certain levels of care. Staff involved should be
sufficient in seniority and number to permit care to proceed expeditiously. It is recognised that,
while some more senior trainees may have many of the skills necessary, this is less so than previously.
Furthermore, the presence of a consultant can remove organisational barriers and assist in prompt
decision making. For the surgical team, this practical assistance is essential given modern day on call
arrangements. Anaesthetic juniors may similarly lack experience and have to manage calls about other
patients simultaneously, causing further delays.

Consequently, each higher risk case (predicted mortality ≥5%) should have the active input of consultant
surgeon and consultant anaesthetist. Surgical procedures with a predicted mortality of ≥10% should be
conducted under the direct supervision of a consultant surgeon and a consultant anaesthetist unless the
responsible consultants have actively satisfied themselves that junior staff have adequate experience and
manpower and are adequately free of competing responsibilities.

Occasional cases may be appropriately managed by unsupervised juniors but this should be an active and
audited senior decision. Calling senior staff at a later stage once problems have developed will usually
be associated with worse outcomes and this event should also be audited. It is also recognised that the
systemic impact of sepsis on patients undergoing major procedures is not always identified initially
and seniors should be cautious about leaving before the case is finished. It is very important that rotas
permit trainees to work with consultants who are delivering care, in order to ensure training of future
consultants.

Formal identification of risk can help identify when surgery for frail and critically ill patients may be futile
and where end of life care may be more appropriate. The wishes of patient and family and senior input
are important. As the population ages, the issue of futile care will increase. Better working relationships
with services providing care for the elderly and primary care, although currently difficult in emergency
settings, can only be an advantage.14

Actions 13
Peri-operative fluid and vasoactive drug therapies
Fluid resuscitation of the emergency patient is essential.26 It should occur in a location appropriate to the
degree of illness and interventions necessary. It may often require senior input. The importance of urgent
source control has been indicated above and location and protocols should take account of that as well,
especially in the sickest patients where deferring source control for prolonged fluid resuscitation could
be detrimental.

The optimal approach to intra-operative fluid and vasoactive drug therapies remains uncertain but
evidence from a number of small trials suggests that the use of cardiac output monitoring, typically
via oesophageal Doppler, to guide fluid therapy during major gastro-intestinal surgery may reduce
complication rates and duration of hospital stay. For this reason, the technology has been recommended
in a recent guideline issued by the NICE as being clinically and financially effective when invasive
monitoring is required.35 Several larger trials of this treatment are under way and will inform future
practice recommendations.

Both excessive and inadequate intravenous fluid administered in the peri-operative and post-operative
period can be harmful, particularly in the elderly.14,36 A fluid plan should be agreed between the
anaesthetic team and senior surgeon, bearing in mind current evidence and the risks of both excessive
and inadequate fluid therapy. This should include blood loss and replacement.

14 Peri-operative fluid and vasactive drug therapies

End of surgery bundle
The post-operative pathway must be determined by the risk of death and complications and receiving
areas must possess the competencies to deal with surgical patients.

A key decision point occurs towards the end of higher risk surgery, much of which is emergency in
nature and thus less than perfectly planned. At this point, decisions need to be made concerning the
disposition of the patient following surgery. Underestimating the degree of existing physiological upset
or of the likely evolution of organ dysfunction can be catastrophic: late admission to critical care carries
a much higher mortality than a planned admission from the operating room. Staff may be relatively
inexperienced, tired or dealing with unfamiliar circumstances and it seems logical to conduct a
structured assessment of risk towards the end of surgery. One method would be to use the Apgar score
for surgery.37 An alternative would be to use the bundle described below38 within the last 30 minutes of
surgery in all cases identified by the pre-operative assessment as having mortality risk ≥5% and in those
who deteriorate during surgery.

1) Risk score patient (≥5% mortality defines high risk)

2) Check arterial blood gases to assess lactate, acid-base status and the ratio of arterial oxygen
concentration to the fraction of inspired oxygen (P:F ratio)
3) Summarise fluids given and draft ongoing fluid requirements.
4) Reverse muscle relaxant; use of nerve stimulator is mandatory.
5) Check and document temperature, plan further correction as necessary.

