Using predicted 30 day mortality to plan postoperative colorectal surgery care: a cohort study

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.

Section: Discussionmentioning

confidence: 99%

Organisational factors and mortality after an emergency laparotomy: multilevel analysis of 39 903 National Emergency Laparotomy Audit patients

Oliver

Bassett

Poulton

et al. 2018

“…4,5 Critical care or protocolised pathways delivered in enhanced care areas are thought to mitigate against the risks of surgery by higher nurse-to-patient ratios, medical input from specialist intensivists, and availability of specific organ support therapies. 6,7 As the global burden of surgery increases, the number of patients at risk of perioperative complications increase correspondingly. Therefore, the capacity to admit prospectively high-risk patients to critical care after surgery becomes an increasing population concern.…”

Section: Editor's Key Pointsmentioning

confidence: 99%

Postoperative critical care and high-acuity care provision in the United Kingdom, Australia, and New Zealand

Wong

Farmer

Wallace

et al. 2019

y The SNAP-2: EPICCS collaborators are listed in Supplementary material. AbstractBackground: Decisions to admit high-risk postoperative patients to critical care may be affected by resource availability. We aimed to quantify adult ICU/high-dependency unit (ICU/HDU) capacity in hospitals from the UK, Australia, and New Zealand (NZ), and to identify and describe additional 'high-acuity' beds capable of managing high-risk patients outside the ICU/HDU environment. Methods: We used a modified Delphi consensus method to design a survey that was disseminated via investigator networks in the UK, Australia, and NZ. Hospital-and ward-level data were collected, including bed numbers, tertiary services offered, presence of an emergency department, ward staffing levels, and the availability of critical care facilities. Results: We received responses from 257 UK (response rate: 97.7%), 35 Australian (response rate: 32.7%), and 17 NZ (response rate: 94.4%) hospitals (total 309). Of these hospitals, 91.6% reported on-site ICU or HDU facilities. UK hospitals

“…For example, patients undergoing colorectal surgery who fell into an intermediate-risk group (albeit not comparable with our indeterminate-fitness category) have reported a higher rate of serious complications if admitted to the ward rather than HDU. 27 The most effective way to assess patient risk is likely to be a combined approach using clinical variables, biomarkers of susceptibility to disease, and physiological testing (CPET). 28 We suggest further development of our model by inclusion of known risk factors independent of CRF to optimise perioperative care.…”

Section: Revised Fitness Stratificationmentioning

confidence: 99%

The cardiopulmonary exercise test grey zone; optimising fitness stratification by application of critical difference

Rose

Davies

Davison³

et al. 2018