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NELA - The National Emergency Laparotomy Audit

One of the most common operations performed for non-elective patients is the emergency laparotomy. An emergency laparotomy is a complex procedure with limited time for planning and patient optimisation, and the mortality far exceeds that of elective bowel surgery. In the UK NELA (The National Emergency Laparotomy Network) aims to look at the structure, process and outcome measures for the quality of care received by patients undergoing emergency laparotomy surgery.

History and aims

More than 30,000 patients have an emergency laparotomy each year in England and Wales. [1] The majority of patients who undergo this procedure have potentially life-threatening conditions needing urgent investigation and management. Many of these patients are high risk and it has been shown that around 15% of patients die within one month of having their operation. [2]

The patients’ journey is often complex requiring input from multiple specialties - from the emergency department through to actual surgery, involving Radiologists, Anaesthetists, Surgeons, Critical care and Geriatricians.

The aim of NELA is to provide robust data on care of the emergency laparotomy patient to drive local quality improvement projects and also allow good practice to be disseminated easily.

All patients aged 18 and over having a general surgical emergency laparotomy (in NHS hospitals in England and Wales) are prospectively enrolled in the project. NELA aims to compare care delivered against standards identified from NCEPOD reports and the Department of Health / Royal College of Surgeons report on the higher risk general surgical patient [3] (which we covered in week 1 of the course).

As well as the broad aims outlined above the project also has more specific objectives:

  • To enable improvement of delivery of care to the emergency laparotomy patient using audit information
  • To provide comparative information on the organisation of care
  • To provide comparative information on patient outcomes following surgery
  • To explore potentials for patient reported outcome measures to be included where possible

The most recent (3rd) patient report [4] was published in July 2016 and reports on data collected from December 2015 to November 2016. A brief summary is included below but the full report can be accessed here.

Key standards

The data submitted by local hospitals was audited against 9 key standards:

  1. CT scan reported before surgery.
  2. Risk of death documented preoperatively.
  3. Arrival in theatre within a timescale appropriate to urgency.
  4. Preoperative review by a consultant surgeon and a consultant anaesthetist when P-POSSUM risk of death ≥5%.
  5. Consultant surgeon and consultant anaesthetist both present in theatre when P-POSSUM risk of death ≥5%.
  6. Consultant surgeon present in theatre when P-POSSUM risk of death ≥5%.
  7. Consultant anaesthetist present in theatre when P-POSSUM risk of death ≥5%.
  8. Admission directly to critical care after surgery when P-POSSUM risk of death >10%.
  9. Assessment by a care for the older person specialist for patients aged 70 years and over.

Key findings

Detailed and local feedback can be found in the main report. However, the overall national adherence with the above standards is summarised in the 2 figures below.

View the graphics on Page 9 of the full document.

The reported 30-day mortality was 10.6%, which confirms the high-risk nature of emergency bowel surgery.

This report showed marked improvements in standard of care delivered (see table 1 below), although areas for improvement still remain.

Key recommendations

Clinicians, hospital managers and commissioners should examine their own results and seek to determine why some patients meet the standards of care identified and why others do not and in doing so seek to deliver more consistent high-quality care. NELA suggest the following key recommendations, the details and data justifying them can be found in the relevant chapters in the original report

Commissioners and providers

Commissioners should review the audit reports for the hospitals for which they provide services. Where the hospitals fall short of standards they should ensure there is adequate commissioning of:

  • Capacity to provide consultant-delivered care, multidisciplinary specialist input, and reliable access to other services, such as CT scanning and reporting, throughout the whole patient journey, regardless of the time of the day or the day of the week
  • Theatre capacity to prevent delays for patients requiring emergency bowel surgery, particularly those requiring surgery within two hours
  • Critical-care capacity to match high-risk caseload, such that all high-risk emergency laparotomy patients can be cared for on a critical care unit after surgery – expected critical care capacity can be modelled from NELA data
  • Care of older people services to provide input for older patients
  • Formal networks to support smaller hospitals in providing acute diagnostic and interventional radiology and endoscopy services

Hospital chief executives and medical directors

In order to deliver high-quality care that meets standards to high-risk emergency patients, attention should be directed at organisational change in the following areas, working towards:

  • Ensuring that care is delivered by consultant anaesthetists and surgeons for high risk emergency laparotomy patients 24 hours per day, seven days per week. Rotas, job plans and staffing levels for surgeons and anaesthetists should reflect this.
  • Ensuring that older patients undergoing emergency laparotomy receive care from geriatricians to the same extent as older patients undergoing hip-fracture repair.
  • Developing policies and supporting training in the use of individual patient risk assessment to guide allocation of resources (e.g. critical care) appropriate to the patient’s needs.
  • Providing emergency theatre capacity that is sufficient to enable patients to receive emergency surgical treatment, particularly those who need surgery within two hours. Prioritisation of time-sensitive emergency surgery can be facilitated by policies for the deferral of elective activity
  • Adhering to national standards for postoperative critical care admission. This may require an increase in critical care capacity so that emergency and elective care can continue in parallel
  • Supporting and facilitating local NELA Leads and perioperative teams to improve care, by ensuring adequate time and resources to support accurate data collection, review adverse patient outcomes and to feed this back to clinical teams and hospital management (including at Board level).
  • Ensuring that clinical coding of procedures is accurate, and embedding links between clinical-coding departments and clinicians to improve this.

Clinical directors and multidisciplinary leadership teams

Hospitals should implement appropriate pathways for the care of emergency general surgical patients, starting at the time of admission to hospital or referral by another team. Multidisciplinary teams (MDTs) should examine these in the light of audit data to determine their efficacy, and identify where and why standards are still not met. Pathways should cover the following areas:

  • Referral of patients for general surgical review if they have been admitted under non-surgical specialties
  • Identification of patients with signs of sepsis, and ensuring the prompt prescription and administration of antibiotics
  • Identification and escalation of patients who would benefit from the early involvement of both consultant surgeons and consultant anaesthetists
  • Rapid request, conduct, and reporting of CT scans
  • Routine documented assessment of the risk of complications and death from surgery
  • Presence intraoperatively of a consultant surgeon and a consultant anaesthetist for high-risk patients with a predicted mortality ≥5%
  • Consideration of admission to critical care for all high-risk patients with a predicted mortality ≥5%
  • Identification of patients who would benefit from input from geriatricians in their perioperative care.

In addition:

  • Every case should have a preoperative risk score, but care must not be provided purely on the basis of a predicted risk score, but utilised as part of the global assessment of a patient.
  • MDT’s should hold regular joint meetings to continuously review essential processes of care and perioperative morbidity and mortality following emergency laparotomy.
  • Continuous quality improvement informed by local data should involve monitoring the impact of care-pathway and process changes with time-series data.

In the next step we will look at an important quality improvement project centred on improving care for emergency laparotomy patients. Before learning about that take a moment to think about the findings and recommendations highlighted in the NELA report. Do they reflect what you see in your own practice? What systems and practices could be changed in your place of work to improve care for the emergency laparotomy patient?


References

  1. Symons N.R.et al. (2013). Mortality in high-risk emergency general surgical admissions. Br J Surg. Sep;100(10:1318-25

  2. Saunders, D.I., Murray, D., Pichel, A.C., Varley, S., Peden, C.J. (2012). Variations in mortality after emergency laparotomy: the first report of the UK Emergency Laparotomy Network. Br J Anaesth. 109(3):368-275

  3. The higher risk general surgical patient

  4. The Third Patient Report of the National Emergency Laparotomy Audit

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This article is from the free online course:

Perioperative Medicine in Action

UCL (University College London)

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