National Emergency Laparotomy Audit Research Articles

Validation of the emergency surgery score (ESS) in a UK patient population and comparison with NELA scoring: a retrospective multicentre cohort study.

Accurate risk scoring in emergency general surgery (EGS) is vital for consent and resource allocation. The emergency surgery score (ESS) has been validated as a reliable preoperative predictor of postoperative outcomes in EGS but has been studied only in the US population. Our primary aim was to perform an external validation study of the ESS in a UK population. Our secondary aim was to compare the accuracy of ESS and National Emergency Laparotomy Audit (NELA) scores. We conducted an observational cohort study of adult patients undergoing emergency laparotomy over three years in two UK centres. ESS was calculated retrospectively. NELA scores and all other variables were obtained from the prospectively collected Emergency Laparotomy and Laparoscopic Scottish Audit (ELLSA) database. The primary and secondary outcomes were 30-day mortality and postoperative intensive care unit (ICU) admission, respectively. A total of 609 patients were included. Median age was 65 years, 52.7% were female, the overall mortality was 9.9% and 23.8% were admitted to ICU. Both ESS and NELA were equally accurate in predicting 30-day mortality (c-statistic=0.78 (95% confidence interval (CI), 0.71-0.85) for ESS and c-statistic=0.83 (95% CI, 0.77-0.88) for NELA, p=0.196) and predicting postoperative ICU admission (c-statistic=0.76 (95% CI, 0.71-0.81) for ESS and 0.80 (95% CI, 0.76-0.85) for NELA, p=0.092). In the UK population, ESS and NELA both predict 30-day mortality and ICU admission with no statistically significant difference but with higher c-statistics for NELA score. Both scores have certain advantages, with ESS being validated for a wider range of outcomes.

O25: Accuracy of NELA score in predicting the risk of mortality following emergency laparotomy in patients aged above and below 80: A cohort study

Abstract Objectives To compare accuracy of National Emergency Laparotomy Audit (NELA) score in predicting the risk of mortality following emergency laparotomy in patients aged above and below 80. Methods In compliance with STROCSS statement standards a retrospective cohort study was conducted. The study period was between January 2017 and January 2022. All adult patients with non-traumatic acute abdominal pathology who underwent emergency laparotomy in two centres were included. The Receiver Operating Characteristic (ROC) curve analysis and Hosmer & Lemeshow test were conducted to evaluate the discrimination and calibration of NELA score in predicting the risk of 30-day mortality in patients aged above and below 80 years. Results A total of 1458 eligible patients were included; 289 patients were aged above 80 with median age of 84 (IQR 81-87) and 1168 patients were aged below 80 with median age of 60 (IQR 46-71). The risk of 30-day mortality was 13.5 % in the above 80 group and 8% in the below 80 group. ROC curve analysis showed that the AUC of NELA score was 0.78 (95% CI 0.73-0.83) in the above 80 group and 0.89 (95% CI 0.87-0.91) in the below 80 group. The score was not well-calibrated for either groups. Conclusions The NELA score is less accurate in predicting the risk of mortality following emergency laparotomy in patients aged above 80 compared to younger patients. This may be explained by the fact that it does not take into account the measures of age-related decline in physical status of the patients.

Malnutrition in emergency general surgery: a survey of National Emergency Laparotomy Audit Leads.

