There are more than 600,000 emergency general surgery admissions per year in England. These patients comprise about 50 percent of general surgical workload but make up 80-90 percent of all general surgical deaths. In recent years surgical colleges and societies in the UK have warned of significant variability in the quality of care between hospitals but, to date, little formal evaluation of the quality of care in emergency general surgery exists.
This thesis uses the Structure/Process/Outcome quality assessment framework, devised by Avedis Donabedian, to examine quality of care in emergency general surgery across all three of these domains.
A study of high risk emergency general surgical admissions using the administrative Hospital Episode Statistics dataset demonstrated significant variability in 30-day in-hospital mortality between NHS Trusts. Investigation of NHS Trust structure was performed using data from the Department of Health. There were significant differences in the provision of intensive care beds and in the utilization of computed tomography and ultrasound scanning between low mortality and high mortality NHS Trusts.
The process of care was assessed using an explicit checklist for the admission phase of care and using ethnographic field notes for patients’ subsequent hospital stay. Across 5 London hospitals, process reliability during admissions to hospital was poor, with nearly 20% of recommended processes omitted. Failures in the process of care were also common in subsequent ward based care. Failures were considered to be highly preventable and frequently caused harm to patients or delayed their discharge.
Overall, this thesis has identified significant variability in the quality of care for emergency general surgical patients in structure, process and outcomes. While the thesis does not evaluate every single aspect of patient care it demonstrates the degree of improvement required in emergency surgical care and provides some recommendations for future quality improvement.