Research led by the Royal College of Anaesthetists (RCoA) around improvements in the care of over 24,000 patients before, during and after emergency bowel surgery has shown enhanced patient care to have reduced the average hospital stay from 19.2 days in 2013 to 16 days in 2018, saving the NHS £34 million annually.

National Emergency Laparotomy Audit (NELA) report

Known as an emergency laparotomy, this surgery is one of the highest risk operations a patient can undergo. The National Emergency Laparotomy Audit (NELA) report, also found a reduction in 30 day mortality from 11.8% in 2013 to 9.6% in 2018, saving approximately 700 lives a year.

The audit identifies improvements in care have been achieved in the following areas:

• 95.5% of high risk patients undergoing emergency laparotomy surgery saw a consultant surgeon and 90% saw a consultant anaesthetist before their surgery
• 77% of emergency laparotomy patients received an assessment of risk (up from 75% in 2017, and 56% in 2013)
• 88.5% of patients received a preoperative CT scan (up from 87% in 2017 and 80% in 2013)

Commissioned by the Healthcare Quality Improvement Partnership as part of the National Clinical Audit Programme, the Fifth annual National Emergency Laparotomy Audit report analyses the care received by approximately 24,000 emergency bowel surgery patients treated in NHS hospitals in England and Wales between December 2017 and November 2018. It is based on data collected by teams at 179 hospitals in England and Wales.

While there have been improvements in key areas of patient care, these are masking significant concerns, with some hospitals falling short of the standards referenced within the NELA report and a number of key targets stagnating.

Concerns:

• only a fifth of patients (19.4%) who had signs of sepsis on admission received antibiotics within the recommended 60 minutes. This has not improved over five years, and has worsened since the last audit.
• over a quarter of patients (27.4%) needing the most urgent surgery did not get to the operating theatre in the recommended time, this has stagnated since 2017.
• 55% of patients are over the age of 65 yet only 19% of these had a formal assessment of their frailty.
• the ‘time of day’ effect remains an issue, with 83% of patients undergoing the procedure during the day seeing both anaesthetic and surgeon consultants and only 70.2% seeing them out of hours. This is particularly concerning given that a greater proportion of high-risk and highest-risk patients have surgery between 6.00pm and 8.00am.

Data from the audit also found that significant variation exists between hospitals and even within the same hospital in the provision of patient care.

Professor Ravi Mahajan, President of the Royal College of Anaesthetists, said: “The reduction in 30 day mortality rates and length of hospital stay show that clinicians are learning from data and implementing changes locally, achieving sustained improvements in results. The recommendations in the report need to be shared across the NHS with hospitals and trusts taking on board the need to focus on consistency of care, integration and cultural development. We must see organisational change before further improvements can be realised.”

Russell Prestwich, emergency laparotomy patient said: “The work of NELA is so valuable. It was not until being party to more information myself and being part of various groups plus speaking at a conference, that you know how vital it is. The survival rates are still scary even though they have improved over time. We need to have better standards of consistent care across the UK and the medical profession needs to learn from where there is good practice already. The collection of data is vital to build on development areas not only for staff, but bring the patient much more into how they are consulted, even if it is an emergency. Having had two emergency laparotomy operations in 2018, I am grateful to have come out the other side. However, the longer term damage mentally in everyday life can still be high and takes its toil through work and family. This is largely left behind after discharge and it can be difficult. Plus, if you have other life changing procedures from the operations themselves the wellbeing of patients can’t be ignored. With more involved in NELA I feel outcomes will hopefully improve over time.”

Source: RCoA