Patients who are malnourished and have emergency general surgery, such as a laparotomy, have worse outcomes than those who are not malnourished. It is paramount to identify these patients and minimise this risk. This study aimed to describe current practices in identifying malnutrition in patients undergoing a laparotomy, specifically focusing on screening, assessment, nutrition pathways and barriers encountered by clinicians. Following piloting and validity assessment, anaesthetic and surgical National Emergency Laparotomy Audit (NELA) Leads at hospitals across England and Wales were emailed an invitation to a survey. Responses were gathered using Qualtrics. Descriptive analysis and correlation with laparotomy volume and professional role were performed in SPSSv26. University of Sheffield ethical approval was obtained (UREC 046205). The results from the survey are reported according to the CHERRIES guidelines. The survey was completed by 166/289 NELA Leads from 117/167 hospitals (57.4% and 70.1% response rates, respectively). Participants reported low rates of nutritional screening (42/166; 25.3%) and assessment (26/166; 15.7%) for malnutrition preoperatively. More than one third of respondents (40.1%) had no awareness of local screening tools; indeed, the Malnutrition Universal Screening Tool (MUST) was used by approximately half of respondents (56.6%). Contrary to guidelines, NELA Leads report albumin levels continue to be used to determine malnutrition risk (73.5%; 122/166). Postoperative nutrition pathways were common (71.7%; 119/166). Reported barriers to nutritional screening and assessment included a lack of time, training and education, organisational support and ownership. Participants indicated nutrition risk is inadequately identified and is an important missing data item from NELA. There was no significant correlation with hospital laparotomy volume in relation to screening or assessment for malnutrition, the use of nutritional support pathways or organisational barriers. There was interprofessional agreement across a number of domains, although some differences did exist. Wide variation exists in the current practice of identifying malnutrition risk in NELA patients. Barriers include a lack of time, knowledge and ownership. Nutrition pathways that encompass the preoperative phase and incorporation of nutrition data in NELA may support improvements in care.

Changes in social care after major emergency general surgery procedures

IntroductionEmergency General Surgery (EGS) is a major part of the provision of healthcare and patients undergoing EGS are at elevated risk of morbidity and mortality. The aim of this study is to determine factors contributing to patients losing their independence and being discharged to residential and nursing homes having previously lived in their own residences. MethodsOur local data uploaded to the National Emergency Laparotomy Audit (NELA) database (2014-2022) was analysed. This national database encompasses all major emergency general surgery cases undertaken in the United Kingdom. The variables considered were patient demographics, ASA score, admission and discharge dates, presenting pathology, operation type, and discharge destination. Comparative analyses segmented patients based on post-discharge EGS destinations. Multivariable logistic regression identified factors linked to residential/nursing home placement post-discharge. Significance was set at p<0.05. ResultsData from all patients in the NELA database (n=1,611) was analysed. Nearly one in ten patients over the age of 70 never returned home. Patients requiring additional support were on average 8.6 years older (p=0.008). Over the age of 80 years, the need for extra social support increased substantially with each increasing year in age and those over the age of 85 years old were more than twice as likely to require extra support than 80-year-olds (p<0.001). Patients who died were 11.4 years older compared to those discharged without additional support (p<0.001). ConclusionA significant proportion of patients, particularly the elderly, do not return to their usual place of residence and require a higher level of care post-emergency surgery. These important social factors need to be considered before operating as they may have significant quality of life and economic implications.

Comparison of P-POSSUM Score and NELA Score as Prime Predictors of Mortality in Emergency Laparotomies at a Tertiary Care Centre: A Retrospective Cohort Study

Introduction: Emergency laparotomies carry significant morbidity and mortality. Preoperative risk assessment is the key part for all emergency laparotomies. Therefore, the use of Physiological and Operative Severity Score for the enumeration of Mortality and morbidity (POSSUM) and National Emergency Laparotomy Audit (NELA) scores helps stratify the risk and highlight the importance of high-risk patients, aiding in the provision of appropriate treatment plans and care. Aim: To determine and compare the Portsmouth-POSSUM (P-POSSUM) score and NELA score in predicting mortality at 30 days and 60 days in patients undergoing emergency laparotomies. Materials and Methods: This retrospective cohort study included all patients who underwent emergency laparotomy at a tertiary care centre from January 2021 to March 2023. A total of 116 patients were included, and demographic variables, laboratory values, and operative details were recorded. Mortality on postoperative day 30 and 60 was observed. All data were recorded in an MS excel spreadsheet, and statistical analysis was performed using Statistical Package for Social Sciences (SPSS) version 19.0. An independent sample t-test was used. Results: Among the total study sample of 116 patients, the 30- day mortality rate was 8.6% (10 out of 116), and the 60-day mortality rate was 13.8% (16 out of 116). The area under the ROC curve (AUC) for mortality prediction was 0.533 (0.361- 0.726) for the P-Possum score and 0.873 (0.799-0.948) for the NELA score, which was significantly higher. Conclusion: The NELA Score demonstrated greater accuracy in predicting early and late mortality compared to the P-POSSUM score in this study. Therefore, the authors highly recommend the use of the NELA score for risk assessment in all emergency laparotomies.