Based on the bundle criteria, the surgeon and anaesthetist should decide jointly the preferred destination
of the patient after surgery. All patients with predicted mortality ≥10% should be admitted to the
appropriate (level 2/3) critical care unit with surgical competencies. This decision will be influenced by
adverse events during surgery or a high likelihood of deterioration in the short to medium term. The
bundle should be used to supplement rather than replace existing indicators of the need for critical care.
Details of the criteria are given in Appendix 3.

The use of ‘bundles’ has been shown to increase the reliability of key steps of care.39 The concept of using a
bundle at the end of high risk surgery should be tested in individual institutions, if necessary adjusted for
context, and if found to increase the reliability of key step delivery, incorporated into routine anaesthetic
paperwork. Joint early discussion with the critical care team is fundamental.

End of surgery bundle 15

Postoperative care
Access to critical care is an essential aspect of adequate peri-operative care for the high-risk group in
order to identify complications early and minimise their impact. All patients should be managed after
surgery in a location determined by risk and staff competence. Hospitals should plan their critical care
resource to match need in order to avoid shortages and define critical care areas accordingly. Patients
should move up and down through a spectrum of levels of care. Levels of care are described40, 41 as shown
in Table 1.

Table 1. Levels of care

Level Description Patient characteristics
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

All patients with a predicted mortality of ≥10% should be admitted to a level 2 or 3 critical care area after
surgery and all patients should have an updated management plan which incorporates haemodynamic
and blood gas parameters, on-going antibiotics, nutrition and thromboembolic prophylaxis.

Importantly, trusts may wish to examine their existing provision particularly around levels 1 and 2. When
compared to level 0 care, the impact of level 1 or 2 care is likely to be much greater in the unscheduled
surgical population than the elective population due to the dynamic nature of the acute illness and its
influence on organ function. Recognition of any deterioration in organ function and timely intervention
is essential to optimise patient benefit. Provision of this level of monitoring is frequently difficult to
deliver in a standard ward environment with a staffing ratio which is frequently <0.20 nurse-to-patient.42
Defining and auditing pathways for such patients affords organisations an opportunity to address
competencies of staff and staffing ratios to deliver a reliable tiered pathway of care.

Considerable gains in outcome are likely with improved level 1 and 2 care and some organisations have
developed bespoke solutions such as the development of post-anaesthesia care unit (PACUs) or co-
locating medium risk patients in pre-defined clinical areas.

Structured care on the PACU

A patient inappropriate for the ward could be admitted to PACU for continued monitoring. Formal joint
assessment should occur after four hours. If the patient is alert and has a normal temperature, mean
arterial pressure, pH, lactate and gas exchange, and the previous three consecutive hourly urine volumes
were all >0.5 ml/kg, transfer to the ward is acceptable unless there is specific clinical concern to the
contrary.

If the above criteria are not met after four hours in PACU, care should be formally taken over by the
critical care team who will continue to care for the patient in PACU until transfer to a critical care bed can
be arranged or the patient is considered ready for transfer to the ward by a senior critical care specialist.

To do this, hospitals will need to ensure that there is a 24/7 PACU service and that a consultant from
anaesthesia/critical care/surgery is identified to take responsibility for this provision and to work with
the PACU manager to ensure delivery of appropriate care.

16 Postoperative care
Ongoing audit will allow assessment of impact of PACU on elective and emergency surgery. Hospitals
will wish to make the difference between PACU and theatre recovery explicit as inadequate staffing may
result in loss of ability to undertake further emergency surgery if a patient is ‘blocking’ recovery. These
events should be audited and classified as an adverse incident.

Co-location of medium risk patients

Existing systems of critical care can leave a large step between high dependency unit (HDU) and ward
care. In cost-limited times, the co-location of medium risk patients in special wards or ward-areas (level
1) could be expected to lead to immediate improvement in standards even if staffed near general surgical
ward levels and without significant investment in additional monitoring.

Immediate benefits would be promoted, providing trusts:

»» establish local protocols drawn up jointly between surgical and critical care departments to define
parameters of care and to ensure seamless transition of patients between units
»» establish co-operative education programmes with critical care for nursing and medical staff
»» establish improved daily communication between units
»» recommend geographical proximity to critical care where possible
»» name a critical care consultant with responsibility for basic education and support for nursing and
junior medical staff.

