Sustaining better care for patients undergoing emergency laparotomy.

Emergency laparotomy is associated with high mortality. Implementation of an evidence-based care bundle has been shown to improve patient outcomes. A quality improvement project to implement a six-component care bundle was undertaken between July 2015 and May 2018. As part of this project, we worked with 27 hospitals in the Emergency Laparotomy Collaborative. Previous pilot implementation of the same bundle in our hospital between December 2012 and July 2013 had shown marked improvement, maintained until April 2014, but then deterioration. Understanding the reasons for this deterioration informed our work to re-implement the bundle and sustain improvement. A cohort of 930 consecutive patients requiring emergency laparotomy between October 2014 and April 2019 were included. Baseline data were collected between October 2014 and June 2015, and the bundle was re-implemented in July 2015. Thirty-day mortality decreased from 11% in the baseline group to 7.3% after bundle implementation. Hospital length of stay decreased from 19.5 to 17.9 days. Full bundle compliance improved from < 60% to > 80% for all patients, with improvement in application of all individual bundle components. This study provides further evidence that outcomes for high-risk surgical patients can be improved with an evidence-based care bundle, but attention must be paid to maintaining bundle compliance. Issues around sustaining improvement must be considered from project initiation.

SMASH standardised perioperative management of patients operated with acute abdominal surgery in a high-risk setting.

OBJECTIVE OF THE STUDY: Emergency laparotomy and other high-risk acute abdominal surgery procedures have a high mortality rate. The perioperative management of these patients is complex and poses several challenges. The objective of the study is to implement and evaluate the outcome of protocol-based standardised care for patients in need of acute abdominal surgery in a Swedish setting. NÄL is a large county hospital in Sweden serving a population of approximately 270,000 inhabitants. The study seeks to determine whether standardised protocol-based perioperative management in emergency abdominal surgical procedures leads to a better outcome measured as short- and long-term mortality and postoperative complications compared with the present standard in Swedish routine care. The study is ongoing, and this article describes the methodology used in the study and discusses the benefits and limitations the study design. RESULTS: There are no results so far. The inclusion rate for the first 22 months is as expected; 404 patients have been included and protocols have been followed and reviewed according to the study plan. 25 patients have been missed and demographic data and outcome data for these patients will be collected and analysed.

Incisional hernia incidence following laparotomy for combat trauma: Investigating 15 years of US war surgery.

BACKGROUND: While the incidence of incisional hernia (IH) following elective laparotomy has been well described, incidence following emergent laparotomy for combat trauma has been much less studied. This retrospective cohort investigates the latter to better describe the burden IH represents for the injured warfighter. METHODS: Data were obtained from the Expeditionary Medical Encounter Database for service members who survived a combat-related injury between January 2002 and December 2016 and underwent abdominal surgery in the first 30 days after injury. Incisional hernia diagnosis at least 30 days after injury was determined from inpatient and outpatient records in the Military Health System's Medical Data Repository.Means and SDs were reported for age and continuous Injury Severity Score, and frequency and percentages were reported for sex, branch of service, paygrade, mechanism of injury, Injury Severity Score, and maximum abdominal Abbreviated Injury Scale. Service members with and without a hernia diagnosis were compared using t test for continuous variables and χ or Fisher exact test (depending on cell size) for categorical variables.Multivariate logistic regression models were used to examine relationships between IH diagnosis and the covariates previously mentioned. Data analysis was completed using SAS software version 9.4 (SAS Institute Inc., Cary, NC). RESULTS: Of the 570 laparotomy patients, 109 (19.1%) developed IH. Of these, 58 (53%) were diagnosed within the first year after injury. An additional 21 (19%) were diagnosed within the following year, and 30 (28%) were diagnosed more than 2 years after injury. Presence of gastrointestinal injury, Abbreviated Injury Scale score of 4 and 5, and 5-year increments of age were positively associated with hernia formation. CONCLUSION: The incidence of postlaparotomy IH in combat trauma is 19.1%, a considerable source of disability for injured warfighters. Further investigation into hernia-preventive closure strategies is warranted. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Continuous wound infiltration versus epidural analgesia for midline abdominal incisions - a randomized-controlled pilot trial (Painless-Pilot trial; DRKS Number: DRKS00008023).