HAS (Hajibandeh Index, American Society of Anesthesiologists Status, and Sarcopenia) Model Versus NELA (National Emergency Laparotomy Audit) Score in Predicting the Risk of Mortality After Emergency Laparotomy: A Retrospective Cohort Study

HAS (Hajibandeh Index, American Society of Anesthesiologists Status, and Sarcopenia) Model Versus NELA (National Emergency Laparotomy Audit) Score in Predicting the Risk of Mortality After Emergency Laparotomy: A Retrospective Cohort Study

Assessment for the risk of malnutrition and nutritional support in older emergency laparotomy patients: a clinical audit

Abstract Aims Patients undergoing urgent abdominal surgery should undergo an assessment of the risk of malnutrition upon admission using the Malnutrition Universal Screening Tool (MUST). This assessment should trigger a response when patients are categorised as high-risk. This clinical audit aimed to determine whether older patients included in the National Emergency Laparotomy Audit (NELA) were identified as being at risk of malnutrition and whether they received appropriate nutritional support to address deficiencies if they were classed as high-risk as per the recommendations of the NICE (2017) guidelines. Methods Patients entered into the NELA database at a single NHS trust who were over 65 or older between January 1, 2021, and December 31, 2022, were included. The patient records were reviewed for the MUST score upon admission, and the presence of nutritional supplementation prescriptions, or dietetic referrals following the identification of a high-risk MUST score of 2 or above. Results Out of the 300 older NELA patients included in this clinical audit, 98% had a recorded MUST score. Between them, 114 patients had a high-risk MUST score, but 35% of these high-risk patients did not undergo a dietetic review. Additionally, 24% of high-risk patients received neither oral nor parenteral supplementation. Conclusions High-risk MUST scores in older NELA patients are readily available to surgical teams within the electronic patient record but do not consistently lead to interventions addressing nutritional deficiencies and nutritional screening is not currently included in NELA.

Operative and non-operative management for intestinal emergencies: findings from a single-centre retrospective cohort study.

Patients with an intestinal emergency who do not have surgery are poorly characterised. This study used electronic healthcare records to provide a rapid insight into the number of patients admitted with an intestinal emergency and compare short-term outcomes for non-operative and operative management. A single-centre retrospective cohort study was conducted at a tertiary NHS hospital (from 1 December 2013 to 31 January 2020). Patients were identified using diagnosis codes for intestinal emergencies, based on the inclusion criteria for the National Emergency Laparotomy Audit. Relevant data were extracted from electronic healthcare records (n=3,997). Nearly half of patients admitted with an intestinal emergency received nonoperative management (43.7%). Of those who underwent surgery, 63.7% were started laparoscopically. The non-operative group had a shorter hospital stay (median: 5.4 days vs 8.2 days [started laparoscopically] or 16.8 days [started open]) and fewer unintended intensive care admissions than the surgical group (2.4% vs 8.7% [started laparoscopically] 21.1% [started open]). However, 30-day mortality for non-operative treatment was double that for surgery (22.4% vs 10.1%). The 30-day mortality rate was found to be even higher for non-operative management (50.3%) compared with surgery (19.5%) in a sub-analysis of patients with admission National Early Warning Score ≥4 (n=683). The proportion of patients with intestinal emergencies who do not have surgery is greater than expected, and it appears that many respond well to non-operative treatment. However, 30-day mortality for non-operative management was high, and the low number of admissions to intensive care suggests that major invasive treatment was not appropriate for most in this group.

