Improvements in care could save the lives of more acute bowel obstruction patients

"Delay in Transit," published by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD), reviewed 686 cases of patients aged 16 and over, in an attempt to improve the high mortality rates for the condition which are currently at around 10 percent in cases where surgery is needed.

Matt Lee, NIHR clinical lecturer in general surgery at the University of Sheffield Medical School, and specialist in the area, led a National Audit of Small Bowel Obstruction in 2017 and was asked to use experience from this to support the new study.

He said: "There are over 22,000 admissions for bowel obstruction in England and Wales each year, of whom 6.4 percent will die within 90 days.

"At the moment, there is considerable variation in both patient care and outcomes. This includes delays in patients experiencing a bowel obstruction being diagnosed and receiving treatment and aftercare."

The study identified the key causes of delays to treatment, finding that in almost 21 percent of cases, there was a delay in providing a CT scan of the patient. In these cases, 61 percent of patients were then subsequently delayed in being diagnosed.

This compared to just six percent if there was no delay in diagnostic imaging. Following diagnosis, around 20 percent of patients saw a delay to their surgery, which in all cases was either due to an operating theatre not being available, or there being no anesthetist.

There was also found to be room for improvement in clinical care, with only 55 percent of patients being subject to an "adequate" risk assessment, and only 38 percent having a nutrition assessment when they were discharged.

"Delay in Transit" makes a series of 11 new recommendations for caring for those with acute bowel obstruction, including:

• Undertaking a CT scan with intravenous contrast promptly to ensure timely diagnosis.
• Undertaking a consultant review in all patients with acute bowel obstruction as soon as clinically indicated, and within 14 hours of admission at the latest
• Measure and document the hydration status of those presenting with symptoms of acute bowel obstruction to minimize the risk of acute kidney injury
• Ensure local policies are in place for the escalation of patients requiring surgery to enable rapid access to an operating theatre.
• Minimise delays to diagnosis and treatment by auditing the time taken between each step in the patients' treatment

Mr Lee said: "These are areas we have the ability to make changes easily which will have a direct benefit for patient outcomes.

"Patients with a bowel obstruction cannot eat properly and our previous report highlighted areas such as the lack of clinical guidelines for monitoring the nutritional intake for this group of patients. This report builds on our research and recommends the need for clinical processes to be introduced such as frequent and repeated assessments of nutritional status, and supporting nutrition where needed.

"Acute bowel obstruction is a common condition, the most common cause of which is blockage of the bowel by scar tissue from previous surgery and close to one in five patients have bowel obstruction because of this.

"As a general surgeon, I'm passionate about improving the care of emergency conditions and this condition has outcomes that could be improved. Emergency care is under great pressure at the moment, so working to improve what we can is vitally important."

Further recommendations from the report include monitoring pain levels throughout a patients' admission, undertaking a review from a nutrition team on diagnosis, and ensuring that special measures are taken for patients with a high level of frailty.