Background It is imperative that an accurate assessment of risk of death is undertaken preoperatively on all patients undergoing an emergency laparotomy. Portsmouth-Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity (P-POSSUM) is one of the most widely used scores. National Emergency Laparotomy Audit (NELA) presents a novel, validated score, but no direct comparison with P-POSSUM exists. We aimed to determine which would be the best predictor of mortality. Methods We analysed all the entries on the online NELA database over a four-and-a-half-year period. The Hosmer–Lemeshow goodness of fit test was performed to assess model calibration. For the outcome of death and for each scoring system, a non-parametric receiver operator characteristic analysis was done. The sensitivity, specificity, area under receiver operator characteristic curve and their standard errors were calculated. Results Data pertaining to 650 patients were included. There were 59 deaths, giving an overall observed mortality rate of 9.1%. Predicted mortality rate for the P-POSSUM score and NELA score were 15.2% and 7.8%, respectively. The discriminative power for mortality was highest for the NELA score (C-index = 0.818, CI: 0.769–0.867, p < 0.001), when compared to P-POSSUM (C-index = 0.769, CI: 0.712–0.827, p < 0.001). Conclusions The NELA score showed good discrimination in predicting mortality in the entire cohort. The P-POSSUM over-predicted observed mortality and the NELA score under-predicted observed mortality.
Objectives: The purpose of this study was to analyze the decision-making process in emergency general surgery in an attempt to ascertain whether surgeons make the correct decision when decisions not to operate in high-risk acutely unwell surgical patients are taken. Background: A decision not to operate is sometimes associated with a certain degree of uncertainty as to the accuracy of the decision. Difficulty lies with the fact that the decisions are made on assumptions, and the tools available are not fool proof. Methods: We retrospectively evaluated “decisions not to operate” over a period of 32 months from April 2013 to August 2015 in a district general hospital in United Kingdom and compared with consecutive similar number of patients who had an operation as recorded in the National Emergency Laparotomy Audit (NELA) database (from January 2014 to August 2015). We looked at the demographics, American Society of Anesthesiologists grade, Portsmouth–Physiological and Operative Severity Score for enumeration of Mortality and Morbidity (P-POSSUM) score, functional status, and 30-day mortality. Results: Two groups (operated [n = 43] and conservative [n = 42]) had similar characteristics. Patients for conservative management had a higher P-POSSUM score ( P < .001) and a poorer functional status ( P < .001) at the time of decision-making compared to those who had surgery. Mortality at 30 days was significantly higher for patients decided for conservative management when compared with those who had surgery (76.2% and 18.6%, respectively). Conclusions: Elderly patients with poorer functional status and predicted risks more often drive multidisciplinary discussions on whether to operate. Within the limitations of not knowing the outcome otherwise, it appears surgeons take a reasonable approach when deciding not to operate.
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