Yes / IMPORTANCE Patients undergoing emergency laparotomy have high mortality, but few
studies exist to improve outcomes for these patients.
OBJECTIVE To assess whether a collaborative approach to implement a 6-point care bundle
is associated with reduction in mortality and length of stay and improvement in the delivery
of standards of care across a group of hospitals.
DESIGN, SETTING, AND PARTICIPANTS The Emergency Laparotomy Collaborative (ELC) was a
UK-based prospective quality improvement study of the implementation of a care bundle
provided to patients requiring emergency laparotomy between October 1, 2015, and
September 30, 2017. Participants were 28 National Health Service hospitals and emergency
surgical patients who were treated at these hospitals and whose data were entered into the
National Emergency Laparotomy Audit (NELA) database. Post-ELC implementation
outcomes were compared with baseline data from July 1, 2014, to September 30, 2015.
Data entry and collection were performed through the NELA.
INTERVENTIONS A 6-point, evidence-based care bundle was used. The bundle included
prompt measurement of blood lactate levels, early review and treatment for sepsis, transfer
to the operating room within defined time goals after the decision to operate, use of
goal-directed fluid therapy, postoperative admission to an intensive care unit, and
multidisciplinary involvement of senior clinicians in the decision and delivery of perioperative
care. Change management and leadership coaching were provided to ELC leadership teams.
MAIN OUTCOME AND MEASURES Primary outcomes were in-hospital mortality, both crude
and Portsmouth Physiological and Operative Severity Score for the enumeration of Mortality
and morbidity (P-POSSUM) risk-adjusted, and length of stay. Secondary outcomes were the
changes after implementation of the separate metrics in the care bundle.
RESULTS A total of 28 hospitals participated in the ELC and completed the project.
The baseline group included 5562 patients (2937 female [52.8%] and a mean [range] age of
65.3 [18.0-114.0] years), whereas the post-ELC group had 9247 patients (4911 female [53.1%]
and a mean [range] age of 65.0 [18.0-99.0] years). Unadjusted mortality rate decreased from
9.8% at baseline to 8.3% in year 2 of the project, and so did risk-adjusted mortality from a
baseline of 5.3% to 4.5% post-ELC. Mean length of stay decreased from 20.1 days during year
1 to 18.9 days during year 2. Significant changes in 5 of the 6 metrics in the care bundle were
achieved.
CONCLUSIONS AND RELEVANCE A collaborative approach using a quality improvement
methodology and a care bundle appeared to be effective in reducing mortality and length
of stay in emergency laparotomy, suggesting that hospitals should adopt such an approach
to see better patient outcomes and care delivery performance. / This study was funded by The Health Foundation, United Kingdom, as part of a Scaling Up Award.
| Identifer | oai:union.ndltd.org:BRADFORD/oai:bradscholars.brad.ac.uk:10454/16914 |
| Date | 20 March 2019 |
| Creators | Aggarwal, G., Peden, C.J., Mohammed, Mohammed A., Pullyblank, A., Williams, B., Stephens, T., Kellett, S., Kirkby-Bott, J., Quiney, N. |
| Source Sets | Bradford Scholars |
| Language | English |
| Detected Language | English |
| Type | Article, Published version |
| Rights | © 2019 Aggarwal G et al. JAMA Surgery. This work is licensed under a Creative Commons Attribution 4.0 International License. http://creativecommons.org/licenses/by/4.0/ |
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