Postoperative care 17
Audit and outcomes
The relative paucity of data in this field needs to be addressed urgently, preferably on a national basis.
Given the mortality and morbidity associated with this group, comparative risk-adjusted outcomes should
be monitored for each hospital and would be completely in line with national policy. At the moment,
HES data may be the best available. The adoption of a defined basket of healthcare resource group (HRG)
codes would facilitate this. International comparisons would provide the greatest re-assurance that care
for this group is optimal.

Local audit of outcomes is an important driver for change. The processes advocated in this report should
be audited in each hospital and key indicators include:
»» outcomes (death, length of stay) from higher risk general surgery
»» frequency of observations in higher risk group
»» accuracy of risk estimate prior to surgery
»» accuracy of risk estimate at end of surgery
»» time to CT from emergency admission or deterioration
»» time from deterioration to operation for higher risk group
»» compliance with the standard for intra-operative surgical team seniority
»» compliance with post-surgery pathway for higher risk patients.
»» unplanned surgical readmissions to critical care within 48 hours of discharge back to the ward.

Emergency laparotomy is a clearly defined point in the pathway of a significant proportion of these patients
and in this group, many of the factors discussed in this report come together. The laparotomy network
audit (http://www.networks.nhs.uk/nhs-networks/emergency-laparotomy-network) is beginning to
look at these patients on a voluntary basis and this study should be supported and expanded.

18 Audit and outcomes

Conclusions
Peri-operative care of higher risk general surgical patients in the UK appears to have significant
deficiencies. Outcomes are variable, appear worse than other countries and generate a large health cost
through prolonged hospital stay and use of intensive care.

While there are several specific initiatives (eg hospital-acquired thrombosis) and patient pathways for
single operations (eg aortic aneurysm), there is a lack of overall recognition and strategy for the care of
all patients at higher risk of death and complications.

This higher risk group comprises 12–15% of cases but contributes 80% or more of postoperative deaths
and complications. This group can be identified at an early point and differential management pathways
applied. Identification of these at risk patients should become a formal part of patient assessment and
included in the pre-operative checklist.

Standards of care are described in this document. Trusts should develop pathways in order to achieve
these. The clinical pathway should identify risk of death for an individual patient, match the needs of
the patient, based on risk of death with timing and choice of diagnostic tests, seniority of clinician in
decision making, timing of surgery and post-operative location of care.

In particular, attention could be better focussed on elective cases who develop complications and on
major emergency cases. A defined and escalating pathway of management, which complements existing
guidance for acute care, should be adopted. The described pathways match urgency to patient need and
include guidance on senior involvement and time to treatment.

An estimated mortality of ≥5% defines a high risk patient.

High risk procedures should be managed by consultant staff. Active input will always be required and
consultants should usually be present for procedures and anaesthesia when the risk of mortality exceeds
10%.

There should be a brief but structured review of risks towards the end of higher risk operations, conducted
jointly between surgeon and anaesthetist. This end of surgery bundle should guide the location of post-
operative care.

Higher risk patients should be managed after surgery in a location capable of meeting their need for higher
levels of care. Trusts should look critically at their provision of enhanced levels of care as investment in
better perioperative care would realise benefits for both cost and outcomes.

The principal life threatening complication is the development of severe sepsis. Patients from this group
account for the greatest use of ICU beds. Improved assessment and treatment would likely improve
outcomes and reduce ICU utilisation.

Outcomes from emergency surgery are difficult to compare due to the range of diagnoses and operations.
A national audit of higher risk emergency surgery is essential. A basket of HES codes is proposed and
should be agreed for ongoing comparison.

Conclusions 19
Figure 1. Care pathway

MRCS to attend patient and to coordinate response.

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.

MEDICAL
Continue to follow NICE CG50

SURGICAL
Immediate life, The patient is septic The patient is NOT
limb or organ saving The need for source control must be established rapidly. Urgency of surgery septic and does not
surgery is indicated. depends on severity of sepsis. require immediate
Resuscitation is intervention
simultaneous with The patient has sepsis but no organ impairment or low score risk. Establish Organise initial treatment
intervention. Example; source control urgently and always within 18 hours. Patient should be and investigations, liaise
the exsanguinating monitored hourly and reassessed by MRCS every 6 hours to check for with consultant surgeon
patient. progression to severe sepsis/septic shock. and plan definitive
treatment.
MRCS to liaise with The patient has severe sepsis or medium-high score risk without
consultant surgeon, hypotension. Establish source control as soon as possible and within 6 hours
anaesthetist and theatre maximum. Reassess hourly for progression to septic shock and provide
staff. appropriate interim critical care.