EGS P32 Audit for evaluation of using the National Emergency Laparotomy Audit (NELA) as risk assessment calculator for high-risk surgical patients undergoing emergency laparotomy

Abstract Background A high-risk surgical operation called an emergency laparotomy has significant mortality and morbidity rate up to 10 times greater than the one performed electively. This entails a significant clinical and financial burden. The National Emergency Laparotomy Audit (NELA) was established in response to the aforementioned data in order to enhance the quality of care for patients having emergency laparotomies and to assist surgeons in reaching the best possible medical choices for their patients. The Emergency, Laparoscopic and Laparotomy Scottish Audit (ELLSA) is an equivalent system in Scotland. However, ELLSA is still not widely used as NELA. Methods This is a single-centre, retrospective audit to evaluate proper risk assessment and NELA registration for patients who had an emergency laparotomy in CEPOD between January 2022 and December 2022. The data was gathered from electronic clinical records via the hospital portal system. This analysis has included the following clinical data (Age, gender, indication of laparotomy, CEPOD form completion, NELA Score, hospital stay, and postoperative surgical outcome). The data was retrieved and analysed using a standard Excel data collection sheet. This audit aims to review and appraise our practise in relation to the NELA guidelines for risk assessment and emergency laparotomy. Results This analysis includes a total of 58 patients.35(60.3%) Males,23(39.7%) females. The included patients had an average age of 62. Almost 48% of these individuals had longer hospital stay more than 10 days. Approximately 21% of CEPOD booking forms had a recorded NELA score. A missing NELA registration form/risk assessment score was found in up to 97% of patient files and operation notes. A retrospective NELA assessment revealed a mortality rate of more than 20% for some included patients. The mortality rate was found to be high, at 21%, for NELA score of &amp;gt;20% mortality and &amp;gt;70% morbidity. Conclusions This Audit has shown that in order to completely comply with NELA guidelines, our practise must be significantly improved. We also need to give risk assessment documentation in patient records more consideration. The high death rate is attributed to patient and family requests for last-ditch surgical interventions, which can be difficult for surgeons to pull off.

EGS P38 Audit of operative notes/ Clinical documentation of emergency laparotomy &amp; laparoscopic bowel resection procedures

Abstract Background Laparotomies and laparoscopic bowel resections are common emergency procedures carried out in General Surgery emergency theatres. Get It Right First Time (GIRFT), Royal College of Surgeons (RCS) and The Association of Surgeons of Great Britain and Ireland (ASGBI) have made best practice recommendations for documenting operative notes, to ensure effective communication with colleagues and for medicolegal purposes. Ensuing medicolegal issues and patient complaints have cost departments in recent times, due to poor documentation. This audit within a busy General surgery unit, assesses the quality of operative documentations against the standards set by GIRFT, RCS and ASGBI. Methods A retrospective audit of operative notes and relevant clinical documentation of 100 emergency laparotomies and laparoscopic bowel resections between August 2022 and March 2023 at a local General surgery unit. Patient Identification Numbers were extracted from the National Emergency Laparotomy Audit (NELA) database. Operative records and clinical documentations were obtained from electronic clinical records. The recommendations from the “GIRFT RCS and ASGBI Best Practice for Laparotomy and Laparoscopic Bowel Resection Surgery Documentation” guidance was used as the Standard. Up to 60 variables were assessed across different stages of the patient journey, from preoperative to intraoperative and postoperative stages. Results In the period reviewed, there was varying performance. Good performance in documentations of Indications, Operator names, patient position, incision, and findings, seen in 99, 100, 100, 100 and 100 percent of cases respectively. Anaesthetist name was documented in 48% of cases, whilst WHO checklist was documented in only 20% of cases. 64 of these cases had bowel resections. In this cohort, methods and location of resection was described in 95% of cases. Only 43% had the state of bowel prefusion at transection site documented. VTE prophylaxis, Antibiotics, sutures/clip plan, were documented in 87, 65 and 13 % of cases respectively. Conclusions The audit highlights deficits in important areas of documentation, despite the set guideline. Important medicolegal issues can arise when documentations are not clear, and steps considered routine as not written in the operative notes or patient’s records. The findings will be disseminated, and recommendations will be suggested across all grades of surgeons, with the aim to re-audit and improve quality of documentation and ultimately improve delivery of surgical care. A plan to have electronic documentation template or checklist for these procedures has been carried out for trial with the aim of developing standardised documentation process.

