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A Case Study: National Emergency Laparotomy Audit
Key Points
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The National Emergency Laparotomy Audit (NELA) collects perioperative data on patients undergoing emergency bowel surgery (emergency laparotomy) from 179 hospitals across England and Wales (2020 figures).
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Data are used nationally, providing real time hospital-level benchmarked performance reports and informing quality improvement programs.
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Outcomes after emergency laparotomy have improved annually since the inception of the audit in 2012.
Introduction
Approximately 30,000 emergency laparotomies are performed annually in England and Wales. In 2012 the UK Emergency Laparotomy Network reported that emergency laparotomies were associated with substantial mortality, and significant variation in outcomes between hospitals and in different patient groups, particularly the elderly or frail. In 2012 the 30-day mortality rate for this procedure in the UK was reported as 14.8%, rising to 24.4% in patients aged 80 or over. That mortality rate was very similar to the rate reported in the United States in 2012, using data from the National Surgical Quality Improvement Program.
The National Emergency Laparotomy Audit (NELA) was commissioned by the National Health Service (NHS) Healthcare Quality Improvement Partnership (HQIP) and funded by NHS England and Wales to collect national data with a dual purpose: to benchmark care and risk-adjusted outcomes against published national standards to provide quality assurance and to contribute to quality improvement (QI). NELA facilitates improvements in care by supporting clinicians in using data to reduce variation in processes of care, aid the implementation of best practice, and thus improve outcomes.
Methods
NELA is a continuous audit of prospective patient-level process and outcome measures. Cases are entered by local clinical teams via a dedicated secure website from 179 hospitals across England and Wales ( https://data.nela.org.uk/ ). They are linked to national data sets from Hospital Episode Statistics (HES) and the Office for National Statistics (ONS), adjusted for case-mix, and reported at a named hospital-level. The multidisciplinary Project Team is based at the Royal College of Anaesthetists’ Health Services Research Centre, partnered with the Royal College of Surgeons’ Clinical Effectiveness Unit. Stakeholder input is provided by a clinical reference group, including lay representation.
The metrics used for data collection ( Tables 57.1 and 57.2 ) are selected from perioperative best practice recommendations published by the English Royal College of Surgeons, National Institute for Health and Care Excellence, National Confidential Enquiry into Patient Outcome and Death, and the UK and Ireland Association of Surgeons.
Table 57.1
Examples of Process Measures Relating to Timeliness of Care Throughout the Perioperative Pathway and Delivery of Care Guided by Assessment of Risks of Complications and Death Including Percentages Reported in Year 1 Compared With Year 6
| Year 1 | Year 6 | |
|---|---|---|
| Computed tomography (CT) scans reported by an in-house consultant radiologist before surgery | 68% | 62% a |
| Access to operating rooms within a time frame appropriate for the urgency of surgery | 80% | 83% |
| Documented assessment, before surgery, of the risks of surgery | 56% | 84% |
| Presence of consultant surgeon and anesthetist in operating room for high-risk patients | 70% | 88.5% |
| Admission to critical care after surgery for high-risk patients | 64% | 85% |
| Assessment by a “scare of the older person” specialist for those aged 65 + and frail (or aged 80 +) | 10% b | 28.8% (30%) |
a This metric only includes in-house consultant reporting for Year 6, whereas Year 1 also included outsourced reports.
b In Year 1, this was measured for patients aged over 70 years.
Table 57.2
Outcome Measures Published at Hospital Level
| Year 1 | Year 6 | |
|---|---|---|
| Risk-adjusted postoperative 30-day mortality (%) | 11.7 | 9.3 |
| Unplanned return to theatre (%) | 10 | 5 |
| Length of hospital stay (days) | 18.1 | 15.4 a |
a Reduction in length of stay representing annual savings estimated at £38,000,000 BP/$51,000,000 USD.
Comparative information on these process and outcome measures are reported in a variety of publicly available formats and granularity:
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Risk-adjusted outcomes published in annual national report accompanied by a hospital-specific annual report, supported by patient-focused infographics
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Quarterly reports published publicly at provider and regional levels
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These are supplemented by additional dashboards available to healthcare providers behind a firewall to ensure patient confidentiality
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Real-time online dashboard with time series data of key process measures and outcomes, and comparators with regional and national averages, and similar-sized peers ( Figs. 57.1 and 57.2 ). Data can be displayed in a run chart or statistical process control (SPC; I or P chart, depending on the data type) format.
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Live exponentially weighted moving average (EWMA) charts provide running information on risk-adjusted hospital-level mortality ( Fig. 57.3 ).
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Exception and excellence reporting, detailing the care of high-risk patients, patients who have died in hospital, and patients who have received all the key standards of care
NELA promotes the use of data for QI. Over time, reporting of data has evolved and NELA was one of the first of the NHS National Audit Programme audits to provide real-time data to users. The annual report remains an important tool for quality assurance, interrogation of trends, and national recommendations; however, the recent strategy to supplement this lengthy annual document with more focused, timely outputs has been effective at facilitating data-driven QI.
The NELA website ( https://www.nela.org.uk/ ) hosts a wealth of resources (toolkits, pathway examples, presentations from national conferences) sharing successes from local sites and examples of best practice.
Nationally, NELA has promoted multispecialty involvement from across specialty groups, including emergency medicine and radiology, as well as surgery, anesthetics, and critical care. Importantly, although NELA facilitates improvement initiatives, service improvements are developed, delivered, and funded locally by care providers.
The UK National Clinical Audits (NCAs) have shaped changes in the way clinical care is delivered, but direct measurement of impact remains difficult. The HQIP framework can be applied to look for specific evidence that an audit has effects at national, local, system, and public levels.
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