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Background Enhanced Recovery After Surgery (ERAS) protocols reduce length of stay, complications and costs for a large number of elective surgical procedures. A similar, structured approach appears to improve outcomes, including mortality, for patients undergoing high-risk emergency general surgery, and specifically emergency laparotomy. These are the first consensus guidelines for optimal care of these patients using an ERAS approach. Methods Experts in aspects of management of the high-risk and emergency general surgical patient were invited to contribute by the International ERAS® Society. Pubmed, Cochrane, Embase, and MEDLINE database searches on English language publications were performed for ERAS elements and relevant specific topics. Studies on each item were selected with particular attention to randomized controlled trials, systematic reviews, meta-analyses and large cohort studies, and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Recommendations were made on the best level of evidence, or extrapolation from studies on non-emergency patients when appropriate. The Delphi method was used to validate final recommendations. The guideline has been divided into two parts: Part 1—Preoperative Care and Part 2—Intraoperative and Postoperative management. This paper provides guidelines for Part 1. Results Twelve components of preoperative care were considered. Consensus was reached after three rounds. Conclusions These guidelines are based on the best available evidence for an ERAS approach to patients undergoing emergency laparotomy. Initial management is particularly important for patients with sepsis and physiological derangement. These guidelines should be used to improve outcomes for these high-risk patients.

Background While specific practices for perioperative care of older adults have been recommended, little is known regarding adherence by US physician anesthesiologists to such practices. To address this gap in knowledge, the ASA Committee on Geriatric Anesthesia and the ASA Perioperative Brain Health Initiative undertook a survey of ASA members to characterize current practices related to perioperative care of older adults. Methods We administered a web-based questionnaire with items assessing the proportion of practice focused on delivery of care to older adults, adherence to recommended practices for older surgical patients, resource needs to improve care, and practice characteristics. Results Responses were collected between May 24, 2018, and June 29, 2018. A total of 25,587 ASA members were invited to participate, and 1737 answered at least one item (6.8%). 96.4% of respondents reported that they had cared for a patient aged 65 or older within the last year. 47.1% of respondents (95% confidence interval, 44.6%, 49.7%) reported using multimodal analgesia among patients aged 65 and older at least 90% of the time, and 25.5% (95% CI, 23.3%, 27.7%) provided preoperative information regarding postoperative cognitive changes at least 90% of the time. Over 80% of respondents reported that preoperative screening for frailty or dementia, postoperative screening for delirium, and preoperative geriatric consultation occurred in fewer than 10% of cases. Development of practice guidelines for geriatric anesthesia care and expansion of web-based resources were most frequently prioritized by respondents as initiatives to improve care in this domain. Discussion Most survey respondents reported providing anesthesia care to older adults, but adherence to recommended practices varied across the six items assessed. Reported rates of screening for common geriatric syndromes, such as frailty, delirium, and dementia, were low among survey respondents. Respondents identified multiple opportunities for ASA initiatives to support efforts to improve care for older surgical patients.

ObjectivesThe Revised Cardiac Risk Index (RCRI) is a tool that can be used to evaluate the 30-day risk of postoperative myocardial infarction, cardiac arrest and mortality. This study aims to confirm its association with postoperative mortality in patients who underwent hip fracture surgery.MethodsAll adults who underwent primary emergency hip fracture surgery in Sweden between January 1, 2008 and December 31, 2017 were included in this study. The database was retrieved by cross-referencing the Swedish National Quality Register for hip fractures with the Swedish National Board of Health and Welfare registers. The outcomes of interest were the association between the RCRI score and mortality at 30 days, 90 days and 1 year postoperatively.Results134 915 cases were included in the current study. There was a statistically significant linear trend in postoperative mortality with increasing RCRI scores at 30 days, 90 days and 1 year. An RCRI score ≥4 was associated with a 3.1 times greater risk of 30-day postoperative mortality (adjusted incidence rate ratio (IRR) 3.13, pConclusionAn increasing RCRI score is strongly associated with an elevated risk 30-day, 90-day and 1-year postoperative mortality after primary hip fracture surgery. The objective and easily retrievable nature of the variables included in the RCRI calculation makes it an appealing choice for risk stratification in the clinical setting.Levels of evidenceLevel III.

