Organisational factors and mortality after an emergency laparotomy: multilevel analysis of 39 903 National Emergency Laparotomy Audit patients.

BACKGROUND: Studies across healthcare systems have demonstrated between-hospital variation in survival after an emergency laparotomy. We postulate that this variation can be explained by differences in perioperative process delivery, underpinning organisational structures, and associated hospital characteristics. METHODS: We performed this nationwide, registry-based, prospective cohort study using data from the National Emergency Laparotomy Audit organisational and patient audit data sets. Outcome measures were all-cause 30- and 90-day postoperative mortality. We estimated adjusted odds ratios (ORs) for perioperative processes and organisational structures and characteristics by fitting multilevel logistic regression models. RESULTS: The cohort comprised 39 903 patients undergoing surgery at 185 hospitals. Controlling for case mix and clustering, a substantial proportion of between-hospital mortality variation was explained by differences in processes, infrastructure, and hospital characteristics. Perioperative care pathways [OR: 0.86; 95% confidence interval (CI): 0.76-0.96; and OR: 0.89; 95% CI: 0.81-0.99] and emergency surgical units (OR: 0.89; 95% CI: 0.80-0.99; and OR: 0.89; 95% CI: 0.81-0.98) were associated with reduced 30- and 90-day mortality, respectively. In contrast, infrequent consultant-delivered intraoperative care was associated with increased 30- and 90-day mortality (OR: 1.61; 95% CI: 1.01-2.56; and OR: 1.61; 95% CI: 1.08-2.39, respectively). Postoperative geriatric medicine review was associated with substantially lower mortality in older (≥70 yr) patients (OR: 0.35; 95% CI: 0.29-0.42; and OR: 0.64; 95% CI: 0.55-0.73, respectively). CONCLUSIONS: This multicentre study identified low-technology, readily implementable structures and processes that are associated with improved survival after an emergency laparotomy. Key components of pathways, perioperative medicine input, and specialist units require further investigation.

Development and internal validation of a novel risk adjustment model for adult patients undergoing emergency laparotomy surgery: the National Emergency Laparotomy Audit risk model.

BACKGROUND: Among patients undergoing emergency laparotomy, 30-day postoperative mortality is around 10-15%. The risk of death among these patients, however, varies greatly because of their clinical characteristics. We developed a risk prediction model for 30-day postoperative mortality to enable better comparison of outcomes between hospitals. METHODS: We analysed data from the National Emergency Laparotomy Audit (NELA) on patients having an emergency laparotomy between December 2013 and November 2015. A prediction model was developed using multivariable logistic regression, with potential risk factors identified from existing prediction models, national guidelines, and clinical experts. Continuous risk factors were transformed if necessary to reflect their non-linear relationship with 30-day mortality. The performance of the model was assessed in terms of its calibration and discrimination. Interval validation was conducted using bootstrap resampling. RESULTS: There were 4458 (11.5%) deaths within 30-days among the 38 830 patients undergoing emergency laparotomy. Variables associated with death included (among others): age, blood pressure, heart rate, physiological variables, malignancy, and ASA physical status classification. The predicted risk of death among patients ranged from 1% to 50%. The model demonstrated excellent calibration and discrimination, with a C-statistic of 0.863 (95% confidence interval, 0.858-0.867). The model retained its high discrimination during internal validation, with a bootstrap derived C-statistic of 0.861. CONCLUSIONS: The NELA risk prediction model for emergency laparotomies discriminates well between low- and high-risk patients and is suitable for producing risk-adjusted provider mortality statistics.

Thirty-day mortality in patients undergoing laparotomy for small bowel obstruction.

BACKGROUND: Small bowel obstruction (SBO) is a common indication for emergency laparotomy. There are currently variations in the timing of surgery for patients with SBO and limited evidence on whether delayed surgery affects outcomes. The aim of this study was to evaluate the impact of time to operation on 30-day mortality in patients requiring emergency laparotomy for SBO. METHODS: Data were collected from the National Emergency Laparotomy Audit (NELA) on all patients aged 18 years or older who underwent emergency laparotomy for all forms of SBO between December 2013 and November 2015. The primary outcome measure was 30-day mortality, with date of death obtained from the Office for National Statistics. Patients were grouped according to the time from admission to surgery (less than 24 h, 24-72 h and more than 72 h). A multilevel logistic regression model was used to explore the impact of patient factors, primarily delay to surgery, on 30-day mortality. RESULTS: Some 9991 patients underwent emergency laparotomy requiring adhesiolysis or small bowel resection for SBO. The overall mortality rate was 7·2 per cent (722 patients). Within each time group, 30-day mortality rates were significantly worse with increasing age, ASA grade, Portsmouth POSSUM score and level of contamination. Patients undergoing emergency laparotomy more than 72 h after admission had a significantly higher risk-adjusted 30-day mortality rate (odds ratio 1·39, 95 per cent c.i. 1·09 to 1·76). CONCLUSION: In patients who require an emergency laparotomy with adhesiolysis or resection for SBO, a delay to surgery of more than 72 h is associated with a higher 30-day postoperative mortality rate.