The NELA risk prediction model for emergency laparotomies discriminates well between low- and high-risk patients and is suitable for producing risk-adjusted provider mortality statistics.
Background: Studies across healthcare systems have demonstrated between-hospital variation in survival after an emergency laparotomy. We postulate that this variation can be explained by differences in perioperative process delivery, underpinning organisational structures, and associated hospital characteristics. Methods: We performed this nationwide, registry-based, prospective cohort study using data from the National Emergency Laparotomy Audit organisational and patient audit data sets. Outcome measures were all-cause 30-and 90-day postoperative mortality. We estimated adjusted odds ratios (ORs) for perioperative processes and organisational structures and characteristics by fitting multilevel logistic regression models. Results: The cohort comprised 39 903 patients undergoing surgery at 185 hospitals. Controlling for case mix and clustering, a substantial proportion of between-hospital mortality variation was explained by differences in processes, infrastructure, and hospital characteristics. Perioperative care pathways [OR: 0.86; 95% confidence interval (CI): 0.76e0.96; and OR: 0.89; 95% CI: 0.81e0.99] and emergency surgical units (OR: 0.89; 95% CI: 0.80e0.99; and OR: 0.89; 95% CI: 0.81e0.98) were associated with reduced 30-and 90-day mortality, respectively. In contrast, infrequent consultant-delivered Quality and Patient Safety intraoperative care was associated with increased 30-and 90-day mortality (OR: 1.61; 95% CI: 1.01e2.56; and OR: 1.61; 95% CI: 1.08e2.39, respectively). Postoperative geriatric medicine review was associated with substantially lower mortality in older (!70 yr) patients (OR: 0.35; 95% CI: 0.29e0.42; and OR: 0.64; 95% CI: 0.55e0.73, respectively). Conclusions: This multicentre study identified low-technology, readily implementable structures and processes that are associated with improved survival after an emergency laparotomy. Key components of pathways, perioperative medicine input, and specialist units require further investigation.
Summary
Although the concept of pre‐operative optimisation is traditionally applied to elective surgery, there is ample opportunity to apply similar principles to patients undergoing emergency laparotomy. The key challenge is achieving meaningful improvements in a patient's condition without introducing delays to time‐sensitive surgery, which may be required in a matter of hours. Optimisation can be considered in two parts: that of the patient's condition; and that of the care pathway. Optimising the patient's condition is less about improving long‐term pathology, and more about correcting physiological derangement, such as electrolyte and fluid balance, blood loss, prompt treatment of sepsis, and ensuring appropriate continuation of medication in the peri‐operative period. Optimising the care pathway involves ensuring that the system is designed to deliver reliably the appropriate interventions, such as prompt antibiotics, and access to computed tomography scanning and the operating theatre with minimal delay.
Background: Socioeconomic circumstances can influence access to healthcare, the standard of care provided, and a variety of outcomes. This study aimed to determine the association between crude and risk-adjusted 30-day mortality and socioeconomic group after emergency laparotomy, measure differences in meeting relevant perioperative standards of care, and investigate whether variation in hospital structure or process could explain any difference in mortality between socioeconomic groups. Methods: This was an observational study of 58 790 patients, with data prospectively collected for the National Emergency Laparotomy Audit in 178 National Health Service hospitals in England between December 1, 2013 and November 31, 2016, linked with national administrative databases. The socioeconomic group was determined according to the Index of Multiple Deprivation quintile of each patient's usual place of residence. Results: Overall, the crude 30-day mortality was 10.3%, with differences between the most-deprived (11.2%) and leastdeprived (9.8%) quintiles (P<0.001). The more-deprived patients were more likely to have multiple comorbidities, were more acutely unwell at the time of surgery, and required a more-urgent surgery. After risk adjustment, the patients in the most-deprived quintile were at significantly higher risk of death compared with all other quintiles (adjusted odds ratio [95% confidence interval]: Q1 [most deprived]: reference; Q2: 0.83 [0.76e0.92]; Q3: 0.84 [0.76e0.92]; Q4: 0.87 [0.79e0.96]; Q5 [least deprived]: 0.77 [0.70e0.86]). We found no evidence that differences in hospital-level structure or patient-level performance in standards of care explained this association. Conclusions: More-deprived patients have higher crude and risk-adjusted 30-day mortality after emergency laparotomy, but this is not explained by differences in the standards of care recorded within the National Emergency Laparotomy Audit.
Aim The aim of this work was to describe process and outcome for patients undergoing emergency colectomy for colitis in England and Wales. Method The National Emergency Laparotomy Audit (NELA) is a national audit including patients undergoing emergency laparotomy and laparoscopic resectional procedures. Data from adult patients under 65 years of age who underwent emergency subtotal colectomy or panproctocolectomy for colitis between 2013 and 2016 were analysed. Results In total 1204 patients were included. Although approximately a third of patients underwent a colectomy within 5 days of admission [37% (440/1204)], 32% (383/1204) were admitted for more than 10 days prior to surgery. Colorectal surgeons were present at operation in 72% (869/1204) of cases and consultant surgeons attended 94% (1137/1204) of procedures. Laparoscopy was attempted in 32% (390/1204) of operations with wide institutional variation in its use (0-100% of cases). The overall 30-day inpatient mortality was 2.9% (35/1204). On multivariable regression analysis, age > 55 years [OR 3.59 (1.05-12.21), P = 0.041], female gender [OR 2.88 (1.27-6.52), P = 0.011] and American Society of Anesthesiologists grade 5 [OR 37.43 (2.72-514.52), P = 0.007] were associated with increased mortality. Conclusion There is a consultant-driven service that is largely delivered by specialist colorectal surgeons. Laparoscopy rates were high although there was wide variation in use across institutions. Preoperative delays were evident, and further work is necessary to determine the underlying reasons for these.
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