NELA National Emergency Laparotomy Audit. Dr Liz Bright Consultant Anaesthetist, WSH Harold Youngman November 2015

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1 NELA National Emergency Laparotomy Audit Dr Liz Bright Consultant Anaesthetist, WSH Harold Youngman November 2015

2 Why do it? Emergency Laparotomy Network audit 2012 Variations in mortality

3 e 10-fold variation in outcome

4 Why do it? Emergency laparotomy network audit 2012 Variations in mortality Audit of HES (Hospital Episode Statistics) of high risk emergency general surgical admissions published 2013 Variations in mortality

5 Variation in outcome

6 ELN Audit Results % Admission to Critical Care 30 % Trusts

7 ELN Audit Results % Consultant Presence 40 % Trusts

8 National Emergency Laparotomy Audit To enable 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

9 Audit against standards

10 Standards Relevant CEPOD documents quite old (1990s) 2011 documents Emergency surgery-standards for unscheduled surgical care The Higher Risk General Surgical Patient- towards improved care for a forgotten group

11 Recommendations High risk patients 10% 30 day mortality Two consultants in theatre (surgeon and anaesthetist) Post-op Critical Care Unit Patients aged over 70 Specialist input pre- and post-op Nutrition

12 NELA Phase 1: Organisational Audit Report published May 2014 Phase 2: Patient audit start 1 st Dec 2013 Now into the second year Funding now available for a total of four years- to Dec 2017

13 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)

14 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

15 February 2013 at West Suffolk Hospital

16 Emergency Laparotomy guideline

17 Emergency Laparotomy guideline

18 Emergency Laparotomy guideline

19 Emergency Laparotomy guideline

20

21 Emergency Laparotomy guideline

22 WSH Trust Intranet page

23 PACU flexible overnight Level 2 care

24 The morning after the night before

25 NELA website

26 NELA data entry

27 Engagement- Trust Board

28 NELA data entry- surgeons

29 NELA data entry

30 Engagement

31 WSH Trust Intranet page

32 Engagement

33 Engagement

34 Engagement- anaesthetists

35 Emergency theatre

36 IOFM

37 IOFM

38 IOFM

39 NELA data entry

40 high quality comparative data

41 The First Patient Report of the National Emergency Laparotomy Audit (covers Dec 2013 to Nov 2014) Published June ,000 patients from 192 of 195 eligible NHS hospitals 30 day inpatient mortality 11% (awaiting independent verification from Office for National Statistics) This is 5 x greater than that for high risk elective surgery

42

43 Process measures- year one report

44 Next steps Funding agreed for a further two years (until Dec 2017) At WSH Appointment for care of the elderly physician Agreed job plan to include review of all emergency laparotomy patients over the age of 70 Consultant surgical review within 12 hours of hospital admission

45 Next steps Do getting the process measures right mean we are getting good outcomes? Watch this space

46 Next steps for me

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