1. The First Patient Report of the National Emergency Laparotomy Audit www.nela.org.ukwww.nela.org.uk info@nela.org.ukinfo@nela.org.uk

2. INSTRUCTIONS FOR USE This slide-set was designed to be modified for presentation of local NELA data to facilitate local QI work Local NELA data is available to all with administrator privileges, via data.nela.org.uk Locations for entry of local NELA data in this slide-set can be identified by searching ‘xx’ The relevant column in the accompanying spreadsheet for this data is shown in the notes part for each slide To view the notes part below each slide – click on ‘View’ tab and select ‘Normal’

3. RAG ratings NELA uses the following key to allocate a RAG rating for the proportion of patients for which each process of care was met: Green 80–100% Amber 50–79% Red 0–49% Grey Data unavailable Except for Case Ascertainment column: Green 70–100% Amber 50–69% Red 0–49% Grey Data unavailable In the subsequent tables, it is helpful to “fill” the cell with the relevant colour to show the level of achievement.

4. Chose the slide you need depending on whether you are presenting data for 1 or 2 hospitals within your Trust

5. Consultant review within 12 hours of admission Recommendations Escalation of care Availability NationalHosp AHosp B Overall48%45%56% 12-6pm34%35%50% >MN68%50%67% Red line is at 80% to show number of hospitals that achieved that process for 80% of its patients. Double click to highlight the text in the cell, right click and select “shape fill” (or bucket icon) to fill the cell with the relevant colour for the RAG rating These graphs show each hospitals level of achievement for each process of care. Hence it illustrates the variability across hsopitals

6. NELA Aims To improve the quality of care provided to patients undergoing emergency laparotomy through provision of high quality data Facilitate local quality improvement Provide comparative data at hospital level to allow identification of high performing sites Only reporting at hospital level –emergency laparotomy care is a “team game” –clinician level reporting is not appropriate

7. THANK YOU for… 20,183 patients 70-80% case ascertainment (HES) 192 participating hospitals in England & Wales 7 Data Quality Hospital AHospital B Cases Enteredxx Case Ascertainmentxx% Missing time dataxx% Complete POSSUM data xx%

8. THANK YOU for… 20,183 patients 70-80% case ascertainment (HES) 192 participating hospitals in England & Wales 8 Data Quality Hospital A Cases Enteredxx Case Ascertainmentxx% Missing time dataxx% Complete POSSUM data xx%

9. EXECUTIVE SUMMARY Variation in meeting standards of care Shortfalls compared to high-risk elective surgery Flexible systems required to deliver reliable care 24 recommendations Local Quality Improvement is vital

10. 10 MORTALITY

11. 11 Overall inpatient mortality 11%

12. 12 Overall inpatient mortality 11% Local inpatient mortality xx % Hosp A xx % Hosp B

13. 13 Overall inpatient mortality 11% Local inpatient mortality xx % Hosp A

14. Primary operative procedure % of cases % Raw inpatient 30-day mortality Small bowel resection1712 Adhesiolysis177 Colectomy: right1310 Hartmann’s procedure1312 Peptic ulcer – suture or repair of perforation610 Colectomy: subtotal615 Drainage of abscess/collection38 Repair of intestinal perforation11 Exploratory/relook laparotomy only226 Peptic ulcer / oversew of bleed119

15. Key themes 1.Timeliness of Care 2.Assessment and Appreciation of Risk 3.Resources 4.Older people 5.Seven-day services

16. Antibiotics Population: 1300 patients admitted with peritonitis, needing surgery within 6 hours of decision to operate 1 hour delay leads to 10% increase in mortality National Results: Median 3.6 hours following admission 25% waited more than 7 hours Recommendations Robust mechanisms to identify & treat patients with signs of sepsis Sepsis CQUIN

17. Consultant review within 12 hours of admission Recommendations Escalation of care Availability NationalHosp AHosp B Overall48%xx% 12-6pm34%N/A >MN68%N/A

18. Consultant review within 12 hours of admission Recommendations Escalation of care Availability NationalHosp A Overall48%xx% 12-6pm34%N/A >MN68%N/A

19. ScannedReported Overall81%68% <2hours70%53% 2-6 hours81%67% 6-18 hours 86%74% CT scan & reporting (Times indicate documented operative urgency) ScannedReported Hosp A xx % Hosp B xx % Local Results: National Results:

20. ScannedReported Overall81%68% <2hours70%53% 2-6 hours81%67% 6-18 hours 86%74% CT scan & reporting (Times indicate documented operative urgency) ScannedReported Hosp A xx % Local Results: National Results:

21. Arrival in theatre within timeframe appropriate to urgency UrgencyNationalHosp AHosp B Overall84% xx % <2hours77%N/A 2-6 hours86%N/A 6-18 hours84%N/A Recommendations Examine theatre provision Policies to prioritise

22. Arrival in theatre within timeframe appropriate to urgency UrgencyNationalHosp A Overall84%xx% <2hours77%N/A 2-6 hours86%N/A 6-18 hours84%N/A Recommendations Examine theatre provision Policies to prioritise

23. Key themes 1.Timeliness of Care 2.Assessment and Appreciation of Risk 3.Resources 4.Older people 5.Seven-day services

24. Assessment of individual risk Recommendations Formal assessment of the risk of death Communicated to prioritise care and allocate resources Ensure availability of consultants, theatres & critical care Risk documented National56% Hosp Axx% Hosp Bxx%

25. Assessment of individual risk Recommendations Formal assessment of the risk of death Communicated to prioritise care and allocate resources Ensure availability of consultants, theatres & critical care Risk documented National56% Hosp Axx%