The patient should be The patient has septic shock. The patient’s chance of survival progressively
transferred to theatre deteriorates with increasing delay to source control. Establish source control
within minutes of the as soon as possible. Transfer to theatre must not be delayed for resuscitation
decision to operate. which should be continued in the anaesthetic room.

20 Figure 1. Care pathway

Appendix 1: Early warning score (EWS)
This is a scoring system used to track abnormal physiology and trigger clinical response. The score is based
on routinely recorded physiological observations such as blood pressure and heart rate. Each observation
is given a score of zero if it is normal, increasing to (typically) three as the observation deviates further
from the normal range. The sum of all parameter scores gives a total EWS. There is currently no national
system in use. Different hospitals use scoring systems that differ in the methodology for generating the
final EWS and in the response. Until a national scoring system (expected to be available in autumn
2011) is established (and audited) the only generally applicable guidance comes from NICE CG50 which
stipulates that hospitals should establish a graded response system according to the following system:

Low-score group: increase frequency of observations and inform nurse in charge.

Medium-score group: urgent call to team with primary medical responsibility and simultaneous call to
personnel with core competencies for acute illness.

High-score group: emergency call to team with critical care competencies and diagnostic skills.

Septic Shock is defined as severe sepsis complicated by persistent hypotension (systolic less than 90mmHg
or >40% decrease from baseline) that is not reversed by fluid resuscitation. An adequate volume of fluid is
considered to be 20ml/kg of crystalloid or an equivalent volume of colloid. In this document hypotension
in the context of severe sepsis is taken to be persistent hypotension that is not fluid responsive.

Appendix 1: Early warning score (EWS) 21

Appendix 2: End of surgery bundle
1) The POSSUM score is the most validated risk prediction method for general and vascular patients
that takes into account pre-operative and peri-operative factors. P-POSSUM may be used for all
patients.43 A predicted mortality risk ≥10% indicates need for critical care admission, except for
patients on end-of-life pathways with appropriate palliative care facilities available at ward level.

2) Hyperlactataemia (>4 mmol/l) and significant metabolic acidosis indicate unresolved

physiological impairment that requires ongoing invasive monitoring +/- physiological support.26
Serum lactate levels may also be used to guide fluid therapy and levels >2 mmol/l indicate the
need for closer monitoring.44 P:F ratio <40kPa is consistent with an acute lung injury. A senior
critical care specialist should be involved in the decision to extubate. A P:F ratio <26kPa is
consistent with a diagnosis of acute respiratory distress syndrome (ARDS): the patient should be
transferred to ICU intubated.

3) Both excessive and inadequate intravenous fluid administered in the peri-operative and post-
operative period can be harmful particularly in the elderly.14 A fluid plan should be agreed
between the anaesthetic team and senior surgeon, bearing in mind current evidence and the risks
of both excessive and inadequate fluid therapy.36 This should include blood loss and replacement.

4) Partial reversal of muscle relaxation is common and poorly recognised. It is a risk factor for
post-operative respiratory failure and aspiration. Nerve stimulation and reversal is mandatory if
a neuromuscular blocker has been given regardless of time interval. A train-of-four (TOF) ratio
of 0.9 is required for airway protection. Unfortunately TOF ratio is difficult to assess accurately by
observation alone.45 To be confidant of airway protection, neostigmine should not be given if the
TOF count is less than two and at least nine minutes should elapse after neostigmine bolus before
extubation is attempted.

5) Hypothermia (core temperature <36°C) increases the incidence of post-operative myocardial

events46 and wound infections. Drug metabolism is reduced such that duration of neuromuscular
blockers can be doubled47 and neostigmine can take 20% longer to take effect.48 NICE clinical
guidance (Management of Inadvertent Perioperative Hypothermia, 2008) should be followed.49

22 Appendix 2: End of surgery bundle

Appendix 3: Unscheduled adult general surgical pathway
This pathway has four identifiable components: Clinical Assessment, Diagnostics, Intra-Operative, and
Post-Operative phases. It was developed by clinical staff from surgery, anaesthesia, intensive care medicine,
radiology and emergency medicine in Central Manchester University Hospitals NHS Foundation Trust.
The pathway will assist colleagues in matching an individual patient’s risk of death to seniority of staff in
decision making and identifying the timing of key interventions. These include the timing and choice of
diagnostic tests and location of post-operative care. The pathway describes measurable standards based
on the report.

