Use of real time mortality risk assessment to inform standards of surgical care in a District General Hospital

Abstract

The Royal College of Surgeons of England recently published guidance in the 'Higher Risk General Surgical Patient' with standards linked to the patients' predicted mortality. Where predicted mortality exceeds 5%, there should be active consultant input in the diagnostic, surgical, anaesthetic and critical care elements of the patient pathway. The aim of this study was assess use of web based risk assessment tool to enable surgical teams to follow these standards. Methods: We set up a web based risk assessment tool based upon PPOSSUM which calculates patients predicted mortality and automatically prompts the surgical and anaesthetic teams which standards are relevant to their patient. The database allows audit against these standards, some of it in real time as a performance dashboard. It has allowed us to continuously assess our risk adjusted mortality rate. The availability of predicted mortality has enabled more informed discussions with patients preoperatively. We have found it to be a useful training tool for surgical and anaesthetic staff in 'calibrating' their views about surgical risk. Results: To date we have data from 290 general surgical abdominal procedures both elective and emergency. There are 47 patients with predicted mortality >= 5%, < 10% and 108 with predicted mortality >= 10%. For patients with predicted mortality >= 5%, 97% had surgery performed by a consultant and 91% had anaesthesia provided by a consultant. For patients with predicted mortality >= 10%, 93% went to critical care post operatively. The overall standardised mortality ratio for the group of patients was 0.66. These represent high levels of compliance with the RCoS standards. Conclusion: The use of real time risk assessment and audit can inform clinical decision making and drive improvement in care.