NELANational Emergency Laparotomy

AuditDr Liz Bright

Consultant Anaesthetist, WSHHarold Youngman November 2015

Why do it?

• Emergency Laparotomy Network audit 2012– Variations in mortality

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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

30 %

100 % Admission to Critical Care

Trusts

100 %

40 %

Consultant Presence

Trusts

ELN Audit Results www.networks.nhs.uk/laparotomy

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 AuditSection 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 mortalityTwo consultants in theatre (surgeon and anaesthetist)Post-op Critical Care Unit

• Patients aged over 70Specialist input pre- and post-opNutrition

NELA

• Phase 1: Organisational AuditReport published May 2014

• Phase 2: Patient audit start 1st Dec 2013Now into the second yearFunding 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