26. LowerHigh Highest National Results

27. LowerHigh Highest 3%8%33%7% Green- predicted national mortality Red – observed national mortality National Results

28. LowerHigh Highest 3%8%33%7% 6%28%7%2% Green- predicted national mortality Red – observed national mortality National Results

29. Pre-op review by both consultants NationalHosp A Both58%xx% Surgeon72%xx% Anaes77%xx%

30. Pre-op review by both consultants NationalHosp A Both58%xx% Surgeon72%xx% Anaes77%xx%

31. Seen pre-op by Consultant Anaesthetist (National Results) Assessed risk 31

32. Both consultants present in theatre Recommendations Competing workload Policy for seniority Match provision for elective high risk surgery All Patients NationalHosp AHosp B Both64%xx% Surgeon85%xx% Anaes74%xx%

33. Both consultants present in theatre Recommendations Competing workload Policy for seniority Match provision for elective high risk surgery All Patients NationalHosp A Both64%xx% Surgeon85%xx% Anaes74%xx%

34. Consultant surgeon presence (National Results) Assessed risk

35. Consultant anaesthetist presence (National Results) Assessed risk

36. Direct postop admission to HDU or ICU Highest risk (>10%, assessed at end of surgery) All patients

37. Direct postop admission to HDU or ICU Highest risk (>10%, assessed at end of surgery) All patients NationalHosp AHosp B All Patients 60% xx % Highest risk 88% xx %

38. Direct postop admission to HDU or ICU Highest risk (>10%, assessed at end of surgery) All patients NationalHosp A All Patients 60% xx % Highest risk 88% xx %

39. Direct postop admission to HDU or ICU Assessed risk

40. Key themes 1.Timeliness of Care 2.Assessment and Appreciation of Risk 3.Resources 4.Older people 5.Seven-day services

41. NELA Organisational Audit: MCOP at 98%, but: Older people Recommendations Assessment of frailty Pathways to involve MCOP specialists Seen by MCOP National7% Hosp Axx% Hosp Bxx%

42. NELA Organisational Audit: MCOP at 98%, but: Older people Recommendations Assessment of frailty Pathways to involve MCOP specialists Seen by MCOP National7% Hosp Axx%

43. Seven-day services Possum predicted mortality Daytime: 7% >midnight:17% Little difference with Preoperative CT scanning and reporting Time to delivery of antibiotics Time to arrival in theatre Direct admission to a critical care

44. Seen pre-op by Consultant (national results)

45. Consultant presence in theatre (national results)

46. Bringing about Improvement Flexible systems to deliver standards that match elective care Assessment of risk associated with better patient care Multidisciplinary Local QI - NELA Dashboard Best Practice

47. Look at local data Graphs tell you whether things have improved, but not how to improve Pull notes and see what is happening If don’t understand what is happening at a patient level, difficult to work out what to change Bringing about Improvement

48. USEFUL REFERENCES & LINKS NELA Project Team (2015) First Patient Audit Report of the National Emergency Laparotomy Audit. http://www.nela.org.uk/reports. Last accessed 26/08/2015 http://www.nela.org.uk/reports NELA Project Team (2014) First Organisational Audit Report of the National Emergency Laparotomy Audit. http://www.hqip.org.uk/assets/NCAPOP-Library/NCAPOP-2014-15/National-Emergency-Laparotomy-Audit-Full- Report-May-2014.pdf. Last accessed 26/08/2015 http://www.hqip.org.uk/assets/NCAPOP-Library/NCAPOP-2014-15/National-Emergency-Laparotomy-Audit-Full- Report-May-2014.pdf NCEPOD (2007) Emergency Admissions: A journey in the right direction? A report of the National Confidential Enquiry into Patient Outcome and Death. www.ncepod.org.uk/2007ea.htm. Last accessed 26/08/2015www.ncepod.org.uk/2007ea.htm Royal College of Surgeons of England (2011) Emergency Surgery Standards for unscheduled surgical care. www.rcseng.ac.uk/publications/docs/emergency-surgery-standards-for-unscheduled-care. Last accessed 26/08/2015 www.rcseng.ac.uk/publications/docs/emergency-surgery-standards-for-unscheduled-care Royal College of Surgeons of England and Department of Health (2011) The Higher Risk General Surgical Patient: towards improved care for a forgotten group. www.rcseng.ac.uk/publications/docs/higher-risk-surgical-patient. Last accessed 26/08/2015www.rcseng.ac.uk/publications/docs/higher-risk-surgical-patient Saunders DI, Murray D, Pichel AC, Varley S, Peden CJ (2012) Variations in mortality after emergency laparotomy: The first report of the UK emergency laparotomy network. Br J Anaesth 109: 368–75. DOI: 10.1093/bja/aes165 Shapter SL, Paul MJ, White SM (2012) Incidence and estimated annual cost of emergency laparotomy in England: is there a major funding shortfall? Anaesthesia 67: 474–8. DOI: 10.1111/j.1365-2044.2011.07046.x Sorensen LT, Malaki A, Wille-Jorgensen P et al (2007) Risk factors for mortality and postoperative complications after gastrointestinal surgery. J Gastrointest Surg 11: 903–10. DOI: 10.1007/s11605-007-0165-4 Vester-Andersen M, Lundstrom LH, Moller MH, et al (2014) Mortality and postoperative care pathways after emergency gastrointestinal surgery in 2904 patients: a population-based cohort study. Br J Anaesth 112: 860–70. DOI: 10.1093/bja/aet487