Abstract
Emergency laparotomy is a common general surgical emergency procedure carried out worldwide. It carries with it a very high morbidity and mortality, second only to surgery for ruptured aortic artery aneurysm. There has been considerable work done to improve the outcomes following emergency laparotomy worldwide. In the United Kingdom, the National Emergency Laparotomy Audit (NELA) was established in 2014. It aims to improve the quality of care for emergency laparotomy patients by providing high quality comparative data collected nationally. It also highlights key standards in the provision of care. The focus of NELA and other quality improvement projects related to emergency laparotomy is improving every step in the patient pathway. This includes access to diagnostic investigations, consultant care, risk stratification and post-operative care in an appropriate destination. Every small improvement in each step would aggregate to provide a considerable reduction in patient mortality and morbidity, as well as reduction in the healthcare burden to the system. The aim of this review is to discuss some of the significant steps in improving the quality of emergency laparotomy care and the accompanying evidence.
Highlights
In 2010, Sir David Brailsford, who was appointed General Manager of Team Sky (Great Britain’s professional cycling team), faced a tough challenge
This concept can be very important when applied to the process of improving emergency laparotomy care
The use of risk assessment tools and clinical judgement to determine patients requiring post operative critical care and having the dialogue with the intensivists is recommended. This is further supported by several audits done comparing outcomes pre National Emergency Laparotomy Audit (NELA) and post NELA.[19]
Summary
In 2010, Sir David Brailsford, who was appointed General Manager of Team Sky (Great Britain’s professional cycling team), faced a tough challenge. The doctrine of marginal gains is about small incremental changes in any process, adding up to significant improvement when they are all added together This concept can be very important when applied to the process of improving emergency laparotomy care. Emergency laparotomy is one of the commonest emergency general surgical procedures, performed for life threatening abdominal conditions in hospitals all over the world It describes an exploratory procedure for which the clinical presentation, underlying pathology, anatomical site of surgery and perioperative management vary considerably.[1] The emergency nature of this operation, the variation in surgical pathology and the limited time available to optimise the patients makes it an extremely high risk operation. There has been a lot of initiative to improve the mortality of patients who undergo an emergency laparotomy. Concerns about over predicting death in the low risk groups led to its modification of the original equation leading to the Portsmouth predictor equation for mortality – the PPOSSUM.[6]
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