Clinical Intra-operative Post-operative

Diagnostics
assessment phase care

Decision based on: Laboratory: Assessment of risk Patients will be

clinical history, clinical assessment of organ associated with located in a clinical
examination, bedside function; microbiology anaesthesia and area dependent on
observations, EWS and assessment. surgery calculated and end of surgery bundle
laboratory tests. documented in notes. assessment.
Radiology:
choice determined by The surgical risk will Principles of care:
clinical examination and be calculated using » Post-operative plan
history. P-POSSUM. determined by
diagnosis/surgery/
Minimise secondary The risk associated clinical condition.
renal morbidity. with anaesthesia will be » Early detection of new
FEATURES

undertaken using the onset acute organ

ASA grade. dysfunction.
» Mobilisation at the
Antibiotics within earliest opportunity.
30mins prior to skin
incision.

Optimisation of
peri-operative fluid
administration,
cardiovascular and
respiratory function.

Monitoring of other
organ function
MRCS and senior MRCS. MRCS and FRCAnaes. MRCS for low
DECISION MAKING

help as indicated by and medium risk

condition. populations.

Appendix 3: Unscheduled adult general surgical pathway 23

 Clinical Intraoperative Postoperative
Diagnostics
assessment phase care

Monitoring EWS plan USS lntra-operative: Maintain minimum

set. Minimum of 4 hrly » Invasive monitoring to of 1hrly observations
observations. CT; selection of contrast optimise intravascular following surgery until
determined by renal fluid therapy and senior review.
Graded response based function. organ perfusion.
on EWS and clinical » Measurement of Antibiotic regime
progress. CT with angiography. arterial blood gases dependent on surgical
and lactate. diagnosis.
Diagnostic plan Discussion about need » Minimise risk of
identified. for interventional / secondary organ Chest physiotherapy and
other procedures before dysfunction eg atrial Mobilisation regime.
Senior review within leaving the radiology fibrillation, basal
12hrs (Consultant or dept. atelectasis, renal Nutritional regime.
MRCS trainee should dysfunction.
not be moved from ESU DVT prophylaxis.
or nor should they be End of Surgery:
handed off to another » Assessment of Use of continuous fluid
team until review has postsurgery organ balance monitoring.
occurred). support needs,
based on operative Daily biochemistry and
lf referred to another findings, clinical state Haematology until
surgical team senior and risk of further stepped down in
INTERVENTIONS

review within 12hrs. deterioration. frequency by senior

» Development of review.
Organ dysfunction Bundle to identify
quantified. low, medium and Post-operative pain
High Risk Groups and relief regime according
Antibiotics as per Trust determine postsurgery to protocolised care.
Surviving Sepsis pathways
guidelines.

24 Appendix 3: Unscheduled adult general surgical pathway

 Clinical Intraoperative Postoperative
Diagnostics
assessment phase care

Patients with a Evidence of luminal Pre-Surgery: Patients within critical

predicted mortality perforation. » ASA3 + at least care.
>10% (using 1 acute organ
P-POSSUM or other Suspected ischaemia/ dysfunction/failure. Patients with new onset
scoring system). infarction/intra- » ASA 4 or 5. organ dysfunction /
abdominal bleeding. » Dialysis dependent failure admission to
2 SIRS criteria + l acute patients. critical care based on
organ dysfunction. » Patients with elevated current EWS protocol.
lactate > 4mmol/L.
Age>65.
HIGH RISK CRITERIA

