Hospitals performing lower volumes of surgeries pose greater mortality risk to patients, report finds

Some patients in need of complex emergency surgery are at higher risk of complications or dying because of the level of expertise in hospitals carrying out a low volume of surgeries, a new report warns today.

Doctors operating on them may not be seeing enough of these cases, the report states, and thus lower volumes are associated with worse outcomes and higher levels of mortality for patients.

This is not just a problem confined to some smaller hospitals, but is found in bigger centres, according to the report “Surgery for Ireland” from the Royal College of Surgeons of Ireland (RCSI).

In particular, emergency abdominal surgery carried out by surgical teams seeing lower numbers of these patients is associated with a higher level of mortality, it said.

The report calls for an overhaul of how emergency services are organised, with the setting up of new networks which would see fewer hospitals doing emergency surgery and more surgeons working across more than one site.

The report said Irish research showed a relationship between volume and outcome for emergency surgery.

A national analysis of emergency abdominal surgery in Irish hospitals found an overall in-hospital mortality rate of 76 per 1,000 discharges for emergency abdominal surgery, which is comparable to other developed countries.

“A considerable survival advantage was observed when patients are managed by higher-volume surgical teams,” the report states.

Hospitals with 3,000 to 4,000 emergency admissions a year do best for outcomes.

The authors said although high-volume surgeons are more likely in bigger hospitals, some surgeons in smaller hospitals perform a similar or greater number of emergency abdominal surgery.

“These surgeons can achieve comparable mortality outcomes despite working in lower-volume hospitals,” it added.

In contrast, patients of low-volume surgeons in bigger hospitals had relatively poorer outcomes despite the availability of better supports are demonstrated to improve care.

The report highlights the onerous rotas some surgeons face carrying out complicated surgery during the day and then frequently being on call for emergencies  out of hours which can impact quality.

Emergency admissions receiving general surgery, colorectal surgery or non-operative surgery in 2019 varied from 5.5pc in University Hospital Limerick to 25.8pc in the Ireland East Group which contains some of biggest hospitals in Dublin.

There is also evidence of variation in practice among hospitals in the number of patients admitted as an emergency under the care of a general surgeon who do not undergo an operation.

These were highest in Kilkenny and Mullingar, Co Westmeath, and lowest in the Mercy Hospital, Cork, and St James’s Hospital, Dublin.

Other issues highlighted include the dependence on locum doctors.

Access to emergency surgery can be retained in a large number of hospitals, for example, 8am to 8pm, without the requirements for availability of overnight surgical activities.

It called for acute surgical assessment units with a senior decision-maker.

RCSI vice-president Professor Deborah McNamara said greater life expectancy among Irish people means that emergency-surgery patients are more complex and have greater co-morbidity. At the same time, advances in surgery, interventional radiology and endoscopy mean that more treatment options than ever before are now available to surgeons and their patients.

“The majority of emergency operations can be delivered safely in most hospitals but the current system, with onerous on-call rotas and low volumes of high-risk cases in many hospitals, makes it difficult for the more complex emergency patients to receive the care they need,” she said.

“Emergency surgery is safest when performed during normal working hours by fully trained staff and where sufficient volumes of surgery are performed to maintain the expertise of the multidisciplinary emergency surgery team.”