A call for clarity: a scoping review of predictors of poor outcome after emergency abdominal surgery for inflammatory bowel disease.

The medical management of inflammatory bowel disease (IBD) is rapidly progressing; however, many patients with the disease still require surgery. Often this is done as an emergency. Initiatives such as the National Emergency Laparotomy Audit have shown how evidence-based emergency surgery improves outcomes for the patient. The aim of this scoping review is to describe the current evidence base on risk stratification in emergency abdominal surgery for IBD. A literature search, abstract and full paper screening resulted in 17 articles representing 63 472 patients from seven countries. It is likely that age, the American Society of Anesthesiologists grade, comorbidity and organ dysfunction play a similar role in risk stratification in IBD patients as in other emergency abdominal surgery cohorts. However, the reporting of what is considered an IBD emergency is variable. Six studies include clear definitions of emergency in our study. The range of what is considered an emergency is within 12 h of admission to any time within an unplanned admission. To have data driven, evidence-based emergency surgical practice in IBD we need consistency of reporting, including the definitions of emergency and urgency. Core descriptor sets in IBD would be valuable.

Beyond high-risk: analysis of the outcomes of extreme-risk patients in the National Emergency Laparotomy Audit.

Patients who require emergency laparotomy are defined as high risk if their 30-day predicted risk of mortality is ≥ 5%. Despite a large difference in the characteristics of patients with a mortality risk score of between 5% and 50%, these outcomes are aggregated by the National Emergency Laparotomy Audit (NELA). Our aim was to describe the outcomes of the cohort of patients at extreme risk of death, which we defined as having a NELA-predicted 30-day mortality of ≥ 50%. All patients enrolled in the NELA database between December 2012 and 2020 were included. We compared patient characteristics; length of hospital stay; rates of unplanned return to the operating theatre; and 90-day survival in extreme-risk groups (predicted ≥ 50%) and high-risk patients (predicted 5-49%). Of 161,337 patients, 5193 (3.2%) had a predicted mortality of ≥ 50%. When patients were further subdivided, 2437 (47%) had predicted mortality of 50-59% (group 50-59); 1484 (29%) predicted mortality of 60-69% (group 60-69); 840 (16%) predicted mortality of 70-79% (group 70-79); and 423 (8%) predicted mortality of ≥ 80% (group 80+). Extreme-risk patients were significantly more likely to have been admitted electively than high-risk patients (p < 0.001). Length of stay increased from a median (IQR [range]) of 26 (16-43 [0-271]) days in group 50-59 to 35 (21-56 [0-368]) days in group 80+, compared with 17 (10-30 [0-1136]) days for high-risk patients. Rates of unplanned return to the operating theatre were higher in extreme-risk groups compared with high-risk patients (11% vs. 8%). The 90-day survival was 43% in group 50-59, 34% in group 60-69, 27% in group 70-79 and 17% in group 80+. These data underscore the need for a differentiated approach when discussing risk with patients at extreme risk of mortality following an emergency laparotomy. Clinicians should focus on patient priorities on quantity and quality of life during informed consent discussions before surgery. Future work should extend beyond the immediate postoperative period to encompass the longer-term outcomes (survival and function) of patients who have emergency laparotomies.

Shock index: Easy to use, but can it predict outcomes following major abdominal emergency surgery?

