Post-operative management following discharge – red flags

Posted: 30/01/2023

Following on from the introduction to the 2023 surgical series, this article considers what are known as ‘red flags’ in surgical care, and how they should be managed.

After surgery there will be a necessary period of recovery. Depending upon the surgery that has been carried out, how invasive the surgery was, the area of the body that was operated on and the type of surgery undertaken, the requirement and nature of that recovery will be different. For example, there may be an almost immediate discharge, or a short inpatient stay; otherwise, there may be a planned or emergency period in ICU. 

The nature of any rehabilitation and recovery advice will depend upon the surgery that has been required, whether the surgery itself was planned or an emergency, and also the individual patient and their support at home.

The general rule in medical care is that the patient should be discharged home as soon as it is safe to do so. It is regarded as safer in most cases for a patient to recover at home, provided there is the necessary support, that the pain is well controlled, and as long as appropriate advice is given on wound care and physical activity. Antibiotics will often, but not always, be prescribed as infection is a known risk following many surgeries.

It is usual when being discharged from hospital after surgery to be advised of possible warning signs of post-operative symptoms that may require follow up, and the timescale for that follow up, whether that requires a return to the hospital via the A&E department, or a more routine, but prompt, GP review. 

When an individual remains in hospital for a period of time following surgery, it is generally not the case that they will need the same information about these warning signs, as they remain under the care of the medical team as an inpatient. Unfortunately, problems can still arise in an inpatient setting – this will be discussed in an article later in this series.

In both settings, either recovering at home or in hospital, problems can occur. This can be because, for example, appropriate ‘safety netting’ advice is not given. ‘Safety netting’ requires an individual who is being safely discharged home to be warned of the possible symptoms that may occur, whether there is a scale of concern about the presentation of those symptoms, and what steps to take if those symptoms arise. There are symptoms that would usually require a patient to seek immediate medical attention*:

• there is fluid discharge from the wound which is leaking through the dressing;
• the area surrounding the surgical site becomes inflamed (ie red / hot);
• the wound has a foul-smelling odour;
• you have a temperature and/or feel feverish and/or have shakes and shivers;
• you have chest pain or pain with breathing, or you are short of breath;
• you have calf pain;
• there is excessive swelling;
• the pain is excessive or suddenly uncontrolled.

It is important in these instances to seek medical advice. This may be in the first instance speaking to your surgeon (if that is possible), the hospital, your GP or the minor injuries unit. Any symptoms which are new, or that are worsening/not resolving as you would have expected, should be reviewed. 

Sometimes simple reassurance is required, but in other cases it may be that an infection has developed, that alternative antibiotics are required, or even further surgery is needed to debride the wound and to ensure good recovery. Immobility as a result of surgery and recovery is also a risk factor for blood clots, and there is a risk of DVT’s (deep vein thrombosis – a type of blood clot in a deep vein, usually the leg) and PE (pulmonary embolism – a type of blood clot in the lung ) developing. These are very serious and can be fatal complications, meaning immediate medical attention is required.

Unfortunately, we see cases where there has been inadequate safety netting advice given before discharge and, where the advice is appropriate, there has been a failure to appropriately respond and manage post-operative symptoms after patients have been discharged.

This is sometimes because of failure to consider the nature and seriousness of the symptom described, failure to ask the patient to reattend for a physical examination, with advice only being given over the telephone, or failure to have an assessment more locally (with their GP, for example).

We have cases where there has been an assessment, but the assessment and management are incomplete. In these cases, the opportunity is missed for earlier intervention which increases the risk of worsening symptoms and illness, and of further complications developing.  This can prolong the recovery from surgery, having an impact on an individual’s ability to return to work and to their day to day lives. The effects can sometimes be much more serious.

Penningtons Manches Cooper has a specialist team of surgical negligence solicitors who deal with the full spectrum of surgery related medical negligence claims. If you think you may have a surgical claim, even if the type of claim has not been mentioned above, please do not hesitate to get in touch with a member of the team for an initial discussion.

* These are general examples and are not intended as medical advice.

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• Informed consent: what is the duty of care required of doctors when advising patients on their treatment options

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