Quality Improvement in Emergency Surgery: Learning From Two Large-Scale Programs to Reduce Mortality After Emergency Laparotomy

Background

More than 1.53 million adults undergo in-patient surgery in the UK National Health Service (NHS) each year with a 30-day mortality of 1.5%. Patients undergoing emergency laparotomy, however, have a much greater risk of death. Emergency laparotomy is a collective term that describes a heterogeneous group of unplanned intra-abdominal surgical procedures that are performed for a variety of indications, including intestinal obstruction, perforation of the bowel, or peritonitis, plus complications of elective surgery. Approximately 30,000 emergency laparotomies are performed annually in England and Wales. Data available before the commencement of the Enhanced Perioperative Care for High-Risk Patients (EPOCH) trial (in 2014) indicated that mortality was high, with a 30-day mortality of between 13.3% and 19%. A key study in 2012, using data from the Emergency Laparotomy Network, found that there were substantial variations in the way that patients requiring emergency laparotomy were cared for. For example, wide variations were found in the grade of surgeon and anesthetist performing the operation, how long it took to get the patient into the operating room (OR), and whether the patient was admitted to critical care afterward. These variations were found to be associated with differences in mortality rates, and it was hypothesized that standardizing care may lead to improved outcomes. These findings aligned with a report by the Royal College of Surgeons of England, commissioned by the UK Department of Health, which proposed extensive improvements to quality of care for this patient group. Recommendations included interventions across the pre, intra, and postoperative phases, such as consultant-led decision making, cardiac output–guided fluid therapy, and early admission to critical care. A four-center observational study found that implementation of a care bundle to support delivery of some of these key interventions was effective at reducing 30-day mortality. This was the background context in the UK NHS that led to the funding, by the National Institute of Health Research, of the EPOCH trial and the Emergency Laparotomy Collaborative (ELC) by the Health Foundation. Concurrently, the Healthcare Quality Improvement Programme (HQIP) funded the National Emergency Laparotomy Audit (NELA), a mandatory national dataset for this patient group.

EPOCH and the ELC: Summary of the Studies and the Main Findings