End of Surgery:
Dialysis dependent » Elevated Lactate
patients. >4mmol/L.
» Patients with P/F
ASA>3 + 1 organ ratio<40kPa.
dysfunction ASA4 & 5. » Patients at risk of
intra-abdominal
Ptients who are hypertension
immunosuppressed e.g. and abdominal
transplant patients, compartment
IVDA. syndrome.
» Patients with massive
IDDM patients. transfusion: risk of
TRALI.
Patients on long » Hypothermia (core
term steroids or Beta temp <36°C at end of
blockade. procedure).
Consultant-led Consultant-level Consultant anaesthetist, Consultant surgeon and
process – identified decision making: surgeon and critical consultant in critical
and communicated to surgery and radiology. care discussion. care.
general consultant on
DECISION MAkING FOR HIGH RISK GROUP

call within hour

Appendix 3: Unscheduled adult general surgical pathway 25

 Clinical Intraoperative Postoperative
Diagnostics
assessment phase care

Arterial blood gases. Definitive surgery within lntra-operative period: Time to admission to
2hrs to operate. » Targeted optimisation critical care within 4hrs
Expedited diagnostic of cardiovascular and of decision to admit to
investigations (CT within Critical care needs respiratory function critical care.
6hrs). discussed with using invasive
anaesthesia and critical techniques.
Goal directed care. » Anaesthesia to
resuscitation. expand.
Avoid further organ
Communication of dysfunction by adoption End of Surgery:
results of investigations of supporting clinical » Consultant surgeon
to consultant surgeon initiatives, eg Acute and anaesthetist to
and general anaesthetic Kidney Injury protocol. assess risk of further
team (FRCAnaes) deterioration and
including emergency ultimate mortality:
theatre within 1 hour. using bundle, clinical
findings (ischaemia,
evidence of
perforation, ongoing
bleeding, new onset
rhythm, need for
vasoactive drugs,
INTERVENTIONS

evidence of ALl,
elevated lactate, renal
dysfunction).
» High risk group will
require level 2 or 3
critical care post-
surgery and should be
admitted to critical
care at the end of
surgery.
» Patients requiring
level 1 critical care
should return to
a ward area with
increased monitoring
frequency (initial
monitoring every
30mins for 2hrs
followed by hourly
until next senior
review (MRCS)).
» Consultant in critical
care involved in
post-surgery pathway
for level 2 and 3
patients.

26 Appendix 3: Unscheduled adult general surgical pathway

 Clinical Intraoperative Postoperative
Diagnostics
assessment phase care

Consultant Surgeon Consultant decision Use of end of surgery All high risk patients
involved in decision making for high risk bundle. admitted to critical care
making for high risk group. within 4hrs of decision
group within 1hr of Decision making team to admit.
identification as high Time to operate within for high risk patients
risk. 2hrs of decision to involves consultant No unplanned
operate for high risk surgeon, intensivist and readmissions to critical
Definitive diagnostic CT group. anaesthetist. care within 48hrs of
as early as possible but discharge back to the
should be within 4hrs For non-high-risk group ward.
of identification as high definitive operation
risk. within same working day
from time of decision to
Patients admitted with operate.
septic shock should
CLINICAL STANDARDS

have an operation to
treat the source of
sepsis within 3hrs of
admission.

Patients with an
intraabdominal
pathology and organ
dysfunction should
be operated on within
6hrs of onset of organ
dysfunction.

Consultant review within

12hrs of emergency
admission for all other
patients.

CT for non-high risk

group within 24hrs of
decision to undertake
a CT.
CT within 4hrs for high Time to operate for both Compliance with Unplanned surgical
risk Group. high and non-high-risk documenting the risk of readmissions to critical
groups. surgery and anaesthesia care within 48hrs of
Definitive decision using P-POSSUM and discharge back to the
within 1 hour of CT. ASA grading. ward.
AUDIT

Compliance with end of Time of admission to

surgery bundle. critical care for high risk
group.

