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Improving outcomes in emergency surgery

Over the past century, safety and quality of care in elective surgery have improved considerably, leading to better patient outcomes. A variety of factors have contributed to this, including support from perioperative medical specialties, improved equipment and technical advances, less invasive interventions and surgical specialization. This transformation of elective general surgery into a series of specialties has led to widespread concerns regarding the adequate provision of similar expertise for urgent presentations of surgical illness. Compared with the rising volume of elective surgery, only a minority of operations are performed as emergency, urgent or unplanned procedures. Emergency conditions, however, contribute considerably to the number of patients (up to 30–40 per cent) admitted to surgical departments. These admissions are associated with high mortality; almost 90 per cent of deaths occurring within 48 h of admission are emergencies1. They are associated with high rates of complications and significant costs for surgical departments2. Many of these conditions, such as the ‘acute abdomen’, need careful investigation, and require complex decision-making about management and the need for intervention, under the care of the surgical team. Several suggestions have been proposed to improve management of these patients, with the aim of providing safe care and better outcomes while minimizing costs. Most of these proposals centre around the creation of consultant-delivered surgical services and the introduction of ‘lean’ systems of care processes3. The global burden of emergency surgery is considerable, as reviewed in this issue of BJS. Challenges that face lowto mediumand high-income countries are similar, yet different. Developing countries may see more patients with emergency conditions that reflect a lack of resources, or emergency presentations of conditions generally treated electively in more affluent countries. In developed countries, the increasing proportion of elderly patients poses a different challenge. Older patients undergoing emergency surgery have an increased risk of complications4, and this increased risk can be reasonably predicted by a ‘frailty index’5, although the widespread use of risk stratification based on different scoring systems6 has not happened for acute surgical disease. Increasing economic pressure on healthcare systems in the Western world is one contributor to the increasing proportion of patients undergoing ambulatory or shortstay surgery. This has reduced the numbers of hospital beds. Patients admitted as an emergency consequently represent a larger part of the in-hospital patient population. This limitation affects urgent admissions, with delays in admission and overcrowding placing additional pressure on staff and resources. Emergency surgery units have been shown to reduce the time to surgical decision and avoid ‘crowding’ in the emergency department7. Claims have been made that concentration of acute-care surgery decreases mortality. It has also been shown that many ‘emergency’ operations performed at night in suboptimal circumstances can be postponed to the following day8. The prerequisite in adopting this strategy must be the provision of adequate and dedicated operating theatre resources during the day and evenings. Some data also seem to support the idea that an acute emergency surgery service reduces complications and hospital stay9. Organizational changes for the delivery of acute surgical care are challenging, but some healthcare systems have tackled this, notably in Finland and Australia. One of the challenges is to create a surgical career incorporating a commitment to acute surgery that seems as attractive as elective surgery. Measuring outcomes in emergency surgery is also problematic, particularly as new diagnostic and therapeutic modalities are introduced. Emergency surgery has been difficult to capture in databases in a similar way to elective surgery. A national clinical registry of emergency surgery is now established in Denmark, with quality-of-care projects released10. It is hoped that other countries will follow suit. Robust definitions are needed for estimation of global disease burden and to monitor quality of care. Quite recently, definitions that cover the scope of emergency general surgery based on the International Classification of Diseases (ICD), ninth revision, have been published11. These will facilitate the introduction of registries