OBJECTIVES: To test the feasibility of a randomized controlled study design comparing epidural analgesia (EDA) with continuous wound infiltration (CWI) in respect to postoperative complications and mobility to design a future multicentre randomized controlled trial. DESIGN, SETTING, PARTICIPANTS: CWI has been developed to address drawbacks of EDA. Previous studies have established the equivalent analgesic potential of CWI compared to EDA. This is a single centre, non-blinded pilot randomized controlled trial at a tertiary surgical centre. Patients undergoing elective non-colorectal surgery via a midline laparotomy were randomized to EDA or CWI. Endpoints included recruitment, feasibility of assessing postoperative mobility with a pedometer and morbidity. No primary endpoint was defined and all analyses were explorative. INTERVENTIONS: CWI with local anaesthetics (experimental group) vs. thoracic EDA (control). RESULTS: Of 846 patients screened within 14 months, 71 were randomized and 62 (31 per group) included in the intention-to-treat analysis. Mobility was assessed in 44 of 62 patients and revealed no differences within the first 3 postoperative days. Overall morbidity did not differ between the two groups (measured via the comprehensive complication index). Median pain scores at rest were comparable between the two groups, while EDA was superior in pain treatment during movement on the first, but not on the second and third postoperative day. Duration of preoperative induction of anaesthesia was shorter with CWI than with EDA. Of 17 serious adverse events, 3 were potentially related to EDA, while none was related to CWI. CONCLUSION: This trial confirmed the feasibility of a randomized trial design to compare CWI and EDA regarding morbidity. Improvements in the education and training of team members are necessary to improve recruitment. TRIAL REGISTRATION: DRKS00008023.

Blunt Abdominal Trauma in a European Trauma Setting: Need for Complex or Non-Complex Skills in Emergency Laparotomy.

BACKGROUND AND AIMS: Blunt abdominal trauma can lead to substantial organ injury and hemorrhage necessitating open abdominal surgery. Currently, the trend in surgeon training is shifting away from general surgery and the surgical treatment of blunt abdominal trauma patients is often done by sub-specialized surgeons. The aim of this study was to identify what emergency procedures are needed after blunt abdominal trauma and whether they can be performed with the skill set of a general surgeon. MATERIALS AND METHODS: The records of blunt abdominal trauma patients requiring emergency laparotomy (n = 100) over the period 2006-2016 (Helsinki University Hospital Trauma Registry) were reviewed. The organ injuries and the complexity of the procedures were evaluated. RESULTS: A total of 89 patients (no need for complex skills, NCS) were treated with the skill set of general surgeons while 11 patients required complex skills. Complex skills patients were more severely injured (New Injury Severity Score 56.4 vs 35.9, p < 0.001) and had a lower systolic blood pressure (mean: 89 vs 112, p = 0.044) and higher mean shock index (heart rate/systolic blood pressure: 1.43 vs 0.95, p = 0.012) on admission compared with NCS patients. The top three NCS procedures were splenectomy (n = 33), bowel repair (n = 31), and urinary bladder repair (n = 16). In patients requiring a complex procedure (CS), the bleeding site was the liver (n = 7) or a major blood vessel (n = 4). CONCLUSION: The majority of patients requiring emergency laparotomy can be managed with the skills of a general surgeon. Non-responder blunt abdominal trauma patients with positive ultrasound are highly likely to require complex skills. The future training of surgeons should concentrate on NCS procedures while at the same time recognizing those injuries requiring complex skills.

Minimally Invasive Surgery Rate as a Quality Metric for Endometrial Cancer.

