Improving outcomes in emergency laparotomy
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Improving outcomes in emergency laparotomy Sam Huddart FRCA Clinical Research Fellow Department of Anaesthetics and Intensive Care Royal Surrey County Hospital, Guildford Presentation from Shaping the Future Direction of Enhanced Recovery Care Pathway Seven Days a Week workshop held in London on 5 December 2013
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Improving outcomes in emergency laparotomy
- 1. ELPQuiC Emergency Laparotomy Pathway Quality Improvement Care-Bundle Improving outcomes in emergency laparotomy Sam Huddart FRCA Clinical Research Fellow Department of Anaesthetics and Intensive Care Royal Surrey County Hospital, Guildford
- 2. Emergency ERAS The Holy Grail of enhanced recovery? ELPQuiC Emergency Laparotomy Pathway Quality Improvement Care-Bundle
- 3. Sources of funding • Health Foundation ‘Shine Award’. 2012 • LiDCO: provided cards for CO monitor ELPQuiC Emergency Laparotomy Pathway Quality Improvement Care-Bundle
- 4. ELPQuiC Emergency Laparotomy Pathway Quality Improvement Care-Bundle
- 8. Key Points • • • • • • • Multicentre QI collaboration Existing baseline data for benchmarking Board-level buy-in before starting Regular local and project meetings Multidisciplinary Locally driven QI strategies Data collection Dec ‘12 – July ‘13 ELPQuiC Emergency Laparotomy Pathway Quality Improvement Care-Bundle
- 9. ELPQuiC Emergency Laparotomy Pathway Quality Improvement Care-Bundle
- 10. ELPQuiC Emergency Laparotomy Pathway Quality Improvement Care-Bundle
- 11. 27% reduction P= 0.1171 ELPQuiC Emergency Laparotomy Pathway Quality Improvement Care-Bundle
- 12. 42% reduction P = 0.045 ELPQuiC Emergency Laparotomy Pathway Quality Improvement Care-Bundle
- 13. Site 4 TH 5 0 -5 Risk adjusted Expected-Observed deaths Site 2 RUH 5 0 -5 Site 1 RSCH 5 0 -5 Site 3 RDEH 5 0 -5 0 20 40 Consecutive patient by operation date 60 13
- 14. p=0.1463 ELPQuiC Emergency Laparotomy Pathway Quality Improvement Care-Bundle
- 20. Site 1 Site 2 Site 3 Site 4 MEWS 65% 78% 99% 99% Pre-op antibiotics 53% 69% 65% 86% Theatre <6 hours 77% 62% 66% 74% Intra-op GDFT 92% 58% 82% 49% ICU post op 95% 56% 75% 62%
- 21. Summary of ELPQuiC • Change is difficult! – – – – Attitudes and behaviour Heterogeneous population Multidisciplinary Acute Care Provision • Improvements in metrics • Improvements in outcomes • Huge potential for further improvements ELPQuiC Emergency Laparotomy Pathway Quality Improvement Care-Bundle
- 22. The future • National Emergency Laparotomy Audit – http://www.nela.org.uk/ • EPOCH trial – Randomised cluster trial – QI for emergency laparotomy – http://www.epochtrial.org/epoch.php ELPQuiC Emergency Laparotomy Pathway Quality Improvement Care-Bundle
- 23. Thank you Nial Quiney & Matt Dickinson Carol Peden Mike Swart Bruce McCormick Guildford Bath Torbay Exeter samhuddart@nhs.net ELPQuiC Emergency Laparotomy Pathway Quality Improvement Care-Bundle
Editor's Notes
- Good afternoon, thank you for inviting me to talk today. My name is Sam Huddart, I am a clinical research fellow in Anaesthetics at the royal surrey county hospital in Guildford. My primary research interest is improving outcomes after emergency major general surgery. I am here to represent the ELPQuiC project in place of Carol Peden and Nial Quiney who could not be here today.
- NICE (2007): Structure of team, strategies for calling appropriate help with escalation of care. Referral to critical care, timely decision making and effective handover NCEPOD 2011: Appropriate preop care, fluid resuscitation, timeliness of surgery, grade of surgeon and anaesthetist, intraop management and post op location RCS 2011: Escalation of care, source control and antibiotics, end of theatre bundle – destination RCS 2011: Organisation structure and infrastructure
- Baseline data
- Y-axis can also be described as Net statistical lives saved