A quality improvement bundle reduced mortality by 39% for patients undergoing emergency laparotomy, according to results from a longitudinal study conducted in four UK hospitals.
"The results we've achieved with this project have been remarkable: around 50,000 of these operations are carried out in the UK each year. We estimate that the improvements we've made could enable hospitals to save an additional 2-3,000 lives," said coauthor Nial Quiney, MBBS, FRCA, a consultant in anaesthesia and intensive care medicine at the Royal Surrey County Hospital, Guildford, United Kingdom, in a news release.
The emergency laparotomy pathway quality improvement care (ELPQuiC) bundle includes five evidence-based components: initial assessment with early warning scores, administration of antibiotics to cases with suspected peritoneal contamination or a sepsis diagnosis, time between decision to operate and surgery of less than 6 hours, goal-directed fluid therapy, and postoperative intensive care.
"In healthcare we often know what measures we should take to improve outcomes for patients, but implementing these and getting them right for every patient is a key challenge," coinvestigator Mohammed A. Mohammed, PhD, professor of Healthcare Quality and Effectiveness at the University of Bradford, West Yorkshire, noted in the release.
"This care bundle has been particularly successful because it doesn't require additional resources, but simply better co-ordination of the resources that the hospitals already have," he added.
The bundle was implemented by a multidisciplinary team at each hospital during an 8-month period. Outcomes were compared between 299 and 427 consecutive patients who underwent emergency laparotomy in the preimplementation and postimplementation periods, respectively.
The adjusted 30-day mortality rate at the hospitals fell from 15.6% before to 9.6% after the bundle was implemented (risk ratio, 0.614; 95% confidence interval, 0.451 - 0.836; P = .002), according to results published online November 10 in the British Journal of Surgery by S. Huddart, FRCA, from the Department of Anaesthesia and Intensive Care, Royal Surrey County Hospital National Health Service Foundation Trust, Guildford, and colleagues.
Only 16.7 patients needed to be treated with the bundle to save one additional life. Overall, 6.47 more patients per every 100 treated survived at least 30 days after the bundle was implemented.
Similarly, the adjusted rate of in-hospital mortality fell from 17.4% (95% confidence interval, 14.1% - 20.8%) before implementation to 10.1% (95 confidence interval, 7.8% - 12.4%; P < .001) after implementation, and 8.11 more patients per every 100 treated survived to hospital discharge.
"Although we have relatively good outcomes from elective surgery, we've known for a long time that emergency surgical admissions have poor outcomes," Dr Quiney said. "This is due to a range of factors, including multi-organ failure and sepsis. Often these emergency cases are elderly patients with additional pre-existing conditions."
"The quality of care following emergency surgery needs to draw level with what is offered following elective surgery. Implementing this care bundle in four hospitals goes a long way towards achieving that," he maintained.
In terms of the bundle's individual components, uptake of goal-directed fluid therapy improved significantly at all four hospitals, and use of postoperative intensive care improved significantly at three of them. The patient case mix remained stable from before to after bundle implementation.
"All hospitals in England and Wales are now required to submit data to the National Emergency Laparotomy Audit," the authors conclude. "This will assist ongoing performance analysis and quality improvement."
Dr Quiney received support by LiDCO, which provided cardiac output monitors, consumables, and education for the study, to deliver a lecture to its Enhanced Recovery Summit in Brussels, Belgium. The other authors have disclosed no relevant financial relationships.
Br J Surg. Published online November 10, 2014. Full text
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Cite this: Care Bundle Reduced Mortality After Emergency Laparotomy - Medscape - Nov 17, 2014.
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