Published Research

Background: Scoring Systems for General Surgical Patients are receiving increased recognition and use because of the need for comparative audit between different surgeons and hospitals. The Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) and its Portsmouth modification P-POSSUM have been suggested as being an appropriate scoring system to use. Our study assessed the feasibility of using the scoring system in our patients.

Methods: All patients admitted over a six-month period, under the care of two Consultant Surgeons, were prospectively scored on admission. These scores were only awarded if all investigations necessary for the POSSUM score were performed; investigations unnecessary for effective treatment were not performed.

Results: 815 patient discharges were recorded over the six-month period, with 521 patients undergoing operative procedures. Of those undergoing an operation we were only able to allocate scores to 155 (30%).

Conclusion: Scoring Systems such as POSSUM are procedure based thereby excluding, by definition, those who do not undergo an operation. However, the majority of our operative cases were also excluded. These and other design flaws lead us to suggest that POSSUM is unlikely to be of use in the wider clinical setting of comparative audit.

Key words: Scoring systems-Audit-Workload

Background: Comparative surgical audit is increasingly important although fraught due to difficulties with risk adjusted analysis. Methods have been proposed to solve this problem and allow for meaningful comparisons of patient outcome. None have been described without faults, making this comparison flawed or overtly complicated. An alternative risk scoring system incorporating the CEPOD grade (Confidential Enquiry into Peri-operative Deaths), the ASA grade (American Society of Anesthesiologists) and the BUPA operative grade was formulated and assessed.

Methods: Prospective audit of 4308 patients admitted under the care of three surgeons between May 1997 and October 1999, creating an initial data set of 3144 procedures with 134 deaths. Each procedure allocated a score on the basis of the CEPOD, BUPA and ASA grade to devise a surgical risk scale (SRS) by adding together the values of the three variables, generating a scale ranging from 3 to 14. Multi-variate logistic regression analysis involving the three variables and uni-variate analysis of the SRS score were undertaken. Receiver operating characteristic and calibration curves were formulated. This process was validated on another data set (2780 patients) derived from all admissions to the same surgeons between November 1999 and December 2000.

Results: Uni-variate logistic analysis of the SRS score revealed it to be significantly predictive of death (b=0.84, p<0.001) and did not over predict mortality for low risk procedures.

Conclusion: The SRS is easy to use, formulate and interpret and that it provides an accurate prediction of mortality in general surgical patients across the entire 'risk' spectrum.

Objectives: To determine whether the temperature of local anaesthetic (1% lignocaine at 8°C, 21°C or 37°C) has any influence on the pain of injection experienced during minor Surgical procedures.

Design: Prospective, randomised, single blind trial.

Setting: Day surgery unit, district general Hospital.

Participants: 100 patients with benign skin lesions were recruited on a random basis over a one year period.

Measurement: Pain experienced by patient recorded on a visual analogue pain scale. The mean pain score of each three temperature groups were analysed using the non-parametric Kruskal-Wallis test.

Results: The median pain score of the three groups were compared. There was no significant difference in the pain experienced by patients in any of the groups (p=0.169)

Conclusions: The pain experienced during local anaesthetic infiltration is not influenced by the temperature of the local anaesthetic.There is no advantage to be gained by warming local anaesthetics in routine elective clinical practice.

Background: Current interest is focused on the use of POSSUM and p-POSSUM for risk-adjusted surgical audit. The Surgical Risk Score (SRS) has been shown to offer an equivalent accuracy. Whilst reflecting national general surgical practice, the validation of the Surgical Risk Score may be criticized for including a high proportion of low risk patients in the cohort. The aim of this study was to compare the accuracy of mortality prediction using SRS to POSSUM and p-POSSUM in a cohort of higher risk patients.

Method: 949 consecutive patients undergoing in-patient surgical procedures in a District General Hospital under the care of a single surgeon were analysed.

Results: Thirty day observed mortality was 8.4%. In comparison, estimated mean mortality calculated using SRS, POSSUM, p-POSSUM scores were 6.8%, 12.6% and 5.9% respectively. No significant difference was observed in the area under the Receiver Operating Characteristic (ROC) curves for the three methods.

Conclusion: The Surgical Risk Score accurately predicted mortality in higher risk surgical patients. The accuracy of prediction equalled that of the POSSUM and p-POSSUM. The Surgical Risk Score benefited from accuracy across the risk spectrum, simplicity, exclusion of bias from surgical factors and ready availability in all surgical patients.