Major abdominal emergency surgery (MAES) is commonly performed for various potentially life-threatening intra-abdominal surgical conditions with high perioperative mortality of up to 45%.1 Certain patient factors (e.g. advanced age, frailty, and presence of multiple comorbidities) and disease factors (e.g. perforated viscus and intra-abdominal sepsis) have been shown to predict higher post-operative complications and mortality following MAES.2 Pre-operative risk stratification scores, such as the Portsmouth-Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (P-POSSUM) and National Emergency Laparotomy Audit (NELA) score, have also been developed to assist clinicians and/or surgeons in decision making and patient counselling. While these scoring systems have been widely studied and validated in patients of various demographics,3 they require input of multiple variables which may be cumbersome, especially in the emergency setting. Simple bedside scoring systems remain attractive for quick risk stratification and guidance of subsequent management.

Patient-reported impact of emergency laparotomy on employment and health status 1year after surgery.

Whilst there has been significant improvement in mortality outcomes after emergency laparotomy, there is little information on longer term outcomes in the year after discharge. The main aim of the study was to assess the impact that an emergency laparotomy has on patients' and employment and health status1year after surgery. This study was a questionnaire study conducted in a single centre district general hospital of patients who had undergone an emergency laparotomy between October 2015 and December 2016. Patients were included according to the National Emergency Laparotomy Audit criteria. At screening, patients who were alive at 1year and had the capacity to consent were approached between January and December 2017. Patients underwent a researcher-led telephone interview using a semi-structured questionnaire to assess the impact of emergency laparotomy on overall, general and physical health (Glasgow Benefit Inventory) as well as employment status. The symptoms that patients experienced and their impact were also recorded. Forty-two patients responded to and completed the questionnaire. Just over one-third of patients experienced a deterioration in their general or physical health and 21% of patients experienced a change in employment. Factors which significantly impacted on health status were stoma issues, postoperative morbidity and a change in employment (p < 0.05). The main symptoms which patients identified as being troublesome were altered bowel habit and stoma issues with a resultant social and psychological impact. One-third of patients experienced a deterioration in their psychosocial and physical health status as well as a change in employment during the first-year postsurgery. Larger research studies are required to define the impact of emergency laparotomy on patients in the longer term and more research is needed to improve perioperative rehabilitation in the postoperative period to ensure optimal functional gain after technically successful surgery.

Comparison between P-POSSUM and NELA risk score for patients undergoing emergency laparotomy in Egyptian patients

Background and aimsThe Portsmouth-Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity (P-POSSUM) is one of the scores that is used most frequently for determining the likelihood of mortality in patients undergoing emergency laparotomy. National Emergency Laparotomy Audit (NELA) presents a novel and validated score. Therefore, we aimed to compare the performance of the NELA and P-POSSUM mortality risk scores in predicting 30-day and 90-day mortality in patients undergoing emergency laparotomy.MethodsBetween August 2020 and October 2022, this cohort study was undertaken at Menoufia University Hospital. We compared the P-POSSUM, preoperative NELA, and postoperative NELA scores in patients undergoing emergency laparotomy. All variables needed to calculate the used scores were collected. The outcomes included the death rates at 30 and 90 days. By calculating the area under the curve (AUC) for every mortality instrument, the discrimination of the various methods was evaluated and compared.ResultsData from 670 patients were included. The observed risk of 30-day and 90-day mortality was 10.3% (69/670) and 13.13% (88/670), respectively. Concerning 30-day mortality, the AUC was 0.774 for the preoperative NELA score, 0.763 for the preoperative P-POSSUM score, and 0.780 for the postoperative NELA score. Regarding 90-day mortality, the AUCs for the preoperative NELA score, preoperative P-POSSUM score, and postoperative NELA score were 0.649 (0.581–0.717), 0.782 (0.737–0.828), and 0.663 (0.608–0.718), respectively. There was noticeable difference in the three models' capacity for discrimination, according to pairwise comparisons.ConclusionsThe probability of 30-day and 90-day death across the entire population was underestimated by the NELA and P-POSSUM scores. There was discernible difference in predictive performance between the two scores.