BACKGROUND: Frailty and cognitive impairment are associated with postoperative delirium but are rarely assessed preoperatively. The study was designed to test the hypothesis that preoperative screening for frailty or cognitive impairment identifies patients at risk for postoperative delirium (primary outcome). METHODS: In this prospective cohort study, we administered frailty and cognitive screening instruments to 229 patients ≥ 70 years old presenting for elective spine surgery. Screening for frailty (5-item FRAIL scale) and cognition (Mini-Cog, Animal Verbal Fluency) were performed at the time of the preoperative evaluation. Demographic data, perioperative variables, and postoperative outcomes were gathered. Delirium was the primary outcome detected by either the Confusion Assessment Method, assessed daily from postoperative day 1 to 3 or until discharge, if patient was discharged sooner, or comprehensive chart review. Secondary outcomes were all other-cause complications, discharge not to home, and hospital length of stay. RESULTS: The cohort was 75 [73 to 79 years] years of age, 124/219 (57%) were male. Many scored positive for pre-frailty (117/218; 54%), frailty (53/218; 24%), and cognitive impairment (50 – 82/219; 23–37%). Fifty-five patients (25%) developed delirium postoperatively. On multivariable analysis, frailty (scores 3 to 5) (OR 6.6; 95% CI 1.96 to 21.9; P = 0.002) versus robust (score 0) on the FRAIL scale, lower animal fluency scores (OR 1.08; 95% CI 1.01 to1.51; P = 0.036) for each point decrease in the number of animals named, and more invasive surgical procedures (OR 2.69; 95% CI 1.31 to 5.50; P = 0.007) versus less invasive procedures were associated with postoperative delirium. CONCLUSIONS: Screening for frailty and cognitive impairment preoperatively using the FRAIL scale and the Animal Verbal Fluency test in older elective spine surgery patients identifies those at high risk for the development of postoperative delirium.

The purpose of this chapter is to provide a review of the literature around emergency general surgery in older patients. Emergency general surgery has a high mortality rate and with the population ageing at an unprecedented rate, older patients have an increased mortality risk due to their age alone. Complications are higher and older patients are more likely not to be discharged home following surgery. However, accurately predicting risk of surgery in elderly patients is very difficult. Simple measures such as concurrent comprehensive geriatric assessment with surgical assessment may help care for the older surgical patient more holistically and offer improved outcomes. With the increasing ageing population and life expectancy, there needs to be a more focus on developing comprehensive programmes for older patients undergoing emergency surgery, to ensure they do not develop complications and to reduce mortality rates.

BACKGROUND: The United States population is aging and projected to undergo an increasing number of general surgical procedures. However, recent trends in the frequency of major abdominal procedures in older adults are currently unknown as improvements in non-operative interventions may obviate the need for major surgery. Thus, we evaluated the trends of major abdominal surgical procedures in older adults in the United States. METHODS: We performed a retrospective cohort study using the National Inpatient Sample from 2002–2014 with trend analysis using National Cancer Institute’s Joinpoint Trend Analysis Software. We identified the average annual percent change (AAPC) in yearly frequency of major abdominal surgical procedures in older adults (≥50 years of age). RESULTS: Our cohort included a total of 3,951,947 survey-weighted discharges that included a major abdominal surgery in adults ≥50 years of age between 2002 and 2014. Of these discharges, 2,529,507 (64.0%) were for elective abdominal surgeries, 2,062,835 (52.0%) were for female patients, and mean (SD) age was 61.4(15.9) years. The frequency of major abdominal procedures (elective and emergent) decreased for adults age 65–74 (AAPC: −1.43, −1.75, −1.11, P85 (AAPC= −3.53; −4.57, −2.48: P

