National Emergency Laparotomy Audit Identifies Concerning Missed Standards

Dawn O'Shea

November 17, 2021

The 7th National Emergency Laparotomy Audit (NELA) has found that the 30-day mortality rate for patients undergoing emergency laparotomy in England and Wales dropped to 8.7% in 2020, a decrease of more than 3% on the 2014 figure of 11.8%. However, this year’s NELA report also raises concerns regarding a number of key targets related to the surgery, including the management of patients with suspected sepsis, the preoperative assessment of elderly patients and alarming mortality rates in some hospitals.

This year’s NELA report contains data for the period December 2019 to November 2020, submitted by 177 of 182 hospitals.

Worryingly, the audit found that seven hospitals had alarmingly high mortality rates related to emergency laparotomy. Of 175 hospitals included in the outlier identification analysis, one had an adjusted mortality rate of 34.3%, which reached alarm status (above upper 99.8% control limit), and a further six hospitals rates that triggered alert status (95% to 99.8% upper control limits).

In comparison, the four hospitals demonstrating the lowest mortality rates were Addenbrookes Hospital in Cambridge (3.58%), Huddersfield Royal Infirmary (3.90%), Norfolk and Norwich University Hospital (5.06%) and the Royal United Hospital in Bath (3.65%). It is hoped that collaborative learning events will provide opportunities for hospital teams to learn from one another and share how improved outcomes can be sustained.

While the audit identified improvements in many key areas of patient care, including a reduction in length of stay, it also found that only a fifth of patients (21.7%) who had signs of sepsis on admission received antibiotics within the recommended 60 minutes. This figure has remained largely stagnant since the data were first recorded in 2015. One in 10 patients received their first dose of antibiotics in theatre (9%), with a median time from admission to decision to operate of 9.8 hours and admission to theatre of 15.3 hours. Overall, the 30-day mortality rate in patients with suspected sepsis on admission is 14.8%. The audit report highlights the delay in the administration of antibiotics to patients with suspected sepsis as a particular concern.

Less than 81% of patients arrived at theatre within the appropriate timescale, in accordance with their recorded category of National Confidential Enquiry into Patient Outcome and Death (NCEPOD) urgency. This compares to 82.7% in 2019. Just over two-thirds (68.4%) of patients requiring immediate surgery arrived at theatre within two hours. This compares to 72.8% in 2019.

A key standard for emergency laparotomy is the early involvement of geriatric specialists in the assessment of patients aged ≥80 years or ≥65 years with a Clinical Frailty Scale (CFS) ≥5. However, the audit discovered that just over a quarter (27.1%) of these vulnerable patients received care from a geriatrician, dropping from 29.2% in 2019.

There has also been a drop in the number of high-risk patients seeing a consultant anaesthetist before surgery, decreasing from 94.0% in 2019 to 75.5% in 2020.

An area of concern highlighted in the report is the rate of unnecessary surgery, with 1.2% of patients in 2020 undergoing a 'negative laparotomy' where no abnormalities were detected. The audit found that indications for surgery and findings at laparotomy did not correlate in around one quarter of patients.

The highest discrepancy rate (7.4%) between computed tomography (CT) and surgical findings was seen in patients who were found to have either ischaemia or bleeding at emergency laparotomy. The more urgent the need for surgery, the higher the discrepancy rate between the CT report and surgical findings. A rate of 6.5% was seen in patients requiring immediate surgery (<2 hours) compared with 4.4% for those who required expedited surgery (>18 hours). Discrepancy rates ranged between hospitals, from 0% to 20%.

Over the last seven years of reporting, 2221 patients (median: 355 annually) have undergone a negative laparotomy. This group of patients had a high 30-day mortality rate of 13.7%. More than 1 in 8 patients who underwent a negative emergency laparotomy in 2020 did not have a consultant surgeon and anaesthetist present in theatre. The overall percentage of negative laparotomies has remained unchanged since the first NELA report was published in 2015.

The report sets out recommendations aimed at addressing the shortfalls identified in the audit.

However, the audit did identify a number of positive developments. The proportion of patients in whom a preoperative risk assessment was documented reached its highest level at 85%.

More than 90% of patients with a risk of death score ≥5% had both a consultant surgeon and anaesthetist present in theatre. This was also true for 81% of patients with a risk of death <5%. Between the hours of 00:00 and 08:00, 85% of high-risk patients had a consultant surgeon and anaesthetist present in theatre for the procedure.

Length of stay has also shown improvement. The mean length of stay in 2020 was 15.1 days compared with 16.2 in 2019. Overall, length of stay has fallen from 19.3 days since NELA’s inception in 2013, representing cost savings to acute Trusts of £42.4 million.

Commenting on the audit findings, Dr Fiona Donald, President of the Royal College of Anaesthetists said: "The year-on-year improvements in mortality rates and time spent in hospital for patients undergoing emergency bowel surgery are heartening. The data shows clinicians are clearly taking heed of the recommendations outlined in the reports, and steadily improving care across the country. This enhancement in patient outcomes is testament to the commitment and dedication of multiple clinical specialties, doctors, nurses, and other allied health professionals."

"The fact that such improvements happened during the pandemic further highlights the dedication of staff to maintain care for non-COVID patients. It is very reassuring to know that despite the NHS going through arguably the biggest challenge it has ever faced, standards of patient care and outcomes have largely been maintained and in some cases improved."

However, she adds: "While it is positive news, it would be wrong to not also acknowledge, and strive to address areas that could be better. The reports have shown a consistently low rate of patients with suspected sepsis receiving antibiotics within one hour, alongside poor rates of geriatrician input for elderly and frail patients. We must remember that even the slightest delay or disruption to emergency laparotomy patients receiving treatment could have devastating consequences and we hope that the recommendations to improve care can be implemented throughout the healthcare system."

"This report must be shared across the NHS, with hospitals, health Boards and Trusts working to maintain the improvements in care, but also taking on board the need to reassess some of their care pathways especially for high-risk and elderly patients, focusing on systematic improvements to ensure improved consistency of care," Dr Donald said.

This clinical summary originally appeared on Univadis, part of the Medscape Professional Network.

Seventh Patient Report of the National Emergency Laparotomy Audit. Royal College of Anaesthetists, National Emergency Laparotomy Audit Project Team. 2021 November.

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