Integrating audit with QI research Carol J. Peden MD, FRCA, FICM, MPH. NELA QI Lead, EPOCH QI Lead Macintosh Professor Royal College of Anaesthetists,

Integrating audit with QI researchCarol J. Peden MD, FRCA, FICM, MPH.NELA QI Lead, EPOCH QI LeadMacintosh Professor Royal College of Anaesthetists, Associate Medical Director for Clinical Quality RUH, Bath and NHS England (South).October 9th 2014

Emergency laparotomy outcomes

A Prospective Observational Study of Outcome of Emergency LaparotomyA Prospective Observational Study of Outcome of Emergency LaparotomyEur J Anaesth 2011. Clarke, Murdoch, Cook, Thomas, PedenEur J Anaesth 2011. Clarke, Murdoch, Cook, Thomas, Peden..

Cook et al Annals Royal College of Surgeons 1997.Cook et al Annals Royal College of Surgeons 1997.

What has been achieved?• Association of Surgeons Report 2007• Emergency Laparotomy network May 2010• NCEPOD report on Elderly November 2010• Ombudsman’s report on Care of the Elderly in Acute Hospitals• RCS Standards for Unscheduled Care April 2011• Anaesthesia Editorial: Emergency Surgery in the Elderly• Department of Health guidelines September 2011 on the

“High Risk Surgical Patient”• RCOA working party to achieve action – ongoing• NCEPOD report December 2011• NELA Network and HQIP

Emergency Laparotomy Network• BJA Saunders et al 2012• 1,835 patients from 35 NHS hospitals• Unadjusted 30-day mortalities:• 14.9 % overall• 24.4 % if over 80 yrs• Compared with:

• Elective colorectal resection 2.7 %• Oesophagectomy 3.1 %• Gastrectomy 4.2%• Liver met. resection 1 %

When is death inevitable after emergency laparotomy?

• Al- Temimi et al J Am Coll Surg 2012;215:503-11• NSQIP database • 37,500 patients• 30 day mortality 14%• Mortality and Post-operative Care Pathways in 2904 patients: a

population based cohort study.Vester-Andersen et al BJA online Feb 2014

• Overall mortality 18.5% -90 day mortality 23.8%• 84% of patients sent to ward• “A multi-disciplinary approach with involvement of both surgeons and

intensivists in the first 2-3 days”

Variation in mortality after emergency surgery in the UKSymons N et al. Brit J Surg 2013; 100: 1318-25.

Mortality 15.6%

National Emergency Laparotomy Audit

“To enable the improvement of the quality of care for patients undergoing emergency laparotomy through the provision of high quality comparative data from all providers of emergency laparotomy.”

•£1million over 3 years•Subcontracted to RCS

Organisational Audit: Yr1• Number of Critical Care Beds as a proportion of total beds**• Number of surgeons on on-call rota**/++• Whether surgical staff are free from elective commitments whilst on-

call **/++• Working patterns of on-call clinical staff (Consultants and Speciality

Trainees)** /++• Specialist Interest of surgeons on on-call rota**/++• Availability of • pre-operative imaging*/**/++• interventional radiology*/**/++• emergency theatres */**/++• routine daily input from elderly care*

* NCEPOD 2010 “An Age Old Problem: a review of the care received by elderly patients undergoing surgery” ** Department of Health Working Group “The Higher Risk General Surgical Patient: Towards Improved Care for a Forgotten Group”

++ RCSEng 2011 “Emergency Surgery Standards for unscheduled surgical care”

NELA organisational Audit

Improving outcomes in Emergency Laparotomy

‘While all changes do not lead to improvement, all improvement

requires change’

Recommendations: Changing the delivery of care in ELPathway implementation

Preoperative risk estimation and documentationEscalation strategies and case prioritisation Clear diagnostic and monitoring plans Timing of diagnostic tests / timing of surgery

1. Individual risk

2. Processes of care

3. Perioperative patient outcomes

Data Domains

Bivariate analysis of inpatient mortality to identify ‘High risk’ subgroups

AgeASAPreop risk stratificationPreop P-POSSUM estimate of 30d mortalityNCEPOD urgency

Key process measures1. Minimal delay to surgical intervention

2. Minimal delay to administration of antibiotic

3. Consultant surgeon

4. Consultant anaesthetist

5. Postoperative critical care admission

Quality Improvement• Yearly reports• Process & Outcome Measures incorporated

into Trust Quality Accounts• Local download of results as required • Presentations / workshops at regional &

national meetings to disseminate best practice

Changing the way we think: understanding urgency and risk

Adapted from Moore et al. Availability of acute care surgeons improves outcomes in patients

requiring emergent colon surgery. Am J Surg 2011;202:837-842.

Emergency Laparotomy Pathway Quality Improvement Care BundleRoyal Surrey County

RUH, Bath

Royal Devon and Exeter

South Devon

ELPQuiCELPQuiCEmergency Laparotomy Pathway Quality Improvement Care-Bundle

ELPQuiCELPQuiCEmergency Laparotomy Pathway Quality Improvement Care-Bundle

CUSUM O/E mortality

Risk adjusted mortality using P-POSSUM

In all hospitals a statistically significant increase in lives saved

P<0.0001

BJS in pressHuddart, Peden, Quiney et al

EPOCH TrialEnhanced Peri-Operative Care for High-risk

patients

• NIHR funded £1.5M

• 90 hospitals admitting acute abdominal surgery

• Principal Investigator Rupert Pearse

• QI Lead Carol Peden

Improving emergency surgery requires reliability and standardisation

• This can be done and the ELPQuIC study shows that improvement may be significant• Standardise pathways of care• Create a sense of urgency!• NELA gives us the data to drive improvement

“Reliability means keeping promises” Don Berwick

Will an emergency laparotomy database improve mortality?• "Without a standard there is no logical basis for

making a decision or taking action."-Joseph M. Juran• "In God we trust, all others bring data."- W. Edwards

Deming

The Future is here!