Use of a pathway quality improvement care bundle to reduce mortality after emergency laparotomy

Abstract

BackgroundEmergency laparotomies in the UK, USA and Denmark are known to have a high risk of death, with accompanying evidence of suboptimal care. The emergency laparotomy pathway quality improvement care (ELPQuiC) bundle is an evidence-based care bundle for patients undergoing emergency laparotomy, consisting of: initial assessment with early warning scores, early antibiotics, interval between decision and operation less than 6 h, goal-directed fluid therapy and postoperative intensive care.MethodsThe ELPQuiC bundle was implemented in four hospitals, using locally identified strategies to assess the impact on risk-adjusted mortality. Comparison of case mix-adjusted 30-day mortality rates before and after care-bundle implementation was made using risk-adjusted cumulative sum (CUSUM) plots and a logistic regression model.ResultsRisk-adjusted CUSUM plots showed an increase in the numbers of lives saved per 100 patients treated in all hospitals, from 6·47 in the baseline interval (299 patients included) to 12·44 after implementation (427 patients included) (P < 0·001). The overall case mix-adjusted risk of death decreased from 15·6 to 9·6 per cent (risk ratio 0·614, 95 per cent c.i. 0·451 to 0·836; P = 0·002). There was an increase in the uptake of the ELPQuiC processes but no significant difference in the patient case-mix profile as determined by the mean Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity risk (0·197 and 0·223 before and after implementation respectively; P = 0·395).ConclusionUse of the ELPQuiC bundle was associated with a significant reduction in the risk of death following emergency laparotomy.

Cost‐effectiveness of a quality improvement bundle for emergency laparotomy

“…This was a post hoc analysis of the ELPQuiC project, using data from the original ELPQuiC publication3. The analysis was conducted in accordance with the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) guidelines17.…”

“…Several studies3, 4, 5 have now demonstrated that significant reductions in mortality are possible using an evidence‐based care bundle approach, which streamlines processes, standardizes care, improves quality and ultimately reduces mortality and morbidity.…”

“…One study, the Emergency Laparotomy Pathway Quality Improvement Care (ELPQuiC) bundle, was conducted in four general district hospitals in England and used a six‐point pathway3. The six points were: prompt assessment using an early warning score; early use of antibiotics when sepsis was diagnosed; operation within 6 h of a decision to operate; use of intraoperative goal‐directed therapy; ICU admission for all patients after surgery; and consultant surgeon and anaesthetist involvement throughout the pathway.…”

“…Despite growing evidence showing improved outcomes linked to clinical pathways3, 4, 5, concerns about additional costs often hamper widespread and rapid adoption8. Implementation costs, costs due to increased ICU admissions, and the presence of consultant surgeons and consultant anaesthetists may increase the hospital expenditure costs for survivors and lead to increased hospital costs.…”

Prioritising emergency laparotomy – a reply

“…To date, we are not aware of such use in this patient group [5]. We would also like to suggest, however, that simple pre-operative risk stratification to guide care management and quality improvement programmes focusing on reliable delivery of evidencebased components of care, such as the ELPQuIC study [6], have much to offer these high risk patients, particularly in low-income countries.…”