As population age, healthcare systems and providers are likely to experience a substantial increase in the proportion of elderly patients requiring emergency surgery. Emergency surgery, compared with planned surgery, is strongly associated with increased risks of adverse postoperative outcomes due to the short time available for diagnosis, optimization, and intervention in patients presenting with physiological derangement. These patient populations, who are often frail and burdened with a variety of co-morbidities, have lower reserves to deal with the stress of the acute condition and the required emergency surgical intervention. In this review article, we discuss topical areas where mitigation of the physiological stress posed by the acute condition and asociated surgical intervention may be feasible. We consider the impact of the adrenergic response and use of beta blockers for these high-risk patients and discuss common risk factors such as frailty and delirium. A proactive multidisciplinary approach to peri-operative care aimed at mitigation of the stress response and proactive management of common conditions in the older emergency surgical patient could yield more favorable outcomes.

Summary Delirium and postoperative neurocognitive disorder are the commonest perioperative complications in patients more than 65 yr of age. However, data suggest that we often fail to screen patients for preoperative cognitive impairment, to warn patients and families of risk, and to take preventive measures to reduce the incidence of perioperative neurocognitive disorders. As part of the American Society of Anesthesiologists (ASA) Perioperative Brain Health Initiative, an international group of experts was invited to review published best practice statements and guidelines. The expert group aimed to achieve consensus on a small number of practical recommendations that could be implemented by anaesthetists and their partners to reduce the incidence of perioperative neurocognitive disorders. Six statements were selected based not only on the strength of the evidence, but also on the potential for impact and the feasibility of widespread implementation. The actions focus on education, cognitive and delirium screening, non-pharmacologic interventions, pain control, and avoidance of antipsychotics. Strategies for effective implementation are discussed. Anaesthetists should be key members of multidisciplinary perioperative care teams to implement these recommendations.

BackgroundChronic diseases are increasingly prevalent in Western countries. Once hospitalised, the chance for another hospitalisation increases sharply with large impact on well-being of patients and costs. The pattern of readmissions is very complex, but poorly understood for multiple chronic diseases.MethodsThis cohort study of administrative discharge data between 2009-2014 from 21 tertiary hospitals (eight USA, five UK, four Australia, four continental Europe) investigated rates and reasons of readmissions to the same hospital within 30 days after unplanned admission with one of the following chronic conditions; heart failure; atrial fibrillation; myocardial infarction; hypertension; stroke; chronic obstructive pulmonary disease (COPD); bacterial pneumonia; diabetes mellitus; chronic renal disease; anaemia; arthritis and other cardiovascular disease. Proportions of readmissions with similar versus different diseases were analysed.ResultsOf 4,901,584 admissions, 866,502 (17.7%) were due to the 12 chronic conditions. In-hospital, 43,573 (5.0%) patients died, leaving 822,929 for readmission analysis. Of those, 87,452 (10.6%) had an emergency 30-day readmission, rates ranged from 2.8% for arthritis to 18.4% for COPD. One third were readmitted with the same condition, ranging from 53% for anaemia to 11% for arthritis. Reasons for readmission were due to another chronic condition in 10% to 35% of the cases, leaving 30% to 70% due to reasons other than the original 12 conditions (most commonly, treatment related complications and infections). The chance of being readmitted with the same cause was lower in the USA, for female patients, with increasing age, more co-morbidities, during study period and with longer initial length of stay.ConclusionReadmission in chronic conditions is very common and often caused by diseases other than the index hospitalisation. Interventions to reduce readmissions should therefore focus not only on the primary condition but on a holistic consideration of all the patient's comorbidities.

