Initial emergency laparotomy outcomes following a transdisciplinary perioperative care pathway in Singapore

Abstract

Aim: Emergency laparotomy (EL) is a common surgery associated with high morbidity and mortality. An enhanced care pathway incorporates evidence-based care bundles with the aim of providing standardized perioperative care. Prior to 2019, EL management in our institution was not standardized. This study aims to assess whether implementation of a transdisciplinary perioperative Emergency Laparotomy (ELAP) pathway improves clinical and efficiency outcomes of EL.Methods: A prospective single-center audit was undertaken between 1 January and 31 December, 2019 following the implementation of the ELAP pathway. Comparisons were made with retrospective data from the preimplementation period between 1 January and 31 December, 2017. Demographics and clinical and efficiency outcomes were compared for patients (age > 16 years old) requiring EL for acute abdominal conditions.Results: There were 152 and 162 patients from preimplementation and postimplementation periods, respectively. There was a nonsignificant reduction of 30-day mortality in the intervention group receiving perioperative pathway care compared with the preintervention group (3.1% versus 5.3%, respectively; P = 0.40). There was a decrease in postoperative complications in the intervention group, in particular for Clavien-Dindo IV complications (11.2% versus 3.1%, p < 0.01). Efficiency outcomes improved postimplementation with increased consultant surgeon and anesthetist presence in operating theater and postoperative geriatric assessment for elderly patients.

The Hellenic Emergency Laparotomy Study (HELAS): A Prospective Multicentre Study on the Outcomes of Emergency Laparotomy in Greece

“…Finally, the results of this study point out ample room for improvement in the field of emergency laparotomy in this country. There is strong evidence from prospective trials that the establishment of consultant-led emergency surgical services, the introduction of multidisciplinary perioperative protocols and evidence-based quality improvement care bundles in conjunction with continuous education and raising awareness of healthcare staff has been associated with improved provision of care, timely management, improved clinical outcomes and reduced hospital costs [ 8 , 9 , 26 , 27 ]. Towards these directions, NELA has established key 10 key performance indicators which are as follows: timely preoperative report of a CT scan by consultant radiologist, preoperative mortality risk calculation, timely arrival of patients in theatre according to the degree of urgency, presence or consultant surgeon and anaesthetist when the calculated mortality risk exceeds 5%, direct admission in the ICU when the calculated mortality exceeds 10% and perioperative geriatric assessment of patients aged 65 and older.…”

“…The unsatisfactory standards of care of emergency surgical admissions compared with elective operations have drawn the attention of the surgical professional bodies in western countries after the millennium [4,5]. During the last decade, there is mounting evidence that data-driven quality improvement interventions can lead to higher adherence to defined standards and perhaps to improved outcomes such as death rates at a national level [7][8][9]. However, most of the evidence comes from studies derived from the UK and the USA [4,7,10,11].…”

Association of Organizational Pathways With the Delay of Emergency Surgery

“…39 The available evidence suggests that in addition to dedicated pathways, individualized risk assessment and triage and active, dedicated fast-track pathways are associated with improved management of high-risk patients based on clinical score. 26,40 The advantage of a specific score would facilitate communication between all involved clinicians. Existing mortality prediction tools do not seem well suited since they do not account for the aforementioned causes of delay.…”