Appendix 3: Unscheduled adult general surgical pathway 27

References
1. Jones RS. Comparative mortality in anaesthesia. Br J Anaesth 2001; 87: 813–815.
2. Haynes AB, Weiser TG, Berry WR et al. A surgical safety checklist to reduce morbidity and
mortality in a global population. N Engl J Med 2009; 360: 491–499.
3. Survival Rates - Heart Surgery in United Kingdom. Care Quality Commission. http://
heartsurgery.cqc.org.uk/Survival.aspx.
4. Jhanji S, Thomas B, Ely A et al. Mortality and utilisation of critical care resources amongst high-
risk surgical patients in a large NHS trust. Anaesthesia 2008; 63: 695–700.
5. Emergency General Surgery: The future. A consensus statement. Association of Surgeons of Great
Britain and Ireland. http://asgbi.org.uk/en/publications/consensus_statements.cfm.
6. Intensive Care National Audit & Research Centre (ICNARC), London 2010. Data derived from
Case Mix Programme Database based on 170,105 admissions to 185 adult, general critical care
units in NHS hospitals across England, Wales and Northern Ireland.
7. Pearse RM, Harrison DA, James P et al. Identification and characterisation of the high-risk
surgical population in the United Kingdom. Crit Care 2006; 10: R81.
8. Cullinane M, Gray AJ, Hargraves CM et al. The 2003 Report of the National Confidential Enquiry
into Peri-Operative Deaths. London: NCEPOD; 2003.
9. Semmens JB, Aitken RJ, Sanfilippo FM et al. The Western Australian Audit of Surgical Mortality:
advancing surgical accountability. Med J Australia 2005; 183: 504–508.
10. Cook TM, Day CJE. Hospital mortality after urgent and emergency laparotomy in patients aged
65yr and over. Risk and prediction of risk using multiple regression analysis. Brit J Anaes 1998; 80:
776–781.
11. Ford PNR, Thomas I, Cook TM et al. Outcome in critically ill octogenarians after surgery: an
observational study. British Journal of Anaesthesia 2007; 99: 824–829.
12. Scottish Audit of Surgical Mortality Report 2008 (2007 data). www.sasm.org.uk
13. de Vries E, Prins H, Crolla R. Effect of a Comprehensive Surgical Safety System on Patient
Outcomes. N Engl J Med 2010; 363: 1,928–1,937.
14. Elective & Emergency Surgery in the Elderly: An Age Old Problem (2010). NCEPOD.
http://www.ncepod.org.uk/2010eese.htm?utm_source=Sign-Up.to&utm_medium=email&utm_
campaign=220074-NHS+Institute+Alert+-+December+2010
15. McQuillan P, Pilkington S, Allan A et al. Confidential inquiry into quality of care before
admission to intensive care. BMJ 1998; 316: 1,853-1,859.
16. Adhikari NKJ, Fowler RA, Bhagwanjee S et al. Critical care and the global burden of critical illness
in adults. Lancet 2010; 376: 1,339–1,346.
17. Aylin P, Yunus A, Bottle A et al. Weekend mortality for emergency admissions. A large,
multicentre study. Qual Saf Health Care 2010; 19: 213–217.
18. Deaths in Acute Hospitals: Caring to the End? NCEPOD. http://www.ncepod.org.uk/2009report2/
Downloads/DAH_report.pdf.
19. Bennett-Guerrero E, Hyam JA, Shaefi S et al. Comparison of P-POSSUM risk-adjusted mortality
rates after surgery between patients in the USA and the UK. Br J Surg. 2003; 90: 1,593–1,598.
20. Clarke A, Murdoch H, Thomas MJ et al. Mortality and postoperative care after emergency
laparotomy. Euro J Anaesthesiol 2011; 28: 16–19.
21. Khuri SF, Henderson WG, De Palma RG et al. Determinants of long-term survival after major
surgery and the adverse effect of postoperative complications. Ann Surg 2005; 242: 326–341.
22. Itani KM, Denwood R, Schifftner T et al. Causes of high mortality in colorectal surgery: a review
of episodes of care in Veterans Affairs hospitals. Am J Surg 2007; 194: 639–645.
23. Clinical guideline 50 – Acutely ill patients in hospital. NICE. http://www.nice.org.uk/CG50.
24. Department of Health. Competencies for Recognising and Responding to Acutely Ill Patients in
Hospital. London: DH; 2009.