Emergency laparotomy is associated with high mortality. Implementation of an evidence-based care bundle has been shown to improve patient outcomes. A quality improvement project to implement a six-component care bundle was undertaken between July 2015 and May 2018. As part of this project, we worked with 27 hospitals in the Emergency Laparotomy Collaborative. Previous pilot implementation of the same bundle in our hospital between December 2012 and July 2013 had shown marked improvement, maintained until April 2014, but then deterioration. Understanding the reasons for this deterioration informed our work to re-implement the bundle and sustain improvement. A cohort of 930 consecutive patients requiring emergency laparotomy between October 2014 and April 2019 were included. Baseline data were collected between October 2014 and June 2015, and the bundle was re-implemented in July 2015. Thirty-day mortality decreased from 11% in the baseline group to 7.3% after bundle implementation. Hospital length of stay decreased from 19.5 to 17.9 days. Full bundle compliance improved from 60% to 80% for all patients, with improvement in application of all individual bundle components. This study provides further evidence that outcomes for high-risk surgical patients can be improved with an evidence-based care bundle, but attention must be paid to maintaining bundle compliance. Issues around sustaining improvement must be considered from project initiation.

Emergency laparotomy is a high-risk surgical procedure with a mortality much higher than that of comparable procedures performed electively. Care of these high-risk patients has been characterized by variability in management and, until relatively recently, a lack of defined standards for best practice. An enhanced recovery approach appears to improve outcomes for patients undergoing emergency laparotomy as pathway components are defined and delivered within set time frames. The importance of timely action on key steps, such as rapid review and management of sepsis, is of particular importance in this group of patients, many of whom are elderly and present in a state of physiological derangement. This chapter will discuss recent developments in management of emergency laparotomy with reference to major studies and pathways with wide applicability. Large-scale audits of process delivery and outcomes have helped support awareness of the issues in delivering high-quality care for emergency laparotomy, and the role of audit and reliable process delivery will be discussed in relation to emergency laparotomy and enhanced recovery.

Background Emergency abdominal surgery is associated with poor patient outcomes. We studied the effectiveness of a national quality improvement (QI) programme to implement a care pathway to improve survival for these patients. Objectives The objectives were to assess whether or not the QI programme improves 90-day survival after emergency abdominal surgery; to assess effects on 180-day survival, hospital stay and hospital readmission; and to better understand these findings through an integrated process evaluation, ethnographic study and cost-effectiveness analysis. Design This was a stepped-wedge cluster randomised trial. Hospitals were organised into 15 geographical clusters, and commenced the QI programme in random order over 85 weeks. Analyses were performed on an intention-to-treat basis. The primary outcome was analysed using a mixed-effects parametric survival model, adjusting for time-related effects. Ethnographic and economics data were collected in six hospitals. The process evaluation included all hospitals. Setting The trial was set in acute surgical services of 93 NHS hospitals. Participants Patients aged ≥ 40 years who were undergoing emergency abdominal surgery were eligible. Intervention The intervention was a QI programme to implement an evidence-based care pathway. Main outcome measures The primary outcome measure was mortality within 90 days of surgery. Secondary outcomes were mortality within 180 days, length of hospital stay and hospital readmission within 180 days. The main economic measure was the quality-adjusted life-years. Data sources Data were obtained from the National Emergency Laparotomy Audit database; qualitative interviews and ethnographic observations; quality-of-life and NHS resource use data were collected via questionnaires. Results Of 15,873 eligible patients from 93 NHS hospitals, primary outcome data were analysed for 8482 participants in the usual care group and 7374 in the QI group. The primary outcome occurred in 1393 participants in the usual care group (16%), compared with 1210 patients in the QI group (16%) [QI vs. usual care hazard ratio (HR) 1.11, 95% confidence interval (CI) 0.96 to 1.28]. No differences were found in mortality at 180 days or hospital readmission; there was a small increase in hospital stay in the QI group (HR for discharge 0.90, 95% CI 0.83 to 0.97). There were only modest improvements in care processes following QI implementation. The ethnographic study revealed good QI engagement, but limited time and resources to implement change, affecting which processes teams addressed, the rate of change and eventual success. In some sites, there were challenges around prioritising the intervention in busy environments and in obtaining senior engagement. The intervention is unlikely to be cost-effective at standard cost-effectiveness thresholds, but may be cost-effective over the lifetime horizon. Limitations Substantial delays were encountered in securing data access to national registries. Fewer patients than expected underwent surgery and the mortality rate was lower than anticipated. Conclusions There was no survival benefit from a QI programme to implement a care pathway for patients undergoing emergency abdominal surgery. The modest impact of the intervention on process measures, despite good clinician engagement, may have been limited by the time and resources needed to improve patient care. Future work Future QI programmes must balance intervention complexity with the practical realities of NHS services to ensure that such programmes can be delivered with the resources available. Trial registration Current Controlled Trials ISRCTN80682973 and The Lancet protocol 13PRT/7655. Funding This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 7, No. 32. See the NIHR Journals Library website for further project information.

