Integrating audit with QI research 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 Clarke, Murdoch, Cook, Thomas, Peden. Cook et al Annals Royal College of Surgeons 1997.

What has been achieved? 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

Emergency Laparotomy Network BJA Saunders et al ,835 patients from 35 NHS hospitals Unadjusted 30-day mortalities: 14.9 % overall 24.4 % if over 80 yrs Compared with: Elective colorectal resection2.7 % Oesophagectomy3.1 % Gastrectomy4.2% Liver met. resection1 %

When is death inevitable after emergency laparotomy? Al- Temimi et al J Am Coll Surg 2012;215: 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”

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

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

Organisational Audit: Yr1 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 on- call **/++ 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”

NELA organisational Audit

Improving outcomes in Emergency Laparotomy ‘ While all changes do not lead to improvement, all improvement requires change’

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 Data Domains

Bivariate analysis of inpatient mortality to identify ‘High risk’ subgroups Age ASA Preop risk stratification Preop P-POSSUM estimate of 30d mortality NCEPOD urgency

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

Quality Improvement 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 Surg 2011;202: ICU Admission MOF Early death Operating Theatre Vasopressors Traditional surgery Septic Abdomen/Traditional approach Diagnostic delayOperative delay ICU Admission Ongoing resuscitation Operating Theatre Damage control/source control Septic Abdomen/Active approach Urgent CT ICU for resuscitation Volume load/Antibiotics

Emergency Laparotomy Pathway Quality Improvement Care Bundle Royal Surrey County RUH, Bath Royal Devon and Exeter South Devon

ELPQuiC Emergency Laparotomy Pathway Quality Improvement Care-Bundle

ELPQuiC

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

EPOCH Trial Enhanced Peri-Operative Care for High-risk patients NIHR funded £1.5M 90 hospitals admitting acute abdominal surgery Principal Investigator Rupert Pearse QI Lead Carol Peden

Improving emergency surgery requires reliability and standardisation 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

Will an emergency laparotomy database improve mortality? "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

The Future is here!