Transcript Dr.C.Peden - NELA`s story - the impact of integrating audit wit

Integrating audit with QI research
Carol J. Peden MD, FRCA, FICM, MPH.
NELA QI Lead, EPOCH QI Lead
Macintosh Professor Royal College of Anaesthetists, Associate Medical
Director for Clinical Quality RUH, Bath and NHS England (South).
October 9th 2014
Emergency laparotomy outcomes
A Prospective Observational Study of Outcome of Emergency Laparotomy
Eur J Anaesth 2011. Clarke, Murdoch, Cook, Thomas, Peden.
Cook et al Annals Royal College of Surgeons 1997.
What has been achieved?
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Association of Surgeons Report 2007
Emergency Laparotomy network May 2010
NCEPOD report on Elderly November 2010
Ombudsman’s report on Care of the Elderly in Acute Hospitals
RCS Standards for Unscheduled Care April 2011
Anaesthesia Editorial: Emergency Surgery in the Elderly
Department of Health guidelines September 2011 on the
“High Risk Surgical Patient”
• RCOA working party to achieve action – ongoing
• NCEPOD report December 2011
• NELA Network and HQIP
Emergency Laparotomy Network
• BJA Saunders et al 2012
• 1,835 patients from 35 NHS hospitals
• Unadjusted 30-day mortalities:
• 14.9 % overall
• 24.4 % if over 80 yrs
• Compared with:
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Elective colorectal resection
Oesophagectomy
Gastrectomy
Liver met. resection
2.7 %
3.1 %
4.2%
1%
When is death inevitable after
emergency laparotomy?
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Al- Temimi et al J Am Coll Surg 2012;215:503-11
NSQIP database
37,500 patients
30 day mortality 14%
Mortality and Post-operative Care Pathways in 2904 patients: a
population based cohort study.
Vester-Andersen et al BJA online Feb 2014
• Overall mortality 18.5% -90 day mortality 23.8%
• 84% of patients sent to ward
• “A multi-disciplinary approach with involvement of both surgeons and
intensivists in the first 2-3 days”
Mortality 15.6%
Variation in mortality after emergency surgery in the UK
Symons N et al. Brit J Surg 2013; 100: 1318-25.
National Emergency Laparotomy Audit
“To enable the improvement of the quality of care for patients
undergoing emergency laparotomy through the provision of
high quality comparative data from all providers of emergency
laparotomy.”
•£1million over 3 years
•Subcontracted to RCS
Organisational Audit: Yr1
• Number of Critical Care Beds as a proportion of total beds**
• Number of surgeons on on-call rota**/++
• Whether surgical staff are free from elective commitments whilst oncall **/++
• Working patterns of on-call clinical staff (Consultants and Speciality
Trainees)** /++
• Specialist Interest of surgeons on on-call rota**/++
• Availability of
• pre-operative imaging*/**/++
• interventional radiology*/**/++
• emergency theatres */**/++
• routine daily input from elderly care*
* NCEPOD 2010 “An Age Old Problem: a review of the care received by elderly patients undergoing surgery”
** Department of Health Working Group “The Higher Risk General Surgical Patient: Towards Improved Care for a Forgotten Group”
++ RCSEng 2011 “Emergency Surgery Standards for unscheduled surgical care”
NELA organisational Audit
Improving outcomes in Emergency
Laparotomy
‘While all changes do not lead to
improvement, all improvement
requires change’
Recommendations:
Changing the delivery of care in EL
Pathway implementation
Preoperative risk estimation and
documentation
Escalation strategies and case prioritisation
Clear diagnostic and monitoring plans
Timing of diagnostic tests / timing of surgery
Data Domains
1. Individual risk
2. Processes of care
3. Perioperative patient outcomes
Bivariate analysis of inpatient mortality
to identify ‘High risk’ subgroups
Age
ASA
Preop risk stratification
Preop P-POSSUM estimate of 30d mortality
NCEPOD urgency
Key process measures
1. Minimal delay to surgical intervention
2. Minimal delay to administration of antibiotic
3. Consultant surgeon
4. Consultant anaesthetist
5. Postoperative critical care admission
Quality Improvement
• Yearly reports
• Process & Outcome Measures incorporated
into Trust Quality Accounts
• Local download of results as required
• Presentations / workshops at regional &
national meetings to disseminate best practice
Changing the way we think:
understanding urgency and risk
Adapted from Moore et al. Availability of acute care surgeons improves outcomes in patients requiring emergent
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colon surgery. Am J Surg 2011;202:837-842
Septic Abdomen/Traditional approach
Diagnostic delay
Operative delay
Operating Theatre
Vasopressors
Traditional surgery
ICU Admission
MOF
Early death
Septic Abdomen/Active approach
Urgent CT
ICU for resuscitation
Volume load/Antibiotics
Operating Theatre
Damage control/source control
ICU Admission
Ongoing resuscitation
Emergency
Laparotomy
Pathway Quality
Improvement Care
Bundle
Royal Surrey County
RUH, Bath
Royal Devon and Exeter
South Devon
Decision to Theatre <6 hours
90%
77%
Proportion of All Patients
80%
74%
70%
60%
50%
66%
62%
47%
46%
50%
43%
40%
Baseline
ELPQuiC
30%
20%
10%
0%
Site 1
Site 2
Site 3
ELPQuiC
Emergency Laparotomy Pathway Quality Improvement Care-Bundle
Site 4
Consultant Anaesthetist in Theatre
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
90.9%
83%
98%
65%
56.1%
47.5%51%
39.2%
Site 1
Pre-ELPQuiC
Post-ELPQuiC
Site 2
Site 3
ELPQuiC
Emergency Laparotomy Pathway Quality Improvement Care-Bundle
Site 4
CUSUM O/E mortality
Risk adjusted mortality using PPOSSUM
In all hospitals a statistically
significant increase in lives saved
P<0.0001
BJS in press
Huddart, Peden, Quiney et al
Site 1 - area 58%
Site 2 - area 41%
MEWS
MEWS
100%
100%
75%
75%
50%
50%
ICU post op
Pre-op antibiotics
25%
ICU post op
0%
0%
GDFT
Theatre <6 hours
Site 4 - area 51%
MEWS
MEWS
100%
100%
75%
75%
50%
25%
Pre-op antibiotics
ICU post op
50%
25%
Pre-op
antibiotics
0%
0%
GDFT
Theatre <6
hours
GDFT
Site 3 - area 56%
ICU post op
Pre-op
antibiotics
25%
Theatre <6 hours
GDFT
Theatre <6
hours
EPOCH Trial
Enhanced Peri-Operative Care for High-risk
patients
• NIHR funded £1.5M
• 90 hospitals admitting acute abdominal surgery
• Principal Investigator Rupert Pearse
• QI Lead Carol Peden
Improving emergency surgery requires
reliability and standardisation
• This can be done and the ELPQuIC study shows
that improvement may be significant
• Standardise pathways of care
• Create a sense of urgency!
• NELA gives us the data to drive improvement
“Reliability means keeping promises”
Don Berwick
Will an emergency laparotomy
database improve mortality?
• "Without a standard there is no logical basis for
making a decision or taking action." -Joseph M.
Juran
• "In God we trust, all others bring data." - W.
Edwards Deming
The Future is here!