Carol J. Peden MD, FRCA, FICM, MPH.
NELA QI Lead, EPOCH QI Lead
Macintosh Professor Royal College of Anaesthetists, Associate Medical
Director for Clinical Quality RUH, Bath and NHS England (South).
October 9 th 2014

Emergency laparotomy outcomes
A Prospective Observational Study of Outcome of Emergency Laparotomy
Eur J Anaesth 2011. Clarke, Murdoch, Cook, Thomas, Peden .
Cook et al Annals Royal College of Surgeons 1997.

• Association of Surgeons Report 2007
• Emergency Laparotomy network May 2010
• NCEPOD report on Elderly November 2010
• Ombudsman’s report on Care of the Elderly in Acute Hospitals
• RCS Standards for Unscheduled Care April 2011
• Anaesthesia Editorial: Emergency Surgery in the Elderly
• Department of Health guidelines September 2011 on the
“High Risk Surgical Patient”
• RCOA working party to achieve action – ongoing
• NCEPOD report December 2011
• NELA Network and HQIP

• BJA Saunders et al 2012
• 1,835 patients from 35 NHS hospitals
• Unadjusted 30-day mortalities:
• 14.9 % overall
• 24.4 % if over 80 yrs
• Compared with:
• Elective colorectal resection
• Oesophagectomy
• Gastrectomy
• Liver met. resection
2.7 %
3.1 %
4.2%
1 %

• Al- Temimi et al J Am Coll Surg 2012;215:503-11
• NSQIP database
• 37,500 patients
• 30 day mortality 14%
• Mortality and Post-operative Care Pathways in 2904 patients: a population based cohort study.
Vester-Andersen et al BJA online Feb 2014
• Overall mortality 18.5% -90 day mortality 23.8%
• 84% of patients sent to ward
• “A multi-disciplinary approach with involvement of both surgeons and intensivists in the first 2-3 days”

Mortality 15.6%
Variation in mortality after emergency surgery in the UK
Symons N et al. Brit J Surg 2013; 100: 1318-25.

National Emergency Laparotomy Audit
“ To enable the improvement of the quality of care for patients undergoing emergency laparotomy through the provision of high quality comparative data from all providers of emergency laparotomy.
”
• £1million over 3 years
• Subcontracted to RCS

• Number of Critical Care Beds as a proportion of total beds**
• Number of surgeons on on-call rota**/++
• Whether surgical staff are free from elective commitments whilst oncall **/++
• Working patterns of on-call clinical staff (Consultants and Speciality
Trainees)** /++
• Specialist Interest of surgeons on on-call rota**/++
• Availability of
• pre-operative imaging*/**/++
• interventional radiology*/**/++
• emergency theatres */**/++
• routine daily input from elderly care*
* NCEPOD 2010 “ An Age Old Problem: a review of the care received by elderly patients undergoing surgery ”
** Department of Health Working Group “The Higher Risk General Surgical Patient: Towards Improved Care for a Forgotten Group”
++ RCSEng 2011 “Emergency Surgery Standards for unscheduled surgical care ”

Improving outcomes in Emergency
Laparotomy

Recommendations:
Changing the delivery of care in EL
Pathway implementation
Preoperative risk estimation and documentation
Escalation strategies and case prioritisation
Clear diagnostic and monitoring plans
Timing of diagnostic tests / timing of surgery

1. Individual risk
2. Processes of care
3. Perioperative patient outcomes

Age
ASA
Preop risk stratification
Preop P-POSSUM estimate of 30d mortality
NCEPOD urgency

1.
Minimal delay to surgical intervention
2.
Minimal delay to administration of antibiotic
3.
Consultant surgeon
4.
Consultant anaesthetist
5.
Postoperative critical care admission

• Yearly reports
• Process & Outcome Measures incorporated into Trust Quality Accounts
• Local download of results as required
• Presentations / workshops at regional & national meetings to disseminate best practice

Changing the way we think: understanding urgency and risk
Adapted from Moore et al. Availability of acute care surgeons improves outcomes in patients requiring emergent colon surgery. Am J Surg2011;202:837-842
.
Septic Abdomen/Traditional approach
Diagnostic delay Operative delay
Septic Abdomen/Active approach
Urgent CT
ICU for resuscitation
Volume load/Antibiotics
Operating Theatre
Vasopressors Traditional surgery
Operating Theatre
Damage control/source control
MOF
ICU Admission
Early death
ICU Admission
Ongoing resuscitation

E mergency
L aparotomy
P athway Qu ality
I mprovement C are
Bundle
Royal Surrey County
RUH, Bath
Royal Devon and Exeter
South Devon

90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
47%
Decision to Theatre <6 hours
77%
74%
66%
62%
50%
46%
43%
Site 1 Site 2 Site 3 Site 4
ELPQuiC
Emergency Laparotomy Pathway Quality Improvement Care-Bundle
Baseline
ELPQuiC

100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Consultant Anaesthetist in Theatre
90,9%
98%
83%
56,1%
65%
47,5%
51%
39,2%
Pre-ELPQuiC
Post-ELPQuiC
Site 1 Site 2 Site 3
ELPQuiC
Emergency Laparotomy Pathway Quality Improvement Care-Bundle
Site 4

CUSUM O/E mortality
Risk adjusted mortality using P-
POSSUM
In all hospitals a statistically significant increase in lives saved
P<0.0001
BJS in press
Huddart, Peden, Quiney et al

ICU post op
Site 1 - area 58%
MEWS
100%
75%
50%
25%
0%
Pre-op antibiotics
ICU post op
Site 2 - area 41%
MEWS
100%
75%
50%
25%
0%
Pre-op antibiotics
GDFT Theatre <6 hours
ICU post op
Site 3 - area 56%
MEWS
100%
75%
50%
25%
0%
Pre-op antibiotics
GDFT
Theatre <6 hours
ICU post op
Site 4 - area 51%
MEWS
100%
75%
50%
25%
0%
Pre-op antibiotics
GDFT Theatre <6 hours GDFT
Theatre <6 hours

EPOCH Trial
E nhanced P eriO perative Ca re for Hi gh-risk patients
• NIHR funded £1.5M
• 90 hospitals admitting acute abdominal surgery
• Principal Investigator Rupert Pearse
• QI Lead Carol Peden

• This can be done and the ELPQuIC study shows that improvement may be significant
• Standardise pathways of care
• Create a sense of urgency!
• NELA gives us the data to drive improvement
“Reliability means keeping promises”
Don Berwick

• "Without a standard there is no logical basis for
making a decision or taking action." -Joseph M.
Juran
• "In God we trust, all others bring data." - W.
Edwards Deming