Emergency Laparotomy Audit The Newcastle/NSW Experience. Peter Pockney Senior Lecturer in Surgery Consultant Surgeon, John Hunter Hospital

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1 Emergency Laparotomy Audit The Newcastle/NSW Experience Peter Pockney Senior Lecturer in Surgery Consultant Surgeon, John Hunter Hospital

2 None Conflicts of Interest

3 Acknowledgements Project Team Dr Merran Holmes, Surgical Research Fellow Dr Gavin Sullivan, Consultant Anaesthetist Dr Shaun Jones, Junior Anaesthetist Dr Joyce Ming, Intern Conjoint Professor Jon Gani, Consultant Surgeon

4 Newcastle, NSW

5 John Hunter Hospital Newcastle, NSW

6 NSW

7 Our Projects To analyse our performance at Emergency Laparotomy Compare, where appropriate, to the standards set by NELA UK Were there obvious lessons we could learn from this experience

8 Our Projects Ongoing NELA duplicate (Jan ) Same inclusion/exclusion criteria Same parameters recorded P-Possum scored Also calculated NSQiP Risk predictor to compare to P- Possum Recorded in a secure, online RedCap database, hosted by the Hunter Medical Research Institute

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10 Our Projects Data collection from April 2017 Retrospective Where do we really start from in terms of NELA comparable outcomes? (2016, 2017 data) processes of care, mortality To learn the Australian versions of the NELA experiences

11 Our Projects Prospective Data collection from August 2017 Beta testing ANZELA-QI database (2017/2018) Use NELA risk predictor calculated & validated in emergency patients Use ANZELA-QI inclusion/exclusion criteria for casemix Use ANZELA-QI dataset (reduced compared to NELA for non-essential data) Include some data not used in NELA (e.g. Frailty Score)

12 Next Steps Other NSW hospitals are now contributing to these projects Already entering data Gosford (Central Coast NSW) Belmont DH (Suburban Newcastle) The Calvary Mater Hospital (Suburban Newcastle) In process of sorting governance Nepean Hospital (W Sydney) The Maitland Hospital (Lower Hunter)

13 NSW

14 NSW

15 NSW

16 NSW

17 NSW

18 NSW

19 Next Steps Current contributors cover population of >1.3m (5.5% of Australian total) Limited to one State (NSW) but 2 (expected to be 3) Local Health Districts Largely Metropolitan We invite more hospitals to contribute to this process, in or out of NSW, rural or urban, whatever size

20 Next Steps Need site specific approval (ethics approved) We grant online access to RedCap to enter data Local hospital can see details of own patients, and comparison to whole dbase, but not details of other units patients

21 Our Results 225 Cases (approximately 3 per week) Weak comparative stats Process lessons

22 Process Lessons Our documented use of risk prediction tools is dire

23 Process Lessons Our documented use of risk prediction tools is dire 8/221, 7/8 finger in the air (clinical judgement), 1/8 P-Possum

24 Process Lessons Our documented use of ICU pre and actual use post op is not good

25 Process Lessons Our documented use of ICU pre and actual use post op is not good 81% of cases not documented as discussed with ICU pre-op 31% cases went to ICU post op 5% unplanned move to ICU post op

26 Process Lessons Our involvement of consultant level staff in theatre was pretty good Surgeons Anaesthetists

27 Process Lessons Our involvement of consultant level staff in theatre was pretty good Surgeons 209/226 consultant surgeon (92.5%) or post SET Fellow (6.4%) Anaesthetists 170/226 consultant anaesthetist (72.5%) or post FANZCA Fellow (10.6%)

28 Process Lessons Our overall mortality looks ok subject to small number influences one more or less death makes a relatively big difference to our rate, none to NELA rate

29 Process Lessons Our overall mortality looks ok subject to small number influences one more or less death makes a relatively big difference to our rate, none to NELA rate 30 day mortality 23/225, 10.2% NELA %, NELA % NELA % 90 day mortality 31/ % NELA combined 2014/5 15.6% NELA %

30 Process Lessons (Audit) Careful quality improvement projects take time, patience and effort Do lead to changes and improvements in practice Might allow us to examine parts of our care processes that could be improved

31 Process Lessons Areas which we think we can do better Transfers from peripheral hospitals (which are not necessarily rural, or remote) Decision to operate on likely futile patients Use of ICU/HDU pre and post surgery Involvement of named consultants in preoperative decisions and processes Record keeping

32 Does a NELA process work here?

33 Does a NELA process work here? Qualified Yes

34 Thank you To take part in the projects: