Emergency Laparotomy Collaborative (ELC)
The Emergency Laparotomy Collaborative (ELC) is a new, two-year quality improvement project aimed at improving standards of care and outcomes for patients undergoing emergency laparotomy.
The ELC has grown from the successful Emergency Laparotomy Pathway Quality Improvement Care bundle project (ELPQuiC). This was carried out three years ago in four hospitals in the South of England. Over an eight-month period, crude 30-day mortality was reduced by 25% and P-POSSUM risk adjusted 30-day mortality by 42%.
It has been shown that patients admitted for emergency surgery are often elderly with a number of comorbidities. This cohort of patients have a mortality rate of approximately 11-15% but have only basic levels of care consistently offered.
The ELC is funded by The Health Foundation (£500,000) as part of one of seven national ‘Scaling Up Awards’ for 2015.
The project is run in collaboration with three Academic Health Science Networks (AHSNs): Kent Surrey and Sussex, Wessex and West of England, and will include almost 30 hospitals.
We aim to encourage collaboration and embed a knowledge of quality improvement to improve the mortality of emergency abdominal surgery.
Like ELPQuIC, the Collaborative aims to deliver 5 key themes using a care bundle approach, including the involvement of consultant surgeons, anaesthetists and intensivists from the time of the patient presenting to hospital, throughout the patient’s time in the operating theatre and beyond. The bundle elements are:
- Use of an Early Warning Score (EWS) or lactate to identify patients most at risk for deterioration and the delivery of prompt resuscitation for these patients.
- Use of a sepsis screening tool to identify septic patients and treatment with Sepsis Six.
- Definitive surgery within 6 hours of decision to operate for patients categorised as Level 1 and 2a in urgency.
- Appropriate dynamic fluid resuscitation and optimisation using goal-directed fluid therapy.
- Postoperative critical care (Level 2 or 3) for all patients.
The project will consist of elements:
- Data sharing from the National Emergency Laparotomy Audit (NELA). This will help understand the standards of care provided and the variation in delivery of the care bundle. Almost all of the above parts of the care bundle are available from the NELA dataset.
- Four supra-regional meetings where all participating hospitals from the three AHSNs meet to examine key parts of the care bundle and its delivery.
- Four local AHSN meetings delivered between the supra-regional meetings. These will start as an educational event looking specifically at quality improvement methodology and behaviour change. In time these will become sharing forums where best practice and techniques developed to overcome specific issues can be shared. These meetings will be run by, and in the geographical area of, each AHSN.
- Ongoing media stream dedicated to the project. This will take the form of a website, as a source of further resources and news of the ELC project, webinars, Twitter and Facebook feeds. Additional resources will be added as required.
In addition to the main project there will be two other smaller projects looking at the financial aspects of emergency laparotomy and the impact of an introduction of a geriatric medical input in the postoperative period for patients over the age of 70 years.
The Emergency Laparotomy Collaborative will finish in Summer 2017. Learning and outputs will be shared with the ELC participants and on a national scale.