STUDY OBJECTIVE: To determine the frequency with which Commission on Cancer-accredited hospitals met a metric of ≥80% minimally invasively performed hysterectomies for endometrial cancer and to compare the clinical outcomes of hospitals meeting this metric with those that did not. DESIGN: Retrospective cohort study. SETTING: Hospitals caring for ≥20 endometrial cancer patients per year recorded in the National Cancer Database in 2015 were included. PATIENTS: Women who had undergone hysterectomy for endometrial cancer and had an epithelial histology, a Charlson comorbidity score of 0, and stage I to III disease. INTERVENTION: Patient characteristics, patterns of care, and outcomes were compared between hospitals performing ≥80% minimally invasive hysterectomies and hospitals not meeting this metric. MEASUREMENTS AND MAIN RESULTS: The hospitals (n = 510) treated 20 670 women with endometrial cancer. In 283 (55%) hospitals ≥80% of hysterectomies were minimally invasively performed (high-minimally invasive surgery [MIS] hospitals, overall MIS rate 89%). In the 227 hospitals that did not meet this metric, 61% of hysterectomies for endometrial cancer were performed using a minimally invasive approach. In high-MIS hospitals, patients were more likely to be white (87% vs 82%, p<.001), privately insured (53% vs 49%, p <.001), and have stage I disease (84% vs 82%, p = .002) and an endometrioid histology (79% vs 76%, p <.001). Surgery was more often performed robotically (80% vs 71%), and conversion to laparotomy was less likely (1.5% vs 3.2%, adjusted odds ratio [aOR], 0.47; 95% confidence interval [CI], 0.39-0.57) (both p <.001). Patients treated at high-MIS hospitals were more likely to have undergone lymph node assessment at the time of surgery (76% vs 69%; aOR, 1.43; 95% CI, 1.35-1.53) and been discharged on the same or next day (74% vs 57%; aOR, 2.27; 95% CI, 2.13-2.42) and were less likely to have an unplanned 30-day readmission (1.8% vs 2.9%; aOR, 0.64; 95% CI, 0.53-0.77). CONCLUSION: An MIS rate of ≥80% for endometrial cancer is feasible on a national scale and is associated with other hospital-level measurements of high-quality care.

Quality improvement and emergency laparotomy care: what have we learnt from recent major QI efforts?

More than 1.53 million adults undergo inpatient surgery in the UK NHS. Patients undergoing emergency abdominal surgery have a much greater risk of death than patients admitted for elective surgery. Widespread variations in key standards of care between hospitals exist and are associated with differences in mortality rates.Recently there have been three large-scale initiatives to improve quality of care for emergency laparotomy patients: the National Emergency Laparotomy Audit, the enhanced perioperative care for high-risk patients trial and the Emergency Laparotomy Collaborative. Here we provide a critical review of what we currently know about the use of structured methods for improving the quality of healthcare services, with reference to the three initiatives. We find that using structured methods to improve care is the hallmark of quality improvement but attention must too be paid to the context in which these methods are used.

Failure to Rescue: A Quality Improvement Imperative in Achieving Zero Death in Damage Control Laparotomy Patients.

Failure to rescue (FTR), defined as death after a major complication in surgical patients, is being used to measure outcomes for quality improvement. Major complications frequently occur in patients undergoing damage control laparotomy (DCL). No previous FTR studies have looked specifically into DCL patients. The aim of this study was to examine risk factors of FTR and identify potential areas for targeted quality improvement in DCL patients. A 10-year retrospective review of all consecutive adult trauma patients who underwent DCL at a Level I trauma center was performed. Demographic and clinical variables were examined for association with FTR. Multivariate regression analysis was performed to identify risk factors of FTR in DCL patients. A total of 199 DCL patients were analyzed. Overall DCL mortality observed was 11.1 per cent (n = 22/199) and overall FTR for the cohort was n = 16/199. FTR represented 72 per cent (n = 16/22) of the total mortality. The significantly increased risk of FTR was associated with older age (P = 0.027), lower initial Glasgow Coma Scale score (P = 0.037), more units of packed red blood cells (P = 0.028), and respiratory complications (P = 0.035). Renal and infectious complications did not significantly increase the risk of FTR in this population. FTR is an important benchmark of quality for trauma patients. This study elucidates potential initial characteristics and complications related to FTR in DCL patients. Efforts in achieving zero death from FTR can potentially improve overall mortality in this subset of patients. Future quality interventions to help minimize FTR should target these specific areas.

Laparotomy closure techniques: Do surgeons follow the latest guidelines? Results of a questionnaire.

