Introduction Emergencies make up greater than one third of all general surgical admissions with many of these patients being elderly with significant co-morbidities. Mortality in this group is high, varying from 15–25%. Concerns over the quality of emergency surgical care prompted the formulation from RCS: Standards for unscheduled care. Using the standards set by this guideline, the practice in a DGH was audited. Primary focus was consultant presence in cases with predicted mortality >10%.
Method Theatre Management System from 01/09/12–31/07/13 identified all emergency laparotomies. All cases were reviewed and elective, non-colorectal and re-laparotomies were excluded. Patient charts were reviewed and a predicted perioperative mortality (Portsmouth-POSSUM score) calculated. Specific outcomes included consultant presence, procedure performed, post-operative level of care and complications.
Results In total 188 laparotomies were identified with 40 emergency colorectal cases. The mean age was 74 years with a male to female ratio of 45:55. Sepsis was the indication in 58% of cases. The mean P-POSSUM was 29.85% (range 1–87) with an observed 30 day mortality of 30%. Benign pathology accounted for 65% of cases with maliganacy the remaining 35%.
Patients operated on a Saturday and Sunday had a mortality of 50–60% with the remainder of the week between 14–25%. Time of day also had an affect on mortality as, whilst only 20% of patients were operated on after midnight, mortality was 50%. In comparison 53% were operated during normal working hours (8 am–5 pm) with a morality of 24%.
A consultant surgeon was present at 80% of all cases, with 76% present at those with a P-POSSUM >10%. Consultant anaesthetist was present at 62.5% and 64% respectively. For patients who died a consultant anaesthetist was only present at 40% of these cases with surgeon at 75%. Neither surgeon nor anaesthetist was present at 25% of these cases.
Conclusion Emergency laparotomy for acute colorectal pathology carries a high morbidity and mortality. In 35% of patients this was an acute presentation of colorectal cancer. Our results are broadly comparable with national figures and consultant presence was generally good. There was a trend towards reduced mortality when present, in particular anaesthetic presence. Use of a tool, such as P-POSSUM may help to highlight cases which would benefit from consultant level anaesthetic and surgical input. A regionally agreed emergency surgery checklist may help guide critical care referral and senior review.
Disclosure of interest None Declared.
Royal College of Surgeons: Emergency surgery, standards for unscheduled care, February 2011
NELA: Organisational Report of the National Emergency Laparotomy Audit, May 2014