352 A National Survey of National Emergency Laparotomy Audit (NELA) Leads to Identify Current Nutrition Practices and Pathways in NELA-Eligible Emergency General Surgery Patients

Abstract Aim No nutritional data are collected by the National Emergency Laparotomy Audit (NELA), despite the association of malnutrition with worse outcomes. This study aimed to describe the current practices, pathways and barriers encountered in identifying malnutrition in NELA-eligible patients. Method Following piloting and validity assessment, anaesthetic and surgical NELA Leads at hospitals across England and Wales that submitted data to NELA’s 7th report were emailed a survey link. Responses were gathered using Qualtrics. Descriptive analysis and correlation with laparotomy volume and professional subtype was performed in SPSSv26. University of Sheffield ethical approval was obtained. Results There were 166/289 NELA Leads and 117/167 hospitals that completed the survey (57.4% and 70.1% response rates, respectively). Respondents reported low rates of nutritional screening (39.2%) and assessment (45.8%) for malnutrition pre-operatively with no awareness of local screening tools (41.6%) despite 68% of units having a Nutrition Support Team. Contrary to guidelines, NELA Leads report albumin levels continue to be used to determine malnutrition risk (73.5%). Post-operative pathways were common (71.7%). Reported barriers to nutritional screening and assessment included a lack of time, training and education, organisational support, and responsibility. NELA Leads indicated nutrition risk is inadequately identified and is an important missing data item from NELA (71.2%). Responses were not correlated with hospital laparotomy volume or professional subtype. Conclusions Identifying malnutrition risk in NELA patients requires attention. Barriers are wide reaching and include a lack of time, knowledge, and ownership. Nutrition pathways that encompass the pre-operative phase and incorporation of malnutrition data in NELA may support improvements.

1193 Review of Pre-Operative Antibiotic Prophylaxis (POAP) in National Emergency Laparotomy Audit (NELA) Patients in a Regional Acute Tertiary Hospital

Abstract Aim The current World Health Organization recommendation for timing before incision (TBI) is that one dose of intravenous pre-operative antibiotic prophylaxis (POAP) should be given on starting anaesthesia, within 120 minutes, to reduce surgical site infections. The Scottish Intercollegiate Guidelines Network suggests TBI of 30-60 minutes for full dosage administration. The aim was to review POAP, including TBI, in NELA patients. Method Emergency laparotomy patients were identified on the Trust theatre system over 73 days, and the NELA database reviewed. Data was collected retrospectively through anaesthetic and operation records and if still inpatient, drug charts and clinical notes. Results 46 patients were identified, and 83% had documented POAP (53% on anaesthetic record, 31% on operation note and 16% before surgery). Of these patients who had a documented POAP, 68% had a recorded TBI; mean time was 99 minutes (range 19 to 386). Of the patients who had a recorded TBI, 77% received POAP within 120 minutes; mean time of these was 59 minutes (range 19 to 112). Conclusions The majority of patients received pre-operative antibiotic prophylaxis, although the documentation was variable, and many doses were not given in the optimal time before incision to reduce surgical site infections. Further work includes liaising with the multidisciplinary team to raise awareness of these results and amending the clerking proforma. A further subgroup analysis focusing on septic patients is underway, as well as a long-term review looking into surgical site infection rates.