PURPOSE: Incisional hernias after laparotomy are associated with significant morbidity and increased costs. Recent research on prevention of incisional hernia formation suggests that a laparotomy closure technique using a slowly absorbable monofilament suture with small fascial steps and bites in a continuous, single layer with a suture length to wound length (SL/WL) ratio of at least 4:1 is effective in lowering morbidity. Little is known about application of this evidence in daily practice. Therefore, a survey was performed among Dutch surgeons. METHODS: All members of the Dutch Surgical Society were invited to participate in a 24-question online survey on techniques and materials used for abdominal wall closure after midline laparotomy. Subgroup analysis was performed based on surgical subspecialty, type of hospital and experience. RESULTS: Response rate was 26% (402 respondents), representing 97% of all Dutch surgical departments. More than 90% of participants closed the abdominal wall in a single mass layer, using a slowly absorbable monofilament running suture The SL/WL ratio of >4:1 is practiced by only 35% of participants and preferred suture size was variable among participants. Risk factors for incisional hernia development were generally identified correctly but more than half of the participants were unaware of the incidence and time of occurrence of incisional hernia. Subgroup analysis found that gastrointestinal and oncologic surgeons preferred smaller diameter sutures and higher suture-length to wound-length ratios. Trauma, vascular and pediatric surgeons had lower estimates of incidence of incisional hernia than other subspecialties. Surgeons employed in academic hospitals were more likely to use small fascial steps and smaller suture sizes than their colleagues in non-academic hospitals. Correct estimates of incisional hernia incidence decreased when surgeons perform less than 10 laparotomies annually. CONCLUSION: Implementation of the latest evidence regarding closure techniques of the abdominal wall is not widespread. Only 35% of surgeons close the abdominal fascia using a suture length to wound length ratio of 4:1, which is recommended based on the latest evidence. Surgical trainees, gastrointestinal and oncological surgeons are most familiar with the recommended technique and use it in their daily practice. Efforts should be directed at improving spreading of this technique.

Outcome of trauma-related emergency laparotomies, in an era of far-reaching specialization.

Background: Far reaching sub-specialization tends to become obligatory for surgeons in most Western countries. It is suggested that exposure of surgeons to emergency laparotomy after trauma is ever declining. Therefore, it can be questioned whether a generalist (i.e., general surgery) with additional differentiation such as the trauma surgeon, will still be needed and can remain sufficiently qualified. This study aimed to evaluate volume trends and outcomes of emergency laparotomies in trauma. Methods: A retrospective cohort study was performed in the University Medical Center Utrecht between January 2008 and January 2018, in which all patients who underwent an emergency laparotomy for trauma were included. Collected data were demographics, trauma-related characteristics, and number of (planned and unplanned) laparotomies with their indications. Primary outcome was in-hospital mortality; secondary outcomes were complications, length of ICU, and overall hospital stay. Results: A total of 268 index emergency laparotomies were evaluated. Total number of patients who presented with an abdominal AIS > 2 remained constant over the past 10 years, as did the percentage of patients that required an emergency laparotomy. Most were polytrauma patients with a mean ISS = 27.5 (SD ± 14.9). The most frequent indication for laparotomy was hemodynamic instability or ongoing blood loss (44%).Unplanned relaparotomies occurred in 21% of the patients, mostly due to relapse of bleeding. Other complications were anastomotic leakage (8.6%), intestinal leakage after bowel contusion (4%). In addition, an incisional hernia was found in 6.3%. Mortality rate was 16.7%, mostly due to neurologic origin (42%). Average length of stay was 16 days with an ICU stay of 5 days. Conclusion: This study shows a persistent number of patients requiring emergency laparotomy after (blunt) abdominal trauma over 10 years in a European trauma center. When performed by a dedicated trauma team, this results in acceptable mortality and complication rates in this severely injured population.

Quality Improvement of Damage Control Laparotomy: Impact of the Establishment of a Single Korean Regional Trauma Center.

