emergency laparotomy audit–p-possum scored –also calculated nsqip risk predictor to compare to...
TRANSCRIPT
Emergency Laparotomy AuditThe Newcastle/NSW Experience
Peter PockneySenior Lecturer in Surgery
Consultant Surgeon, John Hunter Hospital
Conflicts of Interest
• None
Acknowledgements
• Project Team
– Dr Merran Holmes, Surgical Research Fellow
– Dr Gavin Sullivan, Consultant Anaesthetist
– Dr Shaun Jones, Junior Anaesthetist
– Dr Joyce Ming, Intern
– Conjoint Professor Jon Gani, Consultant Surgeon
Newcastle, NSW
John Hunter HospitalNewcastle, NSW
NSW
Our Projects
• To analyse our performance at Emergency Laparotomy
• Compare, where appropriate, to the standards set by NELA UK
• Were there obvious lessons we could learn from this experience
Our Projects
• Ongoing NELA duplicate (Jan 2016 - )
– Same inclusion/exclusion criteria
– Same parameters recorded
– P-Possum scored
– Also calculated NSQiP Risk predictor to compare to P-Possum
• Recorded in a secure, online RedCap database, hosted by the Hunter Medical Research Institute
Our Projects
• Data collection from April 2017
• Retrospective– Where do we really start from in terms of NELA
comparable outcomes? (2016, 2017 data)
– processes of care, mortality
– To learn the Australian versions of the NELA experiences
Our Projects
• Prospective Data collection from August 2017
• “Beta testing” ANZELA-QI database (2017/2018)
– Use ‘NELA’ risk predictor – calculated & validated in emergency patients
– Use ANZELA-QI inclusion/exclusion criteria for casemix
– Use ANZELA-QI dataset (reduced compared to NELA for non-essential data)
– Include some data not used in NELA (e.g. Frailty Score)
Next Steps
• Other NSW hospitals are now contributing to these projects
– Already entering data
• Gosford (Central Coast NSW)
• Belmont DH (Suburban Newcastle)
• The Calvary Mater Hospital (Suburban Newcastle)
– In process of sorting governance
• Nepean Hospital (W Sydney)
• The Maitland Hospital (Lower Hunter)
NSW
NSW
NSW
NSW
NSW
NSW
Next Steps
• Current contributors cover population of >1.3m (5.5% of Australian total)– Limited to one State (NSW) but 2 (expected to be 3)
Local Health Districts
– Largely Metropolitan
• We invite more hospitals to contribute to this process, – in or out of NSW,
– rural or urban,
– whatever size
Next Steps
• Need site specific approval (ethics approved)
• We grant online access to RedCap to enter data
• Local hospital can see details of own patients, and comparison to whole dBase, but not details of other units’ patients
Our Results
• 225 Cases (approximately 3 per week)
• Weak comparative stats
• Process lessons
Process Lessons
• Our documented use of risk prediction tools is dire
Process Lessons
• Our documented use of risk prediction tools is dire
• 8/221,
– 7/8 finger in the air (clinical judgement),
– 1/8 P-Possum
Process Lessons
• Our documented use of ICU pre and actual use post op is not good
Process Lessons
• Our documented use of ICU pre and actual use post op is not good
• 81% of cases not documented as discussed with ICU pre-op
• 31% cases went to ICU post op
• 5% unplanned move to ICU post op
Process Lessons
• Our involvement of consultant level staff in theatre was pretty good
– Surgeons
– Anaesthetists
Process Lessons
• Our involvement of consultant level staff in theatre was pretty good
– Surgeons
• 209/226 consultant surgeon (92.5%) or post SET Fellow (6.4%)
– Anaesthetists
• 170/226 consultant anaesthetist (72.5%) or post FANZCA Fellow (10.6%)
Process Lessons
• Our overall mortality looks ok
– subject to small number influences – one more or less death makes a relatively big difference to our rate, none to NELA rate
Process Lessons
• Our overall mortality looks ok – subject to small number influences – one more or less
death makes a relatively big difference to our rate, none to NELA rate
• 30 day mortality 23/225, 10.2%– NELA 2014 11.7%, – NELA 2015 11.1%– NELA 2016 10.6%
• 90 day mortality 31/225 13.8%– NELA combined 2014/5 15.6%– NELA 2016 13.9%
Process Lessons (Audit)
• Careful quality improvement projects take time, patience and effort
• Do lead to changes and improvements in practice
• Might allow us to examine parts of our care processes that could be improved
Process Lessons
• Areas which we think we can do better
– Transfers from peripheral hospitals (which are not necessarily rural, or remote)
– Decision to operate on likely futile patients
– Use of ICU/HDU pre and post surgery
– Involvement of named consultants in pre-operative decisions and processes
– Record keeping
Does a NELA process work here?
Does a NELA process work here?
• Qualified “Yes”