Purpose: Previous work has demonstrated a survival improvement following the introduction of an enhanced recovery protocol in patients undergoing emergency laparotomy (the emergency laparotomy pathway quality improvement care (ELPQuiC) bundle). Implementation of this bundle increased the use of intra-operative goal directed fluid therapy and ICU admission, both evidence-based strategies recommended to improve kidney outcomes. The aim of this study was to determine if the observed mortality benefit could be explained by a difference in the incidence of AKI pre- and post-implementation of the protocol. Method: The primary outcome was the incidence of AKI in the pre- and post-ELPQuiC bundle patient population in four acute trusts in the United Kingdom. Secondary outcomes included the KDIGO stage specific incidence of AKI. Serum creatinine values were obtained retrospectively at baseline, in the post-operative period and the maximum recorded creatinine between day 1 and day 30 were obtained. Results: A total of 303 patients pre-ELPQuiC bundle and 426 patients post-ELPQuiC bundle implementation were identified across the four centres. The overall AKI incidence was 18.4% in the pre-bundle group versus 19.8% in the post bundle group p = 0.653. No significant differences were observed between the groups. Conclusions: Despite this multi-centre cohort study demonstrating an overall survival benefit, implementation of the quality improvement care bundle did not affect the incidence of AKI.

Socioeconomic circumstances can influence access to healthcare, the standard of care provided, and a variety of outcomes. This study aimed to determine the association between crude and risk-adjusted 30-day mortality and socioeconomic group after emergency laparotomy, measure differences in meeting relevant perioperative standards of care, and investigate whether variation in hospital structure or process could explain any difference in mortality between socioeconomic groups.This was an observational study of 58 790 patients, with data prospectively collected for the National Emergency Laparotomy Audit in 178 National Health Service hospitals in England between December 1, 2013 and November 31, 2016, linked with national administrative databases. The socioeconomic group was determined according to the Index of Multiple Deprivation quintile of each patient's usual place of residence.Overall, the crude 30-day mortality was 10.3%, with differences between the most-deprived (11.2%) and least-deprived (9.8%) quintiles (P0.001). The more-deprived patients were more likely to have multiple comorbidities, were more acutely unwell at the time of surgery, and required a more-urgent surgery. After risk adjustment, the patients in the most-deprived quintile were at significantly higher risk of death compared with all other quintiles (adjusted odds ratio [95% confidence interval]: Q1 [most deprived]: reference; Q2: 0.83 [0.76-0.92]; Q3: 0.84 [0.76-0.92]; Q4: 0.87 [0.79-0.96]; Q5 [least deprived]: 0.77 [0.70-0.86]). We found no evidence that differences in hospital-level structure or patient-level performance in standards of care explained this association.More-deprived patients have higher crude and risk-adjusted 30-day mortality after emergency laparotomy, but this is not explained by differences in the standards of care recorded within the National Emergency Laparotomy Audit.

