NELA National Emergency Laparotomy Audit Dr Liz Bright Consultant Anaesthetist, WSH Harold Youngman November 2015
Why do it? Emergency Laparotomy Network audit 2012 Variations in mortality
e 10-fold variation in outcome
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
Variation in outcome
ELN Audit Results www.networks.nhs.uk/laparotomy 100 % Admission to Critical Care 30 % Trusts
ELN Audit Results www.networks.nhs.uk/laparotomy 100 % Consultant Presence 40 % Trusts
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
Audit against standards
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
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
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
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)
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
February 2013 at West Suffolk Hospital
Emergency Laparotomy guideline
Emergency Laparotomy guideline
Emergency Laparotomy guideline
Emergency Laparotomy guideline
Emergency Laparotomy guideline
WSH Trust Intranet page
PACU flexible overnight Level 2 care
The morning after the night before
NELA website
NELA data entry
Engagement- Trust Board
NELA data entry- surgeons
NELA data entry
Engagement
WSH Trust Intranet page
Engagement
Engagement
Engagement- anaesthetists
Emergency theatre
IOFM
IOFM
IOFM
NELA data entry
high quality comparative data
The First Patient Report of the National Emergency Laparotomy Audit (covers Dec 2013 to Nov 2014) Published June 2015 20,000 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
Process measures- year one report
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
Next steps Do getting the process measures right mean we are getting good outcomes? Watch this space
Next steps for me