Use of a pathway quality improvement care bundle to reduce mortality after emergency laparotomy

Author:

Huddart S1,Peden C J2,Swart M3,McCormick B4,Dickinson M1,Mohammed M A5,Quiney N1,Hemmings V6,Riga A6,Belguamkar A6,Zuleika M6,White D6,Corrigan L7,Howes T7,Richards S7,Dalton S7,Cook T7,Kryztopik R7,Cornwell A8,Goddard J8,Grifiths S8,Frost F8,Pigott A8,Pittman J9,Cossey L9,Smart N9,Daniels I9

Affiliation:

1. Department of Anaesthesia and Intensive Care, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK

2. Department of Anaesthesia and Intensive Care, Royal United Hospital Bath NHS Trust, Bath, UK

3. Department of Anaesthesia and Perioperative Medicine, South Devon Healthcare NHS Foundation Trust, Torbay Hospital, Torquay, UK

4. Department of Anaesthesia and Intensive Care, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK

5. School of Health Studies, University of Bradford, Bradford, UK

6. Royal Surrey County Hospital, Guildford

7. Royal United Hospital Bath, Bath

8. Torbay Hospital, Torquay

9. Royal Devon and Exeter Hospital, Exeter

Abstract

Abstract Background Emergency laparotomies in the UK, USA and Denmark are known to have a high risk of death, with accompanying evidence of suboptimal care. The emergency laparotomy pathway quality improvement care (ELPQuiC) bundle is an evidence-based care bundle for patients undergoing emergency laparotomy, consisting of: initial assessment with early warning scores, early antibiotics, interval between decision and operation less than 6 h, goal-directed fluid therapy and postoperative intensive care. Methods The ELPQuiC bundle was implemented in four hospitals, using locally identified strategies to assess the impact on risk-adjusted mortality. Comparison of case mix-adjusted 30-day mortality rates before and after care-bundle implementation was made using risk-adjusted cumulative sum (CUSUM) plots and a logistic regression model. Results Risk-adjusted CUSUM plots showed an increase in the numbers of lives saved per 100 patients treated in all hospitals, from 6·47 in the baseline interval (299 patients included) to 12·44 after implementation (427 patients included) (P < 0·001). The overall case mix-adjusted risk of death decreased from 15·6 to 9·6 per cent (risk ratio 0·614, 95 per cent c.i. 0·451 to 0·836; P = 0·002). There was an increase in the uptake of the ELPQuiC processes but no significant difference in the patient case-mix profile as determined by the mean Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity risk (0·197 and 0·223 before and after implementation respectively; P = 0·395). Conclusion Use of the ELPQuiC bundle was associated with a significant reduction in the risk of death following emergency laparotomy.

Funder

Health Foundation

Publisher

Oxford University Press (OUP)

Subject

Surgery

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