The timing, causes, and quality of care for patients who die after emergency laparotomy have not been extensively reported. A large database of 13,953 patients undergoing emergency laparotomy, between July 2014 and March 2017, from 28 hospitals in England was studied. Anonymized data was extracted on day of death, patient demographics, operative details, compliance with standards of care, and 30-day and in-patient mortality. Thirty-day mortality was 8.9%, and overall inpatient mortality was 9.8%. Almost 40% of postoperative deaths occurred within three days of surgery, and 70% of these early deaths occurred on the day of surgery or the first postoperative day. Such early deaths could be considered nonbeneficial surgery. Patients who died within three days of surgery had a significantly higher preoperative lactate, American Society of Anesthesiologists Physical Status (ASA-PS) grade, and Physiological and Operative Severity Score for the enumeration of Mortality and morbidity (P-POSSUM). Compliance with perioperative standards of care based on the Emergency Laparotomy Collaborative care bundle was high overall and better for those patients who died within three days of surgery. Multidisciplinary team involvement from intensive care, care of the elderly physicians, and palliative care may help both the communication and the burden of responsibility in deciding on the risk&ndash, benefit of operative versus nonoperative approaches to care.

Summary Background Emergency abdominal surgery is associated with poor patient outcomes. We studied the effectiveness of a national quality improvement (QI) programme to implement a care pathway to improve survival for these patients. Methods We did a stepped-wedge cluster-randomised trial of patients aged 40 years or older undergoing emergency open major abdominal surgery. Eligible UK National Health Service (NHS) hospitals (those that had an emergency general surgical service, a substantial volume of emergency abdominal surgery cases, and contributed data to the National Emergency Laparotomy Audit) were organised into 15 geographical clusters and commenced the QI programme in a random order, based on a computer-generated random sequence, over an 85-week period with one geographical cluster commencing the intervention every 5 weeks from the second to the 16th time period. Patients were masked to the study group, but it was not possible to mask hospital staff or investigators. The primary outcome measure was mortality within 90 days of surgery. Analyses were done on an intention-to-treat basis. This study is registered with the ISRCTN registry, number ISRCTN80682973. Findings Treatment took place between March 3, 2014, and Oct 19, 2015. 22 754 patients were assessed for elegibility. Of 15 873 eligible patients from 93 NHS hospitals, primary outcome data were analysed for 8482 patients in the usual care group and 7374 in the QI group. Eight patients in the usual care group and nine patients in the QI group were not included in the analysis because of missing primary outcome data. The primary outcome of 90-day mortality occurred in 1210 (16%) patients in the QI group compared with 1393 (16%) patients in the usual care group (HR 1·11, 0·96–1·28). Interpretation No survival benefit was observed from this QI programme to implement a care pathway for patients undergoing emergency abdominal surgery. Future QI programmes should ensure that teams have both the time and resources needed to improve patient care. Funding National Institute for Health Research Health Services and Delivery Research Programme.

Background Among patients undergoing emergency laparotomy, 30-day postoperative mortality is around 10–15%. The risk of death among these patients, however, varies greatly because of their clinical characteristics. We developed a risk prediction model for 30-day postoperative mortality to enable better comparison of outcomes between hospitals. Methods We analysed data from the National Emergency Laparotomy Audit (NELA) on patients having an emergency laparotomy between December 2013 and November 2015. A prediction model was developed using multivariable logistic regression, with potential risk factors identified from existing prediction models, national guidelines, and clinical experts. Continuous risk factors were transformed if necessary to reflect their non-linear relationship with 30-day mortality. The performance of the model was assessed in terms of its calibration and discrimination. Interval validation was conducted using bootstrap resampling. Results There were 4458 (11.5%) deaths within 30-days among the 38 830 patients undergoing emergency laparotomy. Variables associated with death included (among others): age, blood pressure, heart rate, physiological variables, malignancy, and ASA physical status classification. The predicted risk of death among patients ranged from 1% to 50%. The model demonstrated excellent calibration and discrimination, with a C-statistic of 0.863 (95% confidence interval, 0.858–0.867). The model retained its high discrimination during internal validation, with a bootstrap derived C-statistic of 0.861. Conclusions The NELA risk prediction model for emergency laparotomies discriminates well between low- and high-risk patients and is suitable for producing risk-adjusted provider mortality statistics.

