The Operating Theatre Journal - Journal - Page 2
Reducing mortality in emergency surgery: Focussing
minds through a national clinical audit in the NHS
A local quality improvement tool
The audit is about more than highlighting national trends. Regional and
local variation highlighted in the audit, continues to allow individual
hospitals to improve. Data from 173 hospitals was included in the latest
national report. Those hospitals are able interrogate live data, as it is
captured.
“Trusts really do enjoy seeing their data live,” explains Lourtie. “The
tools we use mean that you can compare yourself to hospitals that are
like yours, or to the national picture. The visualisation of the data and
what you can pull out has been incredibly useful, and it has become
simple to click on the tool to visualise where you sit.”
Alerting hospitals to problems early
Hospitals are encouraged to capture data through the web tool as
patients progress through the pathway: at pre-op, during the operation,
at post-op stages and at discharge.
Jose Lourtie, head of research for the Royal College of Anaesthetists,
explains how the National Emergency Laparotomy Audit is helping
hospitals to reduce deaths and deliver better patient outcomes.
Supported by the team behind CaseCapture, insights are helping
to prove resourcing needs and drive crucial quality improvement.
Concerns around high mortality rates for emergency laparotomy surgery
led to the creation of a new clinical audit spanning England and Wales
in 2012. The aim: to allow NHS hospitals to better understand and take
action to address widespread variation in care.
A decade later, and significant impact has been realised for the safety
of tens of thousands of patients who undergo emergency bowel surgery
each year.
Improvements in care provision have been informed by the National
Emergency Laparotomy Audit, or NELA, managed by the Royal College
of Anaesthetists on behalf of the Healthcare Quality Improvement
Partnership (HQIP).
“Mortality has reduced from nearly 12% to around 9%,” says Jose
Lourtie, head of research for the royal college. “That is a big reduction
in mortality.”
The annual audit, built using bespoke web-tools created by the team
behind the CaseCapture clinical audit system, has led to a range of
improvements throughout its history, including reduced variation
in care, reduced lengths of stay, and improved patient comfort and
experience. It has also resulted in substantial cost savings. Back in
2018, the royal college recorded that 108,000 bed days had been saved,
equating to £34 million in savings.
“Just the audit existing has focussed minds,” says Lourtie. “We are
much safer than we were when we first started the audit, despite the
challenges and pressures faced in hospitals today.”
Evidence for resource
The latest annual report, published in February 2023, shows that
emergency laparotomy is still a significant surgical focus in the NHS,
with data captured on more than 22,000 procedures in a single year.
Despite significant progress in care standards since measurement began,
the latest report also reveals that falling mortality has plateaued in
recent years. “That needs to be taken in context with everything else
going on, including Covid-19,” says Lourtie.
But he adds that the audit provides the evidence clinicians now need
to take improvements to the next level: “Now our findings show that
we are reaching a point where more resource is required for further
reduction in mortality,” he says.
“Individual sites can utilise that intelligence. They can take it to their
medical directors and say ‘we need more resource in our area, because
we are no longer showing improvement’.”
Such data is also seen by decision makers at a national level: “The
report is signed off by NHS England – so they are aware of what the
figures are showing”, explains Lourtie. “They can see what needs to be
improved nationally.”
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“If it is live, each site can see in real-time what is happening to this
patient cohort,” says Lourtie. This also means that problems can more
easily be highlighted early to minimise impact on patients.
“We flag when organisations need to improve,” he explains. “We
provide them with quarterly reports, so they can see if there is an
issue. And we have implemented a reporting mechanism, so that if
metrics fall below a threshold they trigger an unofficial alert to the
organisation’s lead, for them to act on quality improvement.”
“Sites can then do their analysis and change processes. We as a royal
college can make recommendations, but it is for the hospitals to
implement change.”
An audit technology partner
Having an effective technology partner has proven to be an important
part of the audit’s success, Lourtie explains.
The people behind CaseCapture, in this case providing bespoke clinical
audit tools, “became part of the team”, he says. “They have been very
responsive from the moment we started the audit. They would attend
project team meetings and provide insight. If clinicians were discussing
what data they wanted to collect, we had a partner that would advise
on what that could look like, and how it could be pushed out.”
“The team came with expertise in building audits, and that has meant
that those inputting the data have found it simple and easy to use,”
he adds. “We have been working with the experts in creating tools
to collect data at a national level, who know how to make that work
within the NHS, which can be a difficult environment to operate from
an IT perspective.”
PQIP, NAP and other projects
The royal college has continued to engage with the team behind
CaseCapture on other important audit projects. This includes the
Perioperative Quality Improvement Programme (PQIP), which is used
to understand complications, mortality and patient reported outcomes
associated with millions of operations carried out in the NHS each year.
The audit is not mandatory, but approximately 140 hospitals participated
at the time of the most recent report. “This has allowed us to create
improvement tools and to outline priorities nationally and for each site
locally,” says Lourtie.
The National Audit Project, or NAP, has also been built using
CaseCapture. This is providing new understanding on complications of
low incidence, but high risk. “A CaseCapture dataset was created so
hospitals can log their case, so that it can be examined by a review
panel.”
And a series of snapshot audits, have also been created to help improve
outcomes in particular areas – for example frailty and delirium.
“The team behind CaseCapture have understood the hurdles that need
to be jumped over in the NHS, and have given us tools that are easy
to use both for data capture and extracting insight,” explains Lourtie.
“The relationship has endured for a reason.”
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