The Organisational Report of the National Emergency Laparotomy Audit

1. The Organisational Report of the National Emergency Laparotomy Audit www.nela.org.ukinfo@nela.org.uk

2. Outline • Overview of results • Recommendations • Implications for patient care • Potential solutions • What happens next…

3. Not open for debate… • High risk patients need: • Consultant input • Critical care • Speed is important

4. survival fraction 1.0 cumulative antibiotic initiation 0.8 0.6 fraction of total patients 0.4 0.2 0.0 12-24 24-36 0-0.5 0.5-1 9-12 36+ 1-2 2-3 3-4 4-5 5-6 6-9 time from hypotension onset (hrs) Cumulative Initiation of Effective Antimicrobial Therapy and Survival in Septic Shock Kumar et al. CCM. 2006:34:1589-96.

5. Source Control/Antimicrobial Interaction and Survival in Septic Shock Antimicrobial Initiation Post-Shock < 3 h 3-6 h > 6 h 92% (n=75) 70.3% (n=37) 44.4% (n=63) < 6 h Source Control Initiation Post-Shock 80.0% (n=60) 46.0% (n=50) 19.0% (n=94) 6-24 h 69.0% (n=29) 36.0% (n=25) 13.0% (n=100) > 24 h

6. Timeframes to theatre Immediate Haemorrhage < 3 hours Septic shock < 6 hours Severe sepsis (with organ dysfunction) <18 hours Sepsis (no organ dysfunction)

7. Organisational and Patient Audit Audit Standards Structure Process Patient Factors Risk Adjustment Outcomes Mortality Morbidity Patient Audit

8. Organisational and Patient Audit Audit Standards Structure Process Patient Factors Risk Adjustment Outcomes Mortality Morbidity Patient Audit

9. Audit against standards

10. Caveats • Many of the standards phrased as “adequate” provision • Variety of models of care • A policy does not mean it happens • Patient level data is the key

11. Executive Summary • Provision of essential facilities and staff does not meet current standards at many hospitals • 11 key recommendations • Comment on who needs to be involved in improving quality of care • Patient level data is vital

13. Steal Shamelessly

14. Commissioners and trust boards • Discussion at a high level • Additional services commissioned? • Pooling of local resources

15. Local clinical teams Co-ordinated multidisciplinary approach • Surgery • Anaesthesia • Critical Care • Radiology • Endoscopy • Pathology • Elderly Medicine • Managers • Service improvement Why do deficits exist?

16. Response rate

17. Hospital size/workload • Facilities • Clinical staffing • Peri-operative care • Critical care and outreach • Multidisciplinary input

18. Number of inpatient beds Considerable variation in hospital size

19. Number of inpatient beds Considerable variation in hospital size

20. EL workload (from HES data)

21. EL workload (from HES data)

22. 1. Hospitals should ensure 24-hour access to fully staffed operating theatres so that surgery can take place without undue delay.

23. 1. Hospitals should ensure 24-hour access to fully staffed operating theatres so that surgery can take place without undue delay.

24. 1. Hospitals should ensure 24-hour access to fully staffed operating theatres so that surgery can take place without undue delay.

25. 1. Hospitals should ensure 24-hour access to fully staffed operating theatres so that surgery can take place without undue delay.

26. 2. Surgical staffing levels should be sufficient to safely cover acute and inpatient clinical workloads. A four-tier surgical rota is recommended.

27. 2. Surgical staffing levels should be sufficient to safely cover acute and inpatient clinical workloads. A four-tier surgical rota is recommended.

28. 3. Consultant anaesthetists must be available to provide direct care at all times. During daytime hours this is facilitated by ensuring that emergency theatres are staffed by consultant anaesthetists with job-planned sessions.

29. 3. Consultant anaesthetists must be available to provide direct care at all times. During daytime hours this is facilitated by ensuring that emergency theatres are staffed by consultant anaesthetists with job-planned sessions.

30. 4. Critical care and outreach services need to be staffed at adequate levels to ensure 24-hour specialist input.

31. 4. Critical care and outreach services need to be staffed at adequate levels to ensure 24-hour specialist input.

32. 4. Critical care and outreach services need to be staffed at adequate levels to ensure 24-hour specialist input. Critical care beds per 100 hospital beds • USA: 9 • Europe: 2.5 to 4.4

33. 4. Critical care and outreach services need to be staffed at adequate levels to ensure 24-hour specialist input. Critical care beds per 100 hospital beds • USA: 9 • Europe: 2.5 to 4.4

34. 18.5% mortality • 16% admitted to Crit care • “Admission to standard ward before ICU admission was associated with an increased risk of postoperative death compared with both ICU admission after surgery and standard ward care without ICU admissions.”

35. British Journal of Surgery 2013; 100: 1318–1325 • 367 796 patients • 15·6% mortality • “Intensive care and high-dependency bed resources……were independent predictors of reduced mortality (P <0·001).”

36. 5. Emergency and elective surgical workload should be organised within a hospital so that the care of EGS patients may be appropriately prioritised without competition for facilities from the elective workload.

37. 5. Emergency and elective surgical workload should be organised within a hospital so that the care of EGS patients may be appropriately prioritised without competition for facilities from the elective workload.

38. 6. A sustained multidisciplinary effort is required to provide 24-hour interventional radiology which is essential for units providing an EGS service • Management of choice for many life-threatening general surgical emergencies • Local networks backed up by formalised pathways of referral

39. 6. A sustained multidisciplinary effort is required to provide 24-hour interventional radiology which is essential for units providing an EGS service • Management of choice for many life-threatening general surgical emergencies • Local networks backed up by formalised pathways of referral

40. 7. Every hospital providing emergency laparotomy care should ensure 24-hour availability of essential support services including experienced radiology and pathology reporting.

41. 7. Every hospital providing emergency laparotomy care should ensure 24-hour availability of essential support services including experienced radiology and pathology reporting.

42. 8. Routine daily input from elderly medicine should be available to elderly patients undergoing emergency laparotomy. • Over 70s account for 43% cases, but 64% of deaths (ELN data) • On-site 98% hospitals • But… • 15 (9%) no input • 150 (85%) on request • 11 (6%) proactive • Parallels with #NOF?

43. 9. Pathways for the care of unscheduled surgical patients, and for the early identification and management of sepsis should be universally incorporated into the routine care of all EGS patients.

44. 9. Pathways for the care of unscheduled surgical patients, and for the early identification and management of sepsis should be universally incorporated into the routine care of all EGS patients.

45. 9. Pathways for the care of unscheduled surgical patients, and for the early identification and management of sepsis should be universally incorporated into the routine care of all EGS patients.

46. 9. Pathways for the care of unscheduled surgical patients, and for the early identification and management of sepsis should be universally incorporated into the routine care of all EGS patients.

47. 10. Multidisciplinary reviews of processes and patient outcomes (morbidity and mortality meetings) should be held for all emergency laparotomy patients. This is a basic requirement of professional practice.

48. 10. Multidisciplinary reviews of processes and patient outcomes (morbidity and mortality meetings) should be held for all emergency laparotomy patients. This is a basic requirement of professional practice.

49. 11. Structured handover of care is required at all times by all clinicians treating emergency laparotomy patients. This is a basic requirement of professional practice.

50. 11. Structured handover of care is required at all times by all clinicians treating emergency laparotomy patients. This is a basic requirement of professional practice.