The principles of population health have recently been introduced to anesthesiologists,1 but the concept remains relatively foreign to most practicing physicians. However, population health is a current area of major interest and increasing emphasis in health care in the United States and other deve

Emergency laparotomy is a common intra-abdominal procedure with outcomes recognized to be poor. Efforts are being made to improve these outcomes, both nationally and internationally. This article describes the methodology of a successfully implemented collaborative quality improvement project that improved outcomes following emergency laparotomy in four NHS trusts.

Thirty-day mortality following emergency laparotomy is high, and greater amongst elderly patients. Studies systematically describing peri-operative complications are sparse, and heterogeneous. We used the postoperative morbidity survey to describe the type and frequency of complications, and their relationship with outcomes for 144 patients: 114 < 80 years old, and 30 ≥ 80 years old. Cumulative postoperative morbidity survey scores and patterns of morbidity were similar (p = 0.454); however, 28-day mortality was higher in the elderly (10/30 (33.3%) vs. 11/114 (9.6%), p = 0.008), and hospital stay was longer (median (IQR [range]) 17 (13-35 [6-62]) days vs. 11 (7-21 [2-159]) days, p = 0.006). Regression analysis indicated that cardiovascular, haematological, renal and wound complications were associated with longer hospital stay, and that cardiovascular complications predicted mortality. The postoperative morbidity survey system enabled structured mapping of the number and type of complications, and their relationship with outcome, following emergency laparotomy. These results indicate that rather than a greater propensity to complications following surgery, it was the failure to tolerate these that increased mortality in the elderly.

Background Emergency intra-abdominal laparotomy is a common surgical procedure. Mortality is high with 11%–15% of patients dying within 30 days of surgery. Complication rates are also high and >25% of patients remain in hospital for >20 days. A previous study, ELPQuIC, successfully used a care bundle to reduce mortality in four hospitals. Objectives The aim of the Emergency Laparotomy Collaborative was to scale implementation of the ELPQuIC bundle to 24 NHS Trusts within three Academic Networks to reduce mortality, complications and length of stay. Methods We used the IHI Breakthrough Series Collaborative Model to bring 100+ staff together over two years with 5 large events and 4 local quality improvement events. Data collection was through the National Emergency Laparotomy Audit (NELA). Economic analysis was undertaken. Using NELA data we distributed comparative dashboards showing care bundle adherence and patient outcomes quarterly. The collaborative model enabled Trusts to share progress through dialogue, group reflection and celebration of success. Results 5793 patients had an emergency laparotomy between October 2015 and December 2016. Crude mortality decreased from 9.8% to 8.7% and length of stay decreased by 1.3 days. There were significant improvements in delivery of care bundle components. Economic analysis showed potential savings of £2 M in 15 months, primarily through decreased length of stay. The collaborative promoted innovation with ideas such as ‘virtual peer review’ emerging. Conclusions Implementation of the ELPQuIC care bundle improved process delivery resulting in better outcomes for emergency laparotomy patients across 25 NHS Trusts. QI promotion through a BTS model fostered collaboration and innovation. References 1. National Emergency Laparotomy Audit. The Second Patient Report 2016. Availablefrom NELA 2016. http://www.nela.org.uk/reports. 2. Al-Temimi, Griffee M, Ennis TM et al. When is death inevitable after emergency laparotomy? Analysis of the American College of Surgeons National Surgical Quality Improvement Program database. J Am Coll Surg 2012;215:503–11. 3. Saunders D, Murray D, Varley S, Pichel A, Peden CJ. Variations in mortality after emergency laparotomy: the first report of the UK Emergency Laparotomy Network. BJA 2012;109:368–375. 4. Huddart S, Peden CJ, Swart M et al. Use of a pathway quality improvement care bundle to reduce mortality after emergency laparotomy. BJS 2015;102:57–66.

