Surgical Mortality in Europe

A fascinating paper just published in the Lancet, outlining rates of mortality up to 7 days post operatively across 28 European countries. Data on over 46000 patients was collected. Crude mortality ranged from 1.2% of all cases in Iceland to >20% in Latvia. When adjusted for confounding variables, e.g. smoking, COPD etc, there was a TEN FOLD difference between the best and worst performing systems.

"When compared with the UK, the recorded mortality rates for Poland, Latvia, Romania, and Ireland were higher even after adjustment for all identified confounding variables. This pattern could relate to cultural, demographic, socioeconomic, and political differences between nations, which might affect population health and health-care outcomes."

However there may be other explanations, including the size and volume of surgical units, availability and expertise of intensive care, staffing, training and use (or lack of use) of approaches known to reduce morbidity and mortality such as pre-operative briefings (Gawande and others), appropriate antimicrobial prophylaxis and VTE prophylaxis. Regardless of the cause, yet again we see evidence of huge variation. Time to start learning why this exists. 
 

Gawande and 200 years of surgery

A wonderful piece of writing from Medicines prose laureate. This comes from the NEJM 200th anniversary series and Atul Gawande writes about the history of surgery. My favourite paragraph,

"It would take a little while for surgeons to discover that the use of anesthesia allowed them time to be meticulous. Despite the advantages of anesthesia, Liston, like many other surgeons, proceeded in his usual lightning-quick and bloody way. Spectators in the operating-theater gallery would still get out their pocket watches to time him. The butler's operation, for instance, took an astonishing 25 seconds from incision to wound closure. (Liston operated so fast that he once accidentally amputated an assistant's fingers along with a patient's leg, according to Hollingham. The patient and the assistant both died of sepsis, and a spectator reportedly died of shock, resulting in the only known procedure with a 300% mortality.)"

Risky Business

A report has just been published by the Royal College of Surgeons of England entitled “The Higher Risk General Surgical Patient: towards improved care for a forgotten group”. It is a very sobering examination of the outcome in non cardiac emergency surgery.

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. 

The most amazing statistic in this paper is the fact that “Complications occur in as many as 50% of patients undergoing some common procedures.”
My pet interest of variation in care and outcomes is addressed.

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.

Anyone involved in ensuring good outcomes for surgical patients, or ensuring that hospital resources are used efficiently, (by reducing unnecessary complications) needs to read this.
 
 

Bundles of joy or of sorrow?

The idea of bundles makes intuitive sense, gather together some evidence based interventions and ensure they are implemented reliably all the time, sit back and watch the magic. Pronovost showed the power of bundles in his NEJM paper some years ago. An observational study by Jarman and others in the BMJ last year suggested that using various bundles in a large London hospital was associated with a large reduction in hospital mortality.
So along come the surgeons to upset the consensus. A study in Archives of Surgery compared standard institutional practice with an extended bundle of interventions, all of which had been previously demonstrated in isolation to be effective. These interventions included:

1. No pre-operative bowel preparation
2. Pre-operative and intra-operative patient warming
3. Supplemental oxygen intra and post operatively
4. Intra-operative fluid restriction
5. Use of a surgical wound protector 

Over 200 patients were studied; main outcome measure was surgical site infection rate at 30 days as assessed by blinded infection control experts. The rate of SSI in the control group was 24%, vs. 45% in the bundle arm. Most of these SSIs were superficial.

Any explanation? Its possible that the interventions are ineffective, or less likely that they are counter synergistic, i.e. although singly beneficial, when combined they counteract one another. Alternatively even positive studies may due to chance be negative. The main concern though apart from giving ammunition to those who wish to reject the benefits of standardisation is that there will be a call for more RCTs in this and every other areas. While we have traditionally believed that RCTs are the gold standard, Ioanniddis work is even questioning this dictum. The other big problem in conducting RCTs is that we assume that apart from the intervention being studied, all other factors are uniform. This is clearly  not the case, and this has proven to be a difficult obstacle to surmount in trials of equipment such as new ventilators.

Checklists

Since the study published two years ago in the New England Journal of Medicine by Gawande, which showed the value of checklists in reducing surgical morbidity and mortality in a variety of care settings, developed and developing world, there has been increasing interest in the benefits of checklists in improving patient safety. However the Gawande study has been criticized on a number of fronts, with many people doubting the benefits. The cardinal message of that study was that each of us, no matter how brilliant, will make mistakes. The purpose of the checklist is to reduce the risk of each team member making a mistake. Importantly, two major studies have just been published, which support Gawande's contention that the use of checklists are associated with improved outcomes. De Vries et al writing in the NEJM report a dramatic reduction in mortality and complications.

Neily et al writing in JAMA last month report similarly impressive results. It would appear that the jury is in; the use of checklists as part of a comprehensive approach to reducing surgical complications appears to be proven. Let the checklist reign.