1. The National Emergency Laparotomy Audit Dave Murray National Clinical Lead www.nela.org.uk info@nela.org.uk

2. Overview Background to the audit Inclusion/Exclusion Criteria Audit Dataset Process and Outcome measures Patient data collection Quality Improvement

3. 10-fold variation in outcome

4. Variation in outcome

5. ELN Audit Results www.networks.nhs.uk/laparotomy 30 % 100 % Admission to Critical Care Trusts

6. 100 % 40 % Consultant Presence Trusts ELN Audit Results www.networks.nhs.uk/laparotomy

7. National Emergency Laparotomy Audit “To enable the improvement of the quality of care …through the provision of high quality comparative data from all providers of emergency laparotomy.” Mandatory National Audit Section 251 approval – patient consent NOT required Yearly reporting at hospital level

8. Phase 1: Organisational Audit Complete Report published May 2014 Phase 2: Patient audit starts 1 st Dec 2013

9. Inclusion Criteria –Patients aged 18 years and over undergoing an expedited, urgent or emergency abdominal procedure on the gastrointestinal tract (England and Wales only) –Open & laparoscopic –Perforation, ischaemia, abdominal abscess, bleeding, obstruction. –Bowel resection/repair due to incarcerated hernias –Laparotomy/laparoscopy with inoperable pathology (e.g. peritoneal/hepatic metastases) –Returns to theatre following emergency & elective surgery (including major dehiscence)

10. Exclusion Criteria –Appendicectomy/Cholecystectomy unless incidental –Diagnostic laparotomy/laparoscopy with negative findings –Non-elective hernia repair without bowel resection. –All other intra-abdominal surgery –Vascular (except eg ischaemic bowel post-AAA repair) –Renal –Hepatobiliary –Oesophageal –Urology –Obs & Gynae/ ectopic pregnancy –Trauma

11. Patient Factors Risk Adjustment Outcomes Mortality Morbidity Process Structure Audit Standards Minimum Dataset Evidence based, peer reviewed dataset Useful for Quality improvement Linked to ICNARC, HES/PEDW, ONS No additional tests

12. Audit against standards

13. Patient Pathway: Clear diagnostic and monitoring plans Adoption of escalation strategy with early involvement of senior staff Timing of diagnostic tests / timing of surgery Adequate emergency theatre access with appropriate prioritisation Post-operative location Risk of death estimated and documented: prior to surgery to ensure adjustments made in urgency of care and seniority of staff involved at end of surgery to determine optimal location for post-operative care Key Recommendations: Delivery of Care

14. Key Recommendations: Individualised care High risk patients ≥10% 30d mortality Two consultants in theatre (surgeon and anaesthetist) Post-op Critical Care Unit ‘Elderly’ patients Specialist input pre- and post-op Nutrition

15. The role of Outcome Measures in improving quality of care 30-day mortality Risk adjusted via P-POSSUM Unplanned ‒ return to theatre ‒ escalation of care ‒ 30-day readmission

16. The role of Process Measures in improving quality of care Admission to first dose of antibiotics Time from decision to theatre Pre-op CT scan Objective assessment of risk of death High risk patients directly admitted to critical care post-op Key Standards of Care relate to patient’s predicted risk of death

17. http://data.nela.org

19. booking http://data.nela.org

21. theatre http://data.nela.org

22. Data pre-populated

23. discharge http://data.nela.org

24. Local download of results as required Quality Improvement

25. Summary This is a multidisciplinary problem Will rely on your help and drive 7500 patients die each year following emergency laparotomy Measurement leads to improvement It starts December 2013