1. Audit 069 Introduction Methods Results Discussion References Importance of enhanced access to CT scanning within an Emergency Laparotomy pathway Dr J Sonksen, Mr R Patel, Dr F Baig, Dr K Cooke The Dudley Group NHS Foundation Trust, Russells Hall Hospital, Dudley, West Midlands, DY1 2HQ UK Significant variations in mortality following emergency general surgery exist between UK Acute Trusts 1. Delays in processes of care, especially at the interface between specialties, may contribute. Patients presenting to theatre have often experienced transfer of care between ED +/- Medicine +/- Critical Care to Surgery, as well as referrals in and out of services for complex imaging and assessments (e.g. Radiology and Anaesthetics). For many the underlying pathology is time-critical so ‘Door to Theatre’ (DtT) time is an important process metric to measure. Focused clinical pathways can enhance timeliness of care and improve outcomes following emergency laparotomy 2. We previously reported time to theatre delays 3, including those associated with senior review and imaging. In February 2015 we introduced our Emergency Laparotomy pathway (EmLap) with the aim of breaking down interface barriers while paying attention to detail, to deliver ‘detailed timely care’. Core elements of EmLap include early senior surgical review coupled directly to a unique ‘CTabdo-EmLap’ request within our EPR, with its own specific escalation process. Target times are scan within 2 hours and report 1 hour later. We were interested in examining the role of these changes within the context of introducing the whole pathway. We performed a retrospective before and after audit, to assess the impact of EmLap on ‘Door to Theatre’ (DtT) time and ‘CT time’. DtT time = arrival at hospital to start anaesthetic time, CT time = order to report time We reviewed both the DtT and CT times for patients admitted as an emergency, who subsequently underwent emergency laparotomy where a pre-operative CT scan was part of the surgical work-up. Comparisons were made between four groups; ‘Historical 3’, ‘Pre-EmLap’, ‘Post-EmLap’ and ‘CTabdo-EmLap’. ‘CTabdo-EmLap = Management on EmLap pathway as defined by being the subgroup of the ‘Post-EmLap’ cohort where the CT scan was ordered as CTabdo-EmLap. Management on the EmLap pathway was associated with a significant reduction in both DtT and CT times. The median DtT and CT times reduced by 29.1 and 3.75 hours respectively. Figures 1 and 2 show how the medians, 25 th and 75 th centiles reduced over time, with a marked reduction for those on the pathway. For the CTabdo-EmLap group the DtT and CT times were significantly shorter compared to all other groups. In addition and with respect to CT times only, the full ‘post-Emlap’ cohort had significantly shorter times than the ‘Historical’ or ‘pre-EmLap’ groups (p<0.007 all comparisons, Dunn’s test for pairwise comparison). 1. Mortality in high-risk emergency general surgical admissions. British Journal of Surgery 2013 2. Use of a pathway quality improvement care bundle to reduce mortality after emergency laparotomy. British Journal of Surgery 2014 3. Abstract: Emergency surgical admissions admitted to critical care; are we adhering to guidelines? Intensive Care Medicine, Supplement 1, vol 40, 2014 Fig 1. Door to theatre times; Median, 25 th & 75 th centiles Fig 2. CT request to report times ; Median, 25 th & 75 th centiles Our audit suggests the EmLap pathway can shorten ‘door to theatre’ times and for patients with time-critical abdominal pathology this may save lives. The pre-operative journey for this group of high-risk patients is complex, and requires not only senior oversight but also local knowledge to navigate promptly. Embedding early senior review with an agreed escalation process for CTabdo-EmLap scans into the pathway has helped achieve this, and we believe represents one of the more important of the many ‘marginal gains’ within EmLap. Enhanced access to imaging should be considered a minimum standard within an emergency laparotomy pathway. Results continued Think EmLap Detailed timely care Start the clock – time is critical Corresponding author: julian.sonksen@dgh.nhs.uk