Heart surgery safer at night

By Jeremy Laurance, Health Editor

Operations are now safest when carried out at night, according to a major investigation into deaths following heart surgery.

After decades in which the NHS has fought to reduce risks outside normal working hours, heart patients now get better care after 6pm and before 8am.

The explanation is that patients are more likely to be operated on by a consultant out of hours, rather than a junior surgeon, according to the National Confidential Enquiry into Preoperative Deaths (NCEPOD), whose report is published today.

The big expansion in consultant numbers in recent years and the cut in junior doctors' hours because of EU regulations is making round-the-clock hospital medicine safer – in contrast to primary care, where GPs are less available out of hours.

During the day, heart surgery is more often performed by junior doctors. Over 17 per cent of operations in normal hours were carried out by junior surgeons compared with under 1 per cent at night, investigators found.

George Findlay, intensive care consultant in Cardiff and an author of the report, said: "The message of these findings is not that heart patients should seek operations at night, but that if you need surgery you want to be reviewed by a consultant who makes the decision and is around to see it through."

"The quality of care is closely related to a senior doctor seeing the patient, doing the operation and being around to manage post-operative complications. Out-of- hours patients are more likely to have a senior doctor's input."

The investigators reviewed 800 coronary bypass operations in which the patient died, almost one in 10 of which were carried out at night. Overall, two-thirds of the 800 patients received sub-standard care, due to poor organisation or lack of teamwork. But those cases operated on at night, half of which were categorised as urgent, were more likely to receive an overall assessment of "good practice," it says.

Around 20,000 coronary bypass operations are performed each year in the UK and 1,198 deaths were reported in the three years to 2007. The death rate, at 2 per cent, has remained unchanged for a decade, despite the increasing age and infirmity of the patients being operated on.

But the investigators say there is still room for improvement. They assessed deaths occurring within 30 days of surgery in 39 NHS hospitals and 19 private hospitals in the UK and found poor care was more often due to poor organisation and communication than absence of technical skill.

Dr Findlay said: "We think there are things that can be done that could bring the death rate down further. In about 100 of the 800 cases we reviewed, patients developed complications that were not managed well and which may have led to an adverse outcome."

Professor Tom Treasure, chairman of NCEPOD, said: "The technical skill of the practitioners seems to be of a high standard and the outcomes are impressively good considering that this is a life-threatening disease. But ensuring the right people see the patients and pass them on in the right way is also critical."

Almost one in 10 patients was poorly assessed and the same proportion received inadequate pre-operative investigation. Private hospitals were better at handing over patients between clinical teams than NHS ones. More than one in 10 hospitals failed to provide written information to patients about their operations, the report found.