BACKGROUND: Damage control laparotomy (DCL) is a lifesaving technique to minimize the lethal triad of coagulopathy, hypothermia, and acidosis. The government has nominated and supported our center as one of the regional trauma centers of South Korea since 2014. This study aimed to investigate the improving outcomes of patients undergoing DCL before and after the establishment of the trauma center. METHOD: The period from January 2011 to December 2017 was divided into pre-trauma center (pre-TC) (2011-2013) and trauma center (TC) (2014-2017) periods. Multivariable logistic regression was performed to identify the risk factors and risk-adjusted cumulative sum (RA-CUSUM), and graphs were used to monitor the change in mortality. RESULT: Of the 485 patients who underwent trauma laparotomy, DCL was performed for 119 patients (24.5%). The operation time (99 vs. 80 min, p = 0.022), time from admission to operation (125 vs. 112 min, p = 0.010), time from admission to first treatment (119 vs. 99 min, p = 0.004), and time from admission to first transfusion (70 vs. 52 min, p = 0.009) were significantly shortened in the TC period. The ratio of plasma to packed red blood cells in massive transfusions (≥PRBCs 10 units within the first 24 h) was significantly increased in the TC period (0.56 vs. 0.72, p = 0.004). RA-CUSUM curves revealed that the risk-adjusted 30-day mortality improved and then plateaued in the TC period. CONCLUSION: After the implementation of a trauma center, more prompt intervention and damage control resuscitation could be achieved. Moreover, risk-adjusted mortality of DCL was improved.

Rural Emergency Laparotomy Audit.

BACKGROUND: Emergency laparoscopy/laparotomy is associated with high levels of mortality. The aim of this study was to determine whether outcomes following emergency laparoscopy/laparotomy in rural and regional South Australian hospitals were comparable to those reported in the National Emergency Laparotomy Audit and Perth Emergency Laparotomy Audit. METHODS: A prospective multicentre audit of patients who undergo emergency laparoscopy/laparotomy. Participating hospitals included Mount Gambier and Districts Health Service, Whyalla Hospital and Riverland General Hospital. Inclusion and exclusion criteria were identical to the National Emergency Laparotomy Audit. A modified dataset for patients was collected if patients were up-transferred to another hospital prior to operative management. Data collected included patient demographics, operative management, adherence to processes of care and outcomes. RESULTS: Data were collected for a total of 58 cases. Fifty-one of these had emergency laparoscopy/laparotomy in a rural or regional hospital and seven were transferred in the preoperative period. The median Portsmouth-Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity predicted 30-day post-operative mortality was 3.5%. One hundred percent of patients (51 out of 51) had a consultant anaesthetist and surgeon present in the operating theatre. There were no deaths reported within the 30-day post-operative period. CONCLUSION: Outcomes following emergency laparoscopy/laparotomy in rural and regional South Australian hospitals are comparable to those reported in the National Emergency Laparotomy Audit and Perth Emergency Laparotomy Audit.

Evaluating the effects of surgical subspecialisation on patient outcomes following emergency laparotomy: A retrospective cohort study.

BACKGROUND: General surgeons have become increasingly subspecialised in their elective practice. Emergency laparotomies, however, are performed by a range of subspecialists who may or may not have an interest in the affected area of gastrointestinal tract. This retrospective cohort study evaluates the impact of surgical subspecialisation on patient outcomes following emergency laparotomy. METHODS: Data was collected for patients who underwent an emergency abdominal procedure on the gastrointestinal tract in the North of England from 2001 to 2016. This included demographics, co-morbidities, diagnoses and procedures undertaken. Patients were grouped according to consultants' subspecialist interest. The primary outcome of interest was 30-day postoperative mortality. RESULTS: 24,291 emergency laparotomies were performed with an associated 30-day postoperative mortality of 11.7%. Laparotomies undertaken by upper gastrointestinal (UGI) or colorectal surgeons have significantly lower mortality (10.1%) when compared with other subspecialities (13.5%). More specifically, mortality was decreased for UGI (7.9% vs. 12.9%) and colorectal procedures (10.9% vs. 14.2%) when performed by surgeons with a specialist interest in the relevant area of the gastrointestinal tract (both p < 0.001). The utilisation of laparoscopic surgery is higher, in both UGI (21.8% vs. 9.0%) and colorectal procedures (7.2% vs. 3.5%), when the causative pathology is relevant to the surgeon's subspeciality (both p < 0.001). CONCLUSION: Mortality following emergency laparotomy is improved when performed under the care of gastrointestinal surgeons. Both UGI and colorectal emergency procedures have improved outcomes, with lower mortality and higher rates of laparoscopy, when under the care of a surgeon with a subspecialist interest in the affected area of the gastrointestinal tract.

