Evaluation of the Collaborative Use of an Evidence-Based Care Bundle in Emergency Laparotomy

Abstract

Importance: Patients undergoing emergency laparotomy have high mortality, but few studies exist to improve outcomes for these patients.

Objective: To assess whether a collaborative approach to implement a 6-point care bundle is associated with reduction in mortality and length of stay and improvement in the delivery of standards of care across a group of hospitals.

Design, setting, and participants: The Emergency Laparotomy Collaborative (ELC) was a UK-based prospective quality improvement study of the implementation of a care bundle provided to patients requiring emergency laparotomy between October 1, 2015, and September 30, 2017. Participants were 28 National Health Service hospitals and emergency surgical patients who were treated at these hospitals and whose data were entered into the National Emergency Laparotomy Audit (NELA) database. Post-ELC implementation outcomes were compared with baseline data from July 1, 2014, to September 30, 2015. Data entry and collection were performed through the NELA.

Interventions: A 6-point, evidence-based care bundle was used. The bundle included prompt measurement of blood lactate levels, early review and treatment for sepsis, transfer to the operating room within defined time goals after the decision to operate, use of goal-directed fluid therapy, postoperative admission to an intensive care unit, and multidisciplinary involvement of senior clinicians in the decision and delivery of perioperative care. Change management and leadership coaching were provided to ELC leadership teams.

Main outcome and measures: Primary outcomes were in-hospital mortality, both crude and Portsmouth Physiological and Operative Severity Score for the enumeration of Mortality and morbidity (P-POSSUM) risk-adjusted, and length of stay. Secondary outcomes were the changes after implementation of the separate metrics in the care bundle.

Results: A total of 28 hospitals participated in the ELC and completed the project. The baseline group included 5562 patients (2937 female [52.8%] and a mean [range] age of 65.3 [18.0-114.0] years), whereas the post-ELC group had 9247 patients (4911 female [53.1%] and a mean [range] age of 65.0 [18.0-99.0] years). Unadjusted mortality rate decreased from 9.8% at baseline to 8.3% in year 2 of the project, and so did risk-adjusted mortality from a baseline of 5.3% to 4.5% post-ELC. Mean length of stay decreased from 20.1 days during year 1 to 18.9 days during year 2. Significant changes in 5 of the 6 metrics in the care bundle were achieved.

Conclusions and relevance: A collaborative approach using a quality improvement methodology and a care bundle appeared to be effective in reducing mortality and length of stay in emergency laparotomy, suggesting that hospitals should adopt such an approach to see better patient outcomes and care delivery performance.

Figure 1.. Change in Crude Mortality

This statistical process control chart shows the stepwise reductions in 30-day unadjusted crude mortality. Months 1 to 15 depict the baseline data (ie, no intervention or care bundle from the Emergency Laparotomy Collaborative [ELC]); post-ELC months 16 to 27, year 1 change; and post-ELC months 28 to 39, year 2 change. LCL indicates lower control limit; UCL, upper control limit.

Figure 2.. Change in Length of Stay (LOS)

This statistical process control chart shows the change in baseline LOS. The mean baseline LOS was 20.1 days, which decreased to 18.9 days in post–ELC (Emergency Laparotomy Collaborative) months 13 to 27 and remained at 18.9 days for post-ELC months 28 to 39. The dark blue circles are monthly data readings; the filled orange circles are significant changes on 1 side of the mean line, indicating significance; and the empty orange circles are data points that lead up to significance. If more than 8 points lie on 1 side of the mean line, then the change is significant, which includes empty orange circles and filled orange circles. If the points cross the upper control limit (UCL) or the lower control limit (LCL), this is highly significant.

Figure 3.. Baseline to Post–Emergency Laparotomy Collaborative (ELC) Changes by Lactate Level, Antibiotics Use, Operating Room (OR) Access, and Goal-Directed Fluid Therapy (GDFT) Use

A, Changes in the measurement of blood lactate level from baseline (63.9%) to post-ELC implementation year 1 (71.2%) and year 2 (74.9%), a significant change that crossed the upper control limit (UCL) of the statistical process chart. B, Changes in the use of antibiotics before OR arrival: 57.1% of patients received antibiotics during baseline, which decreased to 56.6% in year 1 and 52.3% in year 2. C, Changes in the percentage of patients who entered the OR within 6 hours of booking, which was 77.2% at baseline but increased to 79.4% in months 16 to 27 and to 80.8% in year 2. D, Changes in the use of GDFT, which was less than 42.3% preoperatively but increased beginning in month 25 onward, a significant change that was sustained and crossed the UCL. The dark blue circles are monthly data readings; the filled orange circles are significant changes on 1 side of the mean line, indicating significance; and the empty orange circles are data points that lead up to significance. If more than 8 points lie on 1 side of the mean line, then the change is significant, which includes empty orange circles and filled orange circles. If the points cross the UCL or the lower control limit (LCL), this is highly significant.

Figure 4.. Baseline to Post–Emergency Laparotomy Collaborative (ELC) Changes by Intensive Care Unit (ICU) Admission and Surgeon and Anesthesiologist Involvement

Changes in the admission rate to the ICU just before ELC implementation (month 14), which was a significant and sustained change that crossed the upper control limit (UCL) (A); the direct involvement of a senior surgeon, which occurred after month 18, crossed the UCL, and was significant (B); and the direct involvement of a senior anesthesiologist experienced by 74.8% of patients at baseline and increased to 85.8% in months 16 to 27 and was sustained in months 28 to 39 (C). See the caption to Figure 3 for explanation of dark blue circles, filled orange circles, and the empty orange circles. LCL indicates lower control limit.