EMERGENCY SURGERY
Prior to surgery, 36% of patients do not receivea documented assessment of risk of death.
has increased from 56% to 64%, over the last year, there remain large differences in standards of care between hospitals. Furthermore, little improvement has occurred at an organisational level to raise standards of care such as timely access to operating theatres, critical care provision, and input from elderly medicine specialists for older patients. Rectifying this will require greater engagement between clinicians, healthcare managers and commissioners. Investing in resources to bring about improvement and the delivery of higher quality care is also likely to be cost effective, as demonstrated by the estimated £22 million of savings to the NHS since the first NELA report of 2015. Professor Mike Grocott, chair of NELA and council member of the Royal College of Anaesthetists, said: “Shortfalls in the perioperative care of these patients before, during and after major surgery may be negatively affecting patient outcomes and use of resources. There is still much work to
be done and it is vital that clinicians, hospital managers and commissioners of healthcare examine these data to determine why standards are not always met and how improvements can be made. This will lead to better care and efficiencies that will benefit both patients and the NHS.” The NELA report makes a number of recommendations targeted at commissioners, hospital chief executives and clinicians, in a bid to reduce variation in the care of patients undergoing emergency bowel surgery. These include: l Assessing and documenting patient risk, to guide allocation of resources.
l Providing sufficient critical care and The ELPQuIC bundle: reducing mortality
Earlier this year, six healthcare projects were selected by the Health Foundation to be part of its new £3.5m ‘Scaling Up Improvement’ programme. Project teams from across the UK will be taking healthcare ideas, interventions and approaches that have been tested and shown to improve care at a small scale and delivering them at a larger scale. The programme will run for two and a half years and each project will receive up to £500,000 of funding to support the implementation and evaluation of the work. One of the projects selected for ‘scaling up’ is based on work undertaken by the Royal Surrey County Hospital NHS Foundation Trust. The Emergency Laparotomy Pathway Quality Improvement Care (ELPQuIC) bundle aims to improve the standards of care for patients undergoing emergency laparotomy surgery, and reduce mortality rates, complications and hospital length of stay. The bundle consists of: early assessment and resuscitation; antibiotics being administered to patients who show signs of sepsis; prompt diagnosis and early surgery; goal-directed fluid therapy in theatres and continued to intensive care units; and post-operative intensive care for all.1
The project also includes making feedback on data on patients undergoing emergency laparotomy routine, and providing coaching to allow hospitals to better understand their data and develop solutions to the problems identified. The bundle was initially introduced in four hospitals (Royal Surrey County Hospital, Royal United Hospital Bath, Torbay Hospital, Royal Devon and Exeter Hospital) in December 2012, and results from the initial implementation of ELPQuIC have shown a reduction in risk- adjusted mortality of 42%.2
ELPQuIC is
now being spread to other acute care NHS Trusts in England, including hospitals from Kent across to Avon, spanning three Academic Health Science Networks.
Reference
1 Source: Health Foundation, accessed at:
http://www.health.org.uk/programmes/ scaling-improvement/projects/adoption- and-large-scale-spread-elpquic-improving- outcomes#sthash.LjGJOYJJ.dpuf
2 Huddart, S, et al, Use of a pathway quality improvement care bundle to reduce mortality after emergency laparotomy. Br J Surg. 2015 Jan;102(1):57-66. doi: 10.1002/bjs.9658. Epub 2014 Nov 10.
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emergency operating theatre capacity, to allow emergency surgery to occur in a timely fashion.
l Ensuring consistent medical staffing at all times.
l Implementing care pathways for emergency surgical patients.
l Planning and reviewing essential processes of care by multi-disciplinary team working.
Dr Dave Murray, NELA national clinical lead, said: “The second phase of reporting for this important national Audit reveals that more hospitals are delivering high levels of service and are meeting the standards for more than 80% of patients. As continued effort is made to improve care across all hospitals, we would expect to see a reduction in mortality following an emergency laparotomy. The audit allows us to identify the best performing hospitals so that good practice can be disseminated among the less well- performing hospitals. Multi-disciplinary teams of doctors from various specialties need to work together to reduce variation and deliver personalised care pathways for this highly vulnerable group of patients.” Dr Liam Brennan, president of the
Royal College of Anaesthetists, said: “While the report highlights significant variation in care for patients who undergo emergency bowel surgery, it has also identified several areas in which NHS clinical teams have implemented recommendations from the 2015 NELA patient report. The acceptance of these recommendations has enabled hospitals to adhere more closely to relevant standards, thereby provide better patient care – and for this they should be commended.”
References
1 Watson, R, et al, Emergency General Surgery: challenges and opportunities, Nuffield Trust, April 2016.
2 The Second Patient Report of the National Emergency Laparotomy Audit, July 2016. (Audit carried out by the National Institute of Academic Anaesthesia’s Health Services Research Centre on behalf of the Royal College of Anaesthetists.) Accessed at:
www.nela.org.uk
OCTOBER 2016
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