Global patient outcomes after elective surgery: prospective cohort study in 27 low-, middle- and high-income countries

Abstract

Background: As global initiatives increase patient access to surgical treatments, there remains a need to understand the adverse effects of surgery and define appropriate levels of perioperative care.Methods: We designed a prospective international 7-day cohort study of outcomes following elective adult inpatient surgery in 27 countries. The primary outcome was in-hospital complications. Secondary outcomes were death following a complication (failure to rescue) and death in hospital. Process measures were admission to critical care immediately after surgery or to treat a complication and duration of hospital stay. A single definition of critical care was used for all countries.Results: A total of 474 hospitals in 19 high-, 7 middle- and 1 low-income country were included in the primary analysis. Data included 44 814 patients with a median hospital stay of 4 (range 2–7) days. A total of 7508 patients (16.8%) developed one or more postoperative complication and 207 died (0.5%). The overall mortality among patients who developed complications was 2.8%. Mortality following complications ranged from 2.4% for pulmonary embolism to 43.9% for cardiac arrest. A total of 4360 (9.7%) patients were admitted to a critical care unit as routine immediately after surgery, of whom 2198 (50.4%) developed a complication, with 105 (2.4%) deaths. A total of 1233 patients (16.4%) were admitted to a critical care unit to treat complications, with 119 (9.7%) deaths. Despite lower baseline risk, outcomes were similar in low- and middle-income compared with high-income countries.Conclusions: Poor patient outcomes are common after inpatient surgery. Global initiatives to increase access to surgical treatments should also address the need for safe perioperative care.Study registration: ISRCTN51817007

An investigation of barriers to the use of the World Health Organization Surgical Safety Checklist in theatres

“…An Australian study that investigated negative events associated with surgery found that 21.9% of surgical admissions were associated with an adverse event, and that 47.6% of these were preventable complications. [2] In more recent studies, the International Surgical Outcomes Study (ISOS) showed that 16.8% of patients developed complications, with a mortality rate of 2.8%, [3] the European Surgical Outcomes Study (EuSOS) showed a mortality of 4%, [4] and in the South African Surgical Outcomes Study (SASOS) the mortality was 3.1%, with the highest hospital mortality being 9.5% [5] Efforts to decrease adverse events and improve patient safety led to the Safe Surgery Saves Lives programme and subsequently to the World Health Organization Surgical Safety Checklist (WHO SSCL). [6] The WHO SSCL was introduced in 2008 and is aimed at improving patient safety and inter-discipline communication and preventing avoidable complications by emphasising current safety procedures.…”

Smartphones and e-tablets in perioperative medicine

“…Recent studies have shown that around one third of deaths after surgery occur in the wards [ 2 ]. This situation has been called « failure to rescue » and has been proposed to explain why hospitals with comparable postoperative morbidity rates may have very different mortality rates: outcome depends more on the ability to detect early and treat properly postoperative complications than in the occurrence of complications [ 17 ].…”

“…There are over 320 million inpatient surgical procedures worldwide [ 1 ]. We learn from the recent International Surgical Outcome Study [ 2 ] that around 17% of these patients develop one or more complications, and among them, that 2.8% die from their complications. One can therefore estimate that around 1.5 million patients/yr (or 3 patients/min!)…”

Post-operative immune suppression is mediated via reversible, Interleukin-10 dependent pathways in circulating monocytes following major abdominal surgery

“…The most prevalent adverse event complicating major surgery is infection [ 1 ]. More than 30% of patients admitted to the surgical ICU following elective inpatient gastrointestinal surgery receive antibiotics at some stage during their hospital admission to treat a clinically significant infection [ 2 , 3 ].…”