National Emergency Laparotomy Audit

National Emergency Laparotomy Audit
Name	National Emergency Laparotomy Audit
Type	Clinical audit
Founded	2013
Headquarters	United Kingdom
Parent organization	Royal College of Anaesthetists

National Emergency Laparotomy Audit The National Emergency Laparotomy Audit is a UK-based clinical audit established to measure and improve outcomes for patients undergoing emergency laparotomy. It operates within networks that include the Royal College of Anaesthetists, the National Institute for Health and Care Excellence, the Royal College of Surgeons of England, and collaborates with NHS Trusts such as Guy's and St Thomas' NHS Foundation Trust, Barts Health NHS Trust, and Manchester University NHS Foundation Trust. The audit aligns with national initiatives like the Getting It Right First Time programme and reports to stakeholders including the Care Quality Commission, Health Education England, and Parliamentarians.

Background

The audit was initiated following concerns raised in reviews such as the National Confidential Enquiry into Patient Outcome and Death and reports by bodies including the Royal College of Surgeons of England and the Royal College of Anaesthetists. It emerged amid contemporaneous reforms led by the Department of Health and Social Care and policy frameworks associated with the NHS Long Term Plan. Early drivers included comparative work from centres like Addenbrooke's Hospital, analyses by academic groups at University College London, and audits performed in parallel by organisations such as Scottish Intercollegiate Guidelines Network and NICE guideline development. Key figures and institutions involved included clinicians from Imperial College London, University of Oxford, and King's College London.

Objectives and Scope

The audit's primary objective is to benchmark perioperative care and outcomes for patients undergoing emergency laparotomy across NHS Trusts including Cambridge University Hospitals NHS Foundation Trust, Royal London Hospital, and St George's University Hospitals NHS Foundation Trust. Scope encompasses adult patients treated for acute abdominal conditions requiring laparotomy, aiming to capture data on timing, risk assessment tools such as the POSSUM and ASA physical status classification system, consultant involvement, critical care admission, and 30-day mortality. Reporting interfaces with programmes such as National Clinical Audit and Patient Outcomes Programme and informs guideline work by NICE and commissioning decisions by NHS England, while engaging professional bodies including the Association of Coloproctology of Great Britain and Ireland.

Methods and Data Collection

Data collection uses prospective case ascertainment in participating hospitals including St Mary's Hospital, Royal Free Hospital, and Leeds General Infirmary. Clinical variables recorded mirror standards promulgated by NICE and include demographics, comorbidities referenced to classifications like Charlson comorbidity index, physiological derangements akin to APACHE II scoring, operative findings, consultant involvement, and critical care admissions corresponding to standards used by Intensive Care National Audit & Research Centre. Data submission pathways involve secure platforms used by audits under the aegis of the Health and Social Care Information Centre and are subject to governance frameworks linked to Information Commissioner's Office guidance. Analytic approaches employ risk-adjusted mortality models developed by academic groups at University of Edinburgh and University of Glasgow and corroborated by peer-reviewed work published in journals akin to The Lancet and BMJ.

Key Findings and Outcomes

Reports have repeatedly highlighted variation in 30-day mortality and length of stay across trusts such as Newcastle upon Tyne Hospitals NHS Foundation Trust and Leicester Royal Infirmary, differences in timely theatre access compared to expectations set by NICE and the Royal College of Surgeons of England, and inconsistent consultant-led care relative to recommendations from the Royal College of Anaesthetists. Findings showed associations between preoperative risk assessment use, perioperative critical care utilisation as per Intensive Care Society guidance, and patient outcomes, informing interventions inspired by quality improvement collaboratives including the Enhanced Recovery After Surgery community. National reports influenced targets championed by NHS England and shaped commissioning conversations in Clinical Commissioning Groups such as NHS South West London Clinical Commissioning Group.

Impact on Clinical Practice and Policy

The audit has driven service change in hospitals like Oxford University Hospitals NHS Foundation Trust and Birmingham Women's and Children's NHS Foundation Trust through adoption of perioperative pathways promoted by Royal College of Anaesthetists and Royal College of Surgeons of England. It informed policy levers in documents from NHS England and contributed evidence to guideline updates by NICE and best-practice statements by the Association of Anaesthetists. Collaborative projects with academic centres at University of Manchester and Newcastle University led to implementation of theatre access metrics and critical care triage processes consistent with recommendations from the Intensive Care Society and the Faculty of Intensive Care Medicine.

Criticisms and Limitations

Critiques have focused on case ascertainment completeness in some trusts such as Blackpool Teaching Hospitals NHS Foundation Trust and on variable data quality similar to challenges documented in other national audits like the National Hip Fracture Database. Limitations include potential selection bias, reliance on routinely collected clinical records akin to issues faced by registries such as the National Joint Registry, and difficulties in attributing causality given observational design as discussed in literature from institutions like University of Cambridge and London School of Hygiene & Tropical Medicine. Stakeholders including professional bodies such as the Royal College of Nursing and patient groups have noted that audit metrics may not fully capture patient-centred outcomes emphasised by organisations like Age UK.

Future Directions and Developments

Future plans involve enhanced linkage with datasets held by NHS Digital, incorporation of patient-reported outcome measures promoted by NHS England and academic partners at University of Southampton, and leveraging machine learning approaches investigated at centres like The Alan Turing Institute and Imperial College London to refine risk prediction. Expansion ambitions include broader international collaboration with registries such as those in Australia and New Zealand and contribution to multinational studies led by groups at Karolinska Institute and Harvard Medical School. Continued engagement with policy-makers including Department of Health and Social Care and professional colleges aims to sustain implementation of standards across NHS Trusts.

Category:Clinical audits in the United Kingdom