1309 A Quality Improvement Project on Small Bowel Obstruction Operative Mortality Rate

Abstract Aim Higher than average emergency laparotomy mortality rates had been identified via the National Emergency Laparotomy Audit (NELA), at a particular hospital. Small bowel obstruction (SBO) is the commonest cause for emergency laparotomy. The aim of this project was to evaluate the management of SBO, and to implement changes to reduce the operative SBO mortality rate. Method NELA was used to assess emergency laparotomy cases between 1st Dec 2018 - 30th Nov 2019; (n = 198), of which there were 24 mortalities. The dataset was filtered for SBO (n = 87), of which there were 12 mortalities. The clinical management of these 12 SBO mortality cases were analysed and compared to the latest ASGBI and NCEPOD recommendations on SBO management. Following this review, a systematic change in the management of SBO was introduced with the aim of reducing time to operation, appropriate candidate selection and avoiding drifting in management. This consisted of producing a SBO management flowchart as well as ensuring allocation of theatre slot within 72 hours for patients suitable for operation. Results Following the intervention, we assessed cases between 1st April 2021 - 31st March 2022 (n = 152), of which there were 13 mortalities. The dataset was filtered for SBO cases (n = 57), of which there were 3 mortalities. Emergency laparotomy mortality rate reduced from 12% to 9%. SBO operative mortality rate reduced from 14% to 5%. Emergency laparotomy deaths relating to SBO reduced from 50% to 23%. Conclusions The intervention resulted in improvement in SBO operative mortality rates as well as overall emergency laparotomy mortality rates.

819 ELLIPSE: Electrical Impedance Analysis in Patients Undergoing Emergency Abdominal Surgery

Abstract Introduction An ageing population represents greater operative risk; therefore, preoperative risk stratification is required to allow patients to make an informed decision. One method of risk stratification is bioelectrical impedance analysis (BIA) which can provide information such as muscle and fat mass, providing a proxy for patient metabolic health. Aim Metabolic health is intrinsically linked to outcomes following surgery. We hypothesised that BIA is a feasible method of assessing patients undergoing emergency abdominal surgery and predicting postoperative outcomes. Method A BIA analyser was used to measure patients body composition. All adult patients who met the National Emergency Laparotomy Audit (NELA) inclusion criteria were prospectively recruited and followed up until 30 days postoperatively. These patients had serial BIA measurements and compared with a healthy population. The phase angle (PA) is a raw variable which can be standardised to a healthy reference population and matched for age and gender. In summary, a higher phase angle is associated with improved outcomes. Results 31 patients were recruited and BIA analysis in patients undergoing emergency abdominal surgery was feasible. Patients with a phase angle lower than the reference population had a greater incidence of complications (p = 0.03) and had more severe complications (p = 0.023). Furthermore, the same patients also had a significantly higher NELA morbidity percentage (p = 0.022). Conclusions Our study shows that conducting BIA analysis in patients undergoing emergency abdominal surgery is feasible. The presence and severity of complications correlates with the phase angle. This represents a successful proof of concept study of BIA to predict postoperative outcomes.

895 A Retrospective Analysis of National Emergency Laparotomy Audit (NELA) Data at a Tertiary Hospital

Abstract Aim To audit emergency laparotomy outcomes in a tertiary hospital and identify areas for improvement. Method Retrospective analysis of 148 cases from Year 8 (12/2020-11/2021) of NELA patient data. Categorical and continuous data were analysed through chi-squared and t-tests, using R (version:4.2.2). Results Our NELA patient length-of-stay (LOS) was 2.2x the national mean (33.59 vs.15.1 days). 14 statistical outliers in LOS were identified which compounded the discrepancy between our median (15 days) and mean (33.59 days). Patients with stomas formed had a significantly higher mean LOS compared to those without (42 vs 26 days). Frail patients did not have a higher LOS, and much higher mean rates of review by geriatricians was noted (87% vs. 24% nationally). A greater percentage of our patients had high pre-operative mortality risk scores compared to nationally (51.5% vs. 43.5%). A higher percentage of our patients had ischaemia (20.8% vs. 8.9%) and haemorrhage (5.6% vs. 2.6%) as indications for surgery. However, our 30-day mortality rate was lower on average (5.5% vs. 9.7%). Conclusions Our hospital's high rates of complicated cases and low mortality rates suggest a high-quality of patient care. Length of stay has been identified as an area for improvement, and we propose implementation of special discussion of long-staying patients in weekly ward round meetings as a potential intervention. While there may be various factors contributing to our higher mean LOS, we postulate that our status as a major stoma centre and tertiary referral centre for complicated cases as likely the primary cause.