While sedation can improve the patient experience of unpleasant procedures, if performed poorly it has the potential to cause harm. Some authorities believe that patients' protective reflexes are impaired at any level of sedation, and sedation merges into anaesthesia in a continuum of loss of consciousness. All anaesthetists should understand the definition of ‘conscious sedation', and be aware of the concepts of ‘deep sedation' and ‘monitored anaesthesia care', which are prevalent in the USA. This paper discusses, in particular, dental sedation guidelines and, more generally, safe sedation practice for other procedures in which sedation is given.

Key Points Question Is a quality improvement collaborative approach to implementation of a care bundle associated with reductions in mortality from emergency laparotomy? Findings In this study of a collaborative project involving 28 hospitals and a total of 14 809 patients, reductions in mortality and length of stay were seen after implementation of a care bundle. Improvement took time to occur and was not seen until the second year of the collaborative project. Meaning The findings suggest that hospitals should consider adopting a care bundle approach and participating in a collaborative group to see improvement in outcomes for patients undergoing emergency laparotomy., 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., This quality improvement study evaluates mortality and other outcomes data of patients who underwent emergency laparotomy before and after they received collaborative care.

Outcomes are essential measures of healthcare effectiveness and efficiency. Traditional measures of outcome, such as mortality and length of stay, are important and easy to measure but have significant limitations when evaluating the peri-operative care of elderly patients. Alternative measures, including clinician-described (e.g. complication rates, functional status, frailty) and patient-reported outcome and experience measures, are important to provide a comprehensive description of peri-operative outcome in the older patient. However, few measurement tools have been developed or validated specifically for the elderly surgical patient. This paper describes the outcome measures currently in use, explores how they might be used to improve the quality of care provision, and indicates priority areas for peri-operative outcomes research in the elderly surgical patients.

Background and objective Emergency laparotomy is a common high-risk surgical procedure, but with few outcome data and few data on postoperative care. We aimed to observe mortality within a mixed general surgical population and to explore the potential impact of postoperative care on mortality. Method A prospective observational study of 124 patients undergoing emergency laparotomy. For all patients, overall mortality and 30-day survival were observed; the predicted death rate (PDR) using the P-POSSUM (Portsmouth predictor - Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity) score and the standardised mortality ratio (SMR) were calculated. Results Twenty-four patients died (19.4%); 21 in the first 30 days (16.9%). Twenty-six patients were over 80 years; 10 died (38%). PDR for all patients was 27.4%. The overall SMR was 0.71. Eighty-seven patients (70.2%) followed a postanaesthesia care unit (PACU)-ward pathway (observed mortality 13.6%; mean PDR 15.4%; SMR 0.82). Thirty (24.2%) patients followed an ICU-high dependency unit (HDU)-ward pathway (observed mortality 40.0%; mean PDR 57.2%; SMR 0.69). Six patients (4.8%) followed a PACU-HDU-ward pathway (observed mortality 0%, mean PDR 41.8%, SMR 0.0). Conclusion Mortality after emergency laparotomy was high and very high in patients more than 80 years of age. The SMR was higher in the PACU-ward pathway compared to the ICU-HDU-ward pathway, suggesting room for improvement in the postoperative period.

Sedation may facilitate the acceptance of surgery under local anaesthesia, and improve the patient's experience. However, surgeons should be aware that there is good evidence that sedation has the potential to harm patients. Some authorities believe that patients' protective reflexes are impaired at any level of sedation. Sedation merges into anaesthesia in a continuum of loss of consciousness. All surgeons should understand the definition of ‘conscious sedation’, and be aware of the concepts of ‘deep sedation’ and ‘monitored anaesthesia care’, which are prevalent in the USA. This paper discusses current sedation guidelines in the particular speciality areas where surgeons may be involved, the evidence for patient complications with sedation, and safe sedation practice.

While sedation can improve the patient experience of unpleasant procedures, if performed poorly it has the potential to cause harm. