Worrying shortfall in care for emergency bowel surgery patients, National Emergency Laparotomy Audit finds

Published: 08 Sep 2015

More patients die from emergency bowel surgery than from any type of high-risk planned surgery. A study published today has revealed that, despite the inherent risks of emergency bowel surgery, the care and resources provided do not match those generally provided for patients undergoing high-risk planned operations.

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Emergency laparotomy (bowel surgery) is a high-risk surgical operation that involves making an incision to operate inside the abdomen to treat life-threatening conditions. The National Emergency Laparotomy Audit (NELA) shows that 11% of patients who undergo emergency laparotomy die within 30 days of their operation. This is up to five times higher than planned surgery including cardiac and cancer surgery, where key resources such as consultant-led care and critical care are more readily provided.

The report authors suggest that resources and other standards of care need to be provided to these emergency cases on a comparable level to that provided for planned elective operations such as cardiac surgery and planned major bowel surgery. This underinvestment in key resources needs to be addressed. Particular areas of concern which were highlighted include:

• Risk of death after surgery was documented in only just over half of patients. Patients who had their risk documented were more likely to be allocated appropriate resources and receive care that met standards for best practice, such as consultant delivered care and critical care
• One in six patients did not arrive in the operating theatre within the recommended timeframes, despite the urgent nature of the surgery
• A stark contrast with planned surgery was evident in admission rates to critical care after surgery (where higher levels of nursing care, monitoring and life-supporting treatment can all be provided). Critical care admission would be considered routine practice for 100% of patients undergoing much lower risk planned cardiac surgery; however, only 60% were admitted there directly after emergency bowel surgery
• The study analysed data on over 20,000 patients from 192 hospitals and observed major variation in death rates between patient groups: for example 3 per cent of patients under 50 died in hospital within 30 days compared to 18 per cent of those over 70 years old. More than a quarter of patients required hospital treatment for more than 20 days, indicating significant levels of complications affecting patients and families, and major costs to the NHS

This is the first time that this information has ever been comprehensively collected. It is encouraging to note that some hospitals are achieving recommended standards of care for every standard evaluated, indicating that it should be possible for all hospitals to improve their performance and therefore reduce death and complications after this type of surgery.

These are some of the findings of NELA which has today revealed a wide variation in care across England and Wales, against existing, clearly defined standards of care. NELA, commissioned by the Healthcare Quality Improvement partnership (HQIP) as part of the National Clinical Audit Programme, provides named hospital-level data from 192 of the 195 hospitals in England and Wales that carry out emergency bowel surgery.

“The clinical pathway is complex and there is huge variation in clinical management which indicates the need to drive this national quality improvement programme,” concludes Dr Dave Murray, NELA National Clinical Lead. “Many hospitals currently meet standards of care for 60-70% of patients, but clinicians, managers and commissioners need to determine why standards are met sometimes and not at others.”

Professor Mike Grocott, Chair of NELA and Director of The Health Service Research Centre (HSRC) of the National Institute of Academic Anaesthesia, (NIAA) explained: “The real benefit is in driving quality improvement that impacts patient outcomes. The potential health impact of an even modest improvement could be substantial. These results have been fed back to individual hospitals, allowing them to identify and reflect upon their own outcomes. The audit team will follow up with the best and worst hospitals to understand what is being done well, sharing best practice to improve performance where necessary.”

Mr Iain Anderson, NELA Surgical Lead commented, “Many clinical teams have substantially restructured the way they deliver care to this critically ill group of patients in the last few years and deserve considerable praise for that. This Audit is an essential step in helping all involved measure and continue that development and in indicating particularly to weaker teams how they might improve services and save lives”.

Lauren Osborne, member of Royal College of Anaesthetists Lay Committee, stated that “This report will inform and shape the future of the quality of care received by an extremely vulnerable group of patients. The NELA report is of critical importance to patient care and warrants attention from key stakeholders.”

The report offers a series of recommendations to reduce variation in the care of patients undergoing emergency bowel surgery including:

• Every patient undergoing emergency bowel surgery should have a formal assessment and documentation of the risk of death and complications. This will help to ensure that patients and families are fully informed of the risks of surgery and that care can be tailored to individual patient need
• This risk assessment should also drive the appropriate allocation and prioritisation of resources, such as rapid access to an operating theatre and critical care admission following surgery, in order to improve patient outcome
• Hospital managers and commissioners should review their local data against national best practice to improve delivery of care