The impact of standardized protocol implementation for surgical damage control and temporary abdominal closure after emergent laparotomy.

BACKGROUND: To standardize care and promote early fascial closure among patients undergoing emergent laparotomy and temporary abdominal closure (TAC), we developed a protocol addressing patient selection, operative technique, resuscitation strategies, and critical care provisions. We hypothesized that primary fascial closure rates would increase following protocol implementation with no difference in complication rates. STUDY DESIGN: We performed a retrospective cohort analysis of 138 adult trauma and emergency general surgery patients who underwent emergent laparotomy and TAC, comparing protocol patients (n = 60) to recent historic controls (n = 78) who would have met protocol inclusion criteria. The protocol includes low-volume 3% hypertonic saline resuscitation, judicious wound vacuum fluid replacement, and early relaparotomy with sequential fascial closure. Demographics, baseline characteristics, illness severity, resuscitation course, operative management, and outcomes were compared. The primary outcome was fascial closure. RESULTS: Baseline characteristics, including age, American Society of Anesthesiologists class, and postoperative lactate levels, were similar between groups. Within 48 hours of initial laparotomy and TAC, protocol patients received significantly lower total intravenous fluid resuscitation volumes (9.7 vs. 11.4 L, p = 0.044) and exhibited higher serum osmolarity (303 vs. 293 mOsm/kg, p = 0.001). The interval between abdominal operations was significantly shorter following protocol implementation (28.2 vs. 32.2 hours, p = 0.027). The incidence of primary fascial closure was significantly higher in the protocol group (93% vs. 81%, p = 0.045, number needed to treat = 8.3). Complication rates were similar between groups. CONCLUSIONS: Protocol implementation was associated with lower crystalloid resuscitation volumes, a transient hyperosmolar state, shorter intervals between operations, and higher fascial closure rates with no difference in complications. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Improving care at scale: process evaluation of a multi-component quality improvement intervention to reduce mortality after emergency abdominal surgery (EPOCH trial).

BACKGROUND: Improving the quality and safety of perioperative care is a global priority. The Enhanced Peri-Operative Care for High-risk patients (EPOCH) trial was a stepped-wedge cluster randomised trial of a quality improvement (QI) programme to improve 90-day survival for patients undergoing emergency abdominal surgery in 93 hospitals in the UK National Health Service. METHODS: The aim of this process evaluation is to describe how the EPOCH intervention was planned, delivered and received, at both cluster and local hospital levels. The QI programme comprised of two interventions: a care pathway and a QI intervention to aid pathway implementation, focussed on stakeholder engagement, QI teamwork, data analysis and feedback and applying the model for improvement. Face-to-face training and online resources were provided to support senior clinicians in each hospital (QI leads) to lead improvement. For this evaluation, we collated programme activity data, administered an exit questionnaire to QI leads and collected ethnographic data in six hospitals. Qualitative data were analysed with thematic or comparative analysis; quantitative data were analysed using descriptive statistics. RESULTS: The EPOCH trial did not demonstrate any improvement in survival or length of hospital stay. Whilst the QI programme was delivered as planned at the cluster level, self-assessed intervention fidelity at the hospital level was variable. Seventy-seven of 93 hospitals responded to the exit questionnaire (60 from a single QI lead response on behalf of the team); 33 respondents described following the QI intervention closely (35%) and there were only 11 of 37 care pathway processes that > 50% of respondents reported attempting to improve. Analysis of qualitative data suggests QI leads were often attempting to deliver the intervention in challenging contexts: the social aspects of change such as engaging colleagues were identified as important but often difficult and clinicians frequently attempted to lead change with limited time or organisational resources. CONCLUSIONS: Significant organisational challenges faced by QI leads shaped their choice of pathway components to focus on and implementation approaches taken. Adaptation causing loss of intervention fidelity was therefore due to rational choices made by those implementing change within constrained contexts. Future large-scale QI programmes will need to focus on dedicating local time and resources to improvement as well as on training to develop QI capabilities. EPOCH TRIAL REGISTRATION: ISRCTN80682973 https://doi.org/10.1186/ISRCTN80682973 Registered 27 February 2014 and Lancet protocol 13PRT/7655.