Organisational factors and mortality after an emergency laparotomy: multilevel analysis of 39 903 National Emergency Laparotomy Audit patients

C M Oliver; M G Bassett; T E Poulton; I D Anderson; D M Murray; M P Grocott; S R Moonesinghe; National Emergency Laparotomy Audit collaborators

doi:10.1016/j.bja.2018.07.040

Organisational factors and mortality after an emergency laparotomy: multilevel analysis of 39 903 National Emergency Laparotomy Audit patients

Br J Anaesth. 2018 Dec;121(6):1346-1356. doi: 10.1016/j.bja.2018.07.040. Epub 2018 Oct 3.

Authors

C M Oliver¹, M G Bassett², T E Poulton³, I D Anderson⁴, D M Murray⁵, M P Grocott⁶, S R Moonesinghe⁷; National Emergency Laparotomy Audit collaborators

Affiliations

¹ 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.
² 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; UCL Department of Applied Health Research, London, UK; Manchester University NHS Foundation Trust, Manchester, UK.
³ 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; UCL Department of Applied Health Research, London, UK.
⁴ National Emergency Laparotomy Audit, Royal College of Anaesthetists, London, UK; Salford Royal Foundation NHS Trust, Salford, UK; University of Manchester, Manchester, UK; Association of Surgeons of Great Britain and Ireland, London, UK.
⁵ National Emergency Laparotomy Audit, Royal College of Anaesthetists, London, UK; James Cook University Hospital, Middlesbrough, UK.
⁶ National Emergency Laparotomy Audit, Royal College of Anaesthetists, London, UK; Anaesthesia and Critical Care Research Group, NIHR Biomedical Research Centre, University Hospital Southampton, Southampton, UK; Faculty of Medicine, University of Southampton, Southampton, UK; Department of Anaesthesiology, Duke University School of Medicine, Durham, NC, USA.
⁷ 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; UCL Department of Applied Health Research, London, UK.

PMID: 30442263
DOI: 10.1016/j.bja.2018.07.040

Abstract

Background: Studies 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.

Methods: We 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.

Results: The 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).

Conclusions: This 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.

Keywords: emergency laparotomy; frailty; health services research; pathological processes; postoperative mortality; surgical procedures.

Publication types

Multicenter Study

MeSH terms

Adolescent
Adult
Aged
Aged, 80 and over
Emergencies*
Female
Hospital Mortality
Humans
Laparotomy / mortality*
Logistic Models
Male
Middle Aged
Multilevel Analysis
Prospective Studies
Young Adult