Two‐year outcomes from the Australian and New Zealand Emergency Laparotomy Audit‐Quality Improvement pilot study

Abstract

Background: The aim of the Australian and New Zealand Emergency Laparotomy Audit-Quality Improvement (ANZELA-QI) pilot study was to determine (i) the outcomes of emergency laparotomy (EL) and (ii) the feasibility of a national, multi-disciplinary quality improvement (QI) project based on a bundle of evidence-based care standards. Methods: An online database was created using the Research Electronic Data Capture (REDCap) programme. National ethics approval with waiver of consent was obtained. Data were entered directly onto REDCap and extracted monthly for eight care standards (preoperative consultant radiologist reporting of computed tomography scans, preoperative mortality risk score, consultant presence in theatre, timely access to theatre and critical care commensurate with risk and involvement of aged care). Monthly QI run charts using 'traffic' light graphics (green ≥80%, amber ≥50% to <80% and red <50%) reported compliance with the standards. Results: Sixty hospitals indicated interest, but difficulties with site-specific ethics approval resulted in only 24 hospitals participating (2886 EL in 2755 patients). The overall inhospital mortality was 7.1% (2.3%-13.3%) and average length of stay 15.5 (8.6-22.7) days. Both significantly declined. Preoperative risk assessment (overall 45%) improved almost three-fold during the study. Only 60% had timely access to theatre and only 70% with a predicted mortality risk of >10% were admitted to critical care. Conclusion: Overall mortality compared favourably with similar international studies and declined in association with participation in the audit. Compliance with some care standards shows considerable scope to improve EL care using QI methodology. † Key standards were based on NELA's original standards of care. ‡ Green (bold) RAGG rated: standard met by ≥80% of patients; amber (italics): standard met by ≥50% to 80% of patients; red (bold italics): standard met by <50% of patients. § Total number of hospitals = 24.

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

“…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. Even though not all these indicators are based on high level evidence, they represent reasonable standards in quality improvement projects aiming to improve the care of emergency laparotomies [ 12 ].…”

“…However, most of the evidence comes from studies derived from the UK and the USA [ 4 , 7 , 10 , 11 ]. The generalisation of the findings of these studies to other countries is limited due to the significant variation of the outcomes and relevant standards of care between hospitals and countries [ 12 , 13 ]. Therefore, the aim of this study is to present prospectively collected morbidity and mortality outcomes of emergency laparotomy in a multicentre setting and to compare them with international benchmark rates from the literature.…”

An audit of perioperative end-of-life care practices and documentation relating to patients who died in a surgical unit in three Victorian hospitals

“…These high-risk patients needing predominantly emergency care, would be the most likely to benefit from preoperative goals of care and shared decision-making discussions. Surgical subgroups of these high-risk patients are currently being investigated, such as those requiring emergency laparotomy surgery, 11 and those investigating neck of femur hip fracture. 16 Our study found major differences in the location of death within the hospital depending on operative status; the most common location of death for operative patients was the ICU, whereas the majority of patients in the non-operative group died on a ward.…”

“…7,8 The Australian National Standards of Quality and Health Safety for EOLC in acute hospitals, 9 and many US and UK best practice palliative care guidelines, recommend that older patients should have advance care planning (ACP) consisting of goals of care discussions, advance directives and an appointed healthcare proxy (substitute decision-maker), before undergoing surgery. 10 Although there are established surgical mortality audits such as the Victorian Audit of Surgical Mortality and Australia and New Zealand Emergency Laparotomy Audit 11 that collect medical and operative data in relation to deaths, little is known about the end-of-life discussions and communication with regard to surgical patients in Australian hospitals. In this study, we aimed to assess aspects of EOLC practices and documentation in the acute hospital setting via a retrospective audit of deceased patients who had been admitted into surgical units in three Australian hospitals.…”

Clearing elective surgery waiting lists after the COVID ‐19 pandemic cannot be allowed to compromise emergency surgery care

“…The 2021 Australian and New Zealand Emergency Laparotomy Audit found that among seriously ill patients, only 59.7% with a surgical urgency of within 18 hours or 23.6% of those with surgical urgency of within two hours underwent surgery within these windows, and that inter‐hospital variation was considerable. 10 In England and Wales, the figures were, in contrast, 80.9% and 68.4% respectively. 11…”