• C M Oliver, M G Bassett, T E Poulton, I D Anderson, D M Murray, M P Grocott, S R Moonesinghe, and National Emergency Laparotomy Audit collaborators.
• UCL Division of Surgery and Interventional Science, London, UK; UCLH Surgical Outcomes Research Centre, Department of Anaesthesia and Perioperative Medicine, University College London Hospitals NHS Foundation Trust, London, UK; National Emergency Laparotomy Audit, Royal College of Anaesthetists, London, UK; Health Services Research Centre, National Institute for Academic Anaesthesia, Royal College of Anaesthetists, London, UK. Electronic address: charles.oliver@ucl.ac.uk.
• Br J Anaesth. 2018 Dec 1; 121 (6): 1346-1356.

BackgroundStudies across healthcare systems have demonstrated between-hospital variation in survival after an emergency laparotomy. We postulate that this variation can be explained by differences in perioperative process delivery, underpinning organisational structures, and associated hospital characteristics.MethodsWe performed this nationwide, registry-based, prospective cohort study using data from the National Emergency Laparotomy Audit organisational and patient audit data sets. Outcome measures were all-cause 30- and 90-day postoperative mortality. We estimated adjusted odds ratios (ORs) for perioperative processes and organisational structures and characteristics by fitting multilevel logistic regression models.ResultsThe cohort comprised 39 903 patients undergoing surgery at 185 hospitals. Controlling for case mix and clustering, a substantial proportion of between-hospital mortality variation was explained by differences in processes, infrastructure, and hospital characteristics. Perioperative care pathways [OR: 0.86; 95% confidence interval (CI): 0.76-0.96; and OR: 0.89; 95% CI: 0.81-0.99] and emergency surgical units (OR: 0.89; 95% CI: 0.80-0.99; and OR: 0.89; 95% CI: 0.81-0.98) were associated with reduced 30- and 90-day mortality, respectively. In contrast, infrequent consultant-delivered intraoperative care was associated with increased 30- and 90-day mortality (OR: 1.61; 95% CI: 1.01-2.56; and OR: 1.61; 95% CI: 1.08-2.39, respectively). Postoperative geriatric medicine review was associated with substantially lower mortality in older (≥70 yr) patients (OR: 0.35; 95% CI: 0.29-0.42; and OR: 0.64; 95% CI: 0.55-0.73, respectively).ConclusionsThis multicentre study identified low-technology, readily implementable structures and processes that are associated with improved survival after an emergency laparotomy. Key components of pathways, perioperative medicine input, and specialist units require further investigation.Copyright © 2018 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.

22 keywords...

hide…