28 References
25. Ghaferi AA, Birkmeyer JD, Dimick JB. Variation in hospital mortality associated with inpatient
surgery. N Engl J Med 2009; 361: 1,368–1,375.
26. Levy MM, Dellinger RP, Townsend SR et al. Surviving Sepsis Campaign: results of an international
guideline-based performance improvement program targeting severe sepsis. Crit Care Med 2010;
38: 367–374.
27. Kumar A, Kazmi M, Ronald J et al. Rapidity of source control implementation following onset of
hypotension is a major determinant of survival in human septic shock. Crit Care Med 2004; 32
(Suppl): A158.
28. Care of the Critically Ill Surgical Patient Course. Available around the country, organised by The
Royal College of Surgeons of England (www.rcseng.ac.uk).
29. Sundararajan V, Korman T, Macisaac C et al. The microbiology and outcome of sepsis in Victoria,
Australia. Epidemiol Infect 2006; 134: 307–314.
30. Angus DC, Linde-Zwirble WT, Lidicker J et al. Epidemiology of severe sepsis in the United States:
analysis of incidence, outcome, and associated costs of care. Crit Care Med.2001; 29: 1,303–1,310.
31. Annane D, Aegerter P, Jars-Guincestre MC, Guidet B. Current epidemiology of septic shock: the
CUB-Rea Network. Am J Respir Crit Care Med 2003; 168: 165–172.
32. ASGBI survey on Emergency Surgery, 2010. ASGBI. http://www.asgbi.org.uk/en/members/asgbi_
surveys.cfm
33. The Royal College of Surgeons of England. Emergency Surgery: Standards for unscheduled
surgical care. London: RCSE; 2011.
34. Risk Predication in Surgery. http://www.riskprediction.org.uk/index.php
35. CardioQ-ODM (oesophageal Doppler monitor): consultation document. NICE. http://guidance.
nice.org.uk/MT/80/Consultation/DraftNICEGuidance
36. Powell-Tuck J, Gosling P, Lobo DN et al. British consensus guidelines on intravenous fluid therapy
for adult surgical patients. Redditch: BAPEN; 2008. Available from http://www.bapen.org.uk/pdfs/
bapen_pubs/giftasup.pdf
37. Gawande AA, Kwaan MR, Regenbogen SE. An Apgar Score for Surgery. J Am Coll Surg 2007; 204:
201–208.
38. Peden CJ. Improving outcome in high risk surgical patients. Practicum for Masters in Public Health
(Clinical Effectiveness). Boston: Harvard School of Public Health; 2009.
39. Resar R, Pronovost P, Haraden C et al. Using a bundle approach to improve ventilator care
processes and reduce ventilator-associated pneumonia. Jt Comm J Qual Patient Saf 2005; 31:
243–248.
40. Critical Care Level. NHS Data Model and Dictionary Service. http://www.datadictionary.nhs.uk/
data_dictionary/attributes/c/cou/critical_care_level_de.asp?shownav=1
41. The Intensive Care Society. Levels of Critical care for Adult Patients. Standards and Guidelines.
London: ICS; 2009.
42. Needleman J, Buerhaus P, Pankratz V et al. Nurse staffing and in-patient hospital mortality. N Engl
J Med 2011; 364: 1,037.
43. Prytherch DR, Whiteley MS, Higgins B et al. POSSUM and Portsmouth POSSUM for predicting
mortality. Br J Surg 1998; 85: 1,217–1,220.
44. Wenkui Y, Ning L, Jianfeng G et al. Restricted peri-operative fluid administration adjusted by
serum lactate level improved outcome after major elective surgery for gastrointestinal malignancy.
Surgery 2010; 147: 542–552.
45. Eriksson LI, Sundman E, Olsson R et al. Functional assessment of the pharynx at rest and
during swallowing in partially paralyzed humans: simultaneous videomanometry and
mechanomyography of awake human volunteers. Anesthesiology 1997; 87: 1,035–1,043.
46. Frank SM, Fleisher LA, Breslow MJ et al. Periopertaive maintenance of normothermia reduces the
incidence of morbid cardiac events: A randomised clinical trial. JAMA 1997; 277: 1,127–1,134.

References 29
47. Heier T Caldwell JE, Sessler DI, Miller RD. Mild intraoperative hypothermia increases duration
of action and spontaneous recovery of vecuronium blockade during nitrous oxide-isoflurane
anaesthesia in humans. Anesthesiology 1991; 74: 815–819.
48. Heier T, Clough D, Wright PM et al. The influence of mild hypothermia on the pharmacokinetics
and time course of action of neostigmine in anesthetised volunteers. Anesthesiology 2002; 97:
90–95.
49. Clinical guideline 65 – Perioperative Hypothermia (inadvertant). NICE. http://www.nice.org.uk/
CG65.

30 References
The Royal College of Surgeons of England
35–43 Lincoln’s Inn Fields
London WC2A 3PE.
www.rcseng.ac.uk
Registered charity no 212808