The First Patient Report of the National Emergency Laparotomy Audit

1. The First Patient Report of the National Emergency Laparotomy Audit www.nela.org.ukinfo@nela.org.uk

2. NELA Aims • To improve the quality of care provided to patients undergoing emergency laparotomy through provision of high quality data • Facilitate local quality improvement • Provide comparative data at hospital level to allow identification of high performing sites • Only reporting at hospital level • emergency laparotomy care is a “team game” • clinician level reporting is not appropriate

3. THANK YOU for… 20,183 patients 70-80% case ascertainment (HES) 192 participating hospitals in England & Wales 7

4. THANK YOU for… 20,183 patients 70-80% case ascertainment (HES) 192 participating hospitals in England & Wales 8

5. EXECUTIVE SUMMARY Variation in meeting standards of care Shortfalls compared to high-risk elective surgery Flexible systems required to deliver reliable care 24 recommendations Local Quality Improvement is vital

6. MORTALITY 10

7. Overall inpatient mortality 11% 11

8. Overall inpatient mortality 11% Local inpatient mortality xx% Hosp A xx% Hosp B 12

9. Overall inpatient mortality 11% Local inpatient mortality xx% Hosp A 13

11. Key themes Timeliness of Care Assessment and Appreciation of Risk Resources Older people Seven-day services

12. Antibiotics Population: 1300 patients admitted with peritonitis, needing surgery within 6 hours of decision to operate 1 hour delay leads to 10% increase in mortality National Results: Median 3.6 hours following admission 25% waited more than 7 hours Recommendations Robust mechanisms to identify & treat patients with signs of sepsis Sepsis CQUIN

13. Consultant review within 12 hours of admission Recommendations • Escalation of care • Availability

14. Consultant review within 12 hours of admission Recommendations • Escalation of care • Availability

15. CT scan & reporting(Times indicate documented operative urgency) National Results: Local Results:

16. CT scan & reporting(Times indicate documented operative urgency) National Results: Local Results:

17. Arrival in theatre within timeframe appropriate to urgency Recommendations • Examine theatre provision • Policies to prioritise

18. Arrival in theatre within timeframe appropriate to urgency Recommendations • Examine theatre provision • Policies to prioritise

19. Key themes Timeliness of Care Assessment and Appreciation of Risk Resources Older people Seven-day services

20. Assessment of individual risk Recommendations • Formal assessment of the risk of death • Communicated to prioritise care and allocate resources • Ensure availability of consultants, theatres & critical care

21. Assessment of individual risk Recommendations • Formal assessment of the risk of death • Communicated to prioritise care and allocate resources • Ensure availability of consultants, theatres & critical care

22. National Results Lower High Highest

23. National Results 3% 8% 33% 7% Lower High Highest Green- predicted national mortality Red – observed national mortality

24. National Results 3% 8% 33% 7% 2% 6% 28% 7% Lower High Highest Green- predicted national mortality Red – observed national mortality

25. Pre-op review by both consultants

26. Pre-op review by both consultants

27. Seen pre-op by Consultant Anaesthetist (National Results) Assessed risk 31

28. Both consultants present in theatre Recommendations • Competing workload • Policy for seniority • Match provision for elective high risk surgery

29. Both consultants present in theatre Recommendations • Competing workload • Policy for seniority • Match provision for elective high risk surgery

30. Consultant surgeon presence (National Results) Assessed risk

31. Consultant anaesthetist presence(National Results) Assessed risk

32. Direct postop admission to HDU or ICU Highest risk (>10%, assessed at end of surgery) All patients

33. Direct postop admission to HDU or ICU Highest risk (>10%, assessed at end of surgery) All patients

34. Direct postop admission to HDU or ICU Highest risk (>10%, assessed at end of surgery) All patients

35. Direct postop admission to HDU or ICU Assessed risk

36. Key themes Timeliness of Care Assessment and Appreciation of Risk Resources Older people Seven-day services

37. Older people NELA Organisational Audit: MCOP at 98%, but: Recommendations • Assessment of frailty • Pathways to involve MCOP specialists

38. Older people NELA Organisational Audit: MCOP at 98%, but: Recommendations • Assessment of frailty • Pathways to involve MCOP specialists

39. Seven-day services Possum predicted mortality • Daytime: 7% • >midnight: 17% Little difference with • Preoperative CT scanning and reporting • Time to delivery of antibiotics • Time to arrival in theatre • Direct admission to a critical care

40. Seen pre-op by Consultant (national results)

41. Consultant presence in theatre (national results)

42. Bringing about Improvement Best Practice Flexible systems to deliver standards that match elective care Assessment of risk associated with better patient care Multidisciplinary Local QI - NELA Dashboard

43. Bringing about Improvement • Look at local data • Graphs tell you whether things have improved, but not how to improve • Pull notes and see what is happening • If don’t understand what is happening at a patient level, difficult to work out what to change

44. USEFUL REFERENCES & LINKS NELA Project Team (2015) First Patient Audit Report of the National Emergency Laparotomy Audit. http://www.nela.org.uk/reports. Last accessed 26/08/2015 NELA Project Team (2014) First Organisational Audit Report of the National Emergency Laparotomy Audit. http://www.hqip.org.uk/assets/NCAPOP-Library/NCAPOP-2014-15/National-Emergency-Laparotomy-Audit-Full-Report-May-2014.pdf. Last accessed 26/08/2015 NCEPOD (2007) Emergency Admissions: A journey in the right direction? A report of the National Confidential Enquiry into Patient Outcome and Death. www.ncepod.org.uk/2007ea.htm. Last accessed 26/08/2015 Royal College of Surgeons of England (2011) Emergency Surgery Standards for unscheduled surgical care. www.rcseng.ac.uk/publications/docs/emergency-surgery-standards-for-unscheduled-care. Last accessed 26/08/2015 Royal College of Surgeons of England and Department of Health (2011) The Higher Risk General Surgical Patient: towards improved care for a forgotten group. www.rcseng.ac.uk/publications/docs/higher-risk-surgical-patient. Last accessed 26/08/2015 Saunders DI, Murray D, Pichel AC, Varley S, Peden CJ (2012) Variations in mortality after emergency laparotomy: The first report of the UK emergency laparotomy network. Br J Anaesth 109: 368–75. DOI: 10.1093/bja/aes165 Shapter SL, Paul MJ, White SM (2012) Incidence and estimated annual cost of emergency laparotomy in England: is there a major funding shortfall? Anaesthesia 67: 474–8. DOI: 10.1111/j.1365-2044.2011.07046.x Sorensen LT, Malaki A, Wille-Jorgensen P et al (2007) Risk factors for mortality and postoperative complications after gastrointestinal surgery. J Gastrointest Surg 11: 903–10. DOI: 10.1007/s11605-007-0165-4 Vester-Andersen M, Lundstrom LH, Moller MH, et al (2014) Mortality and postoperative care pathways after emergency gastrointestinal surgery in 2904 patients: a population-based cohort study. Br J Anaesth 112: 860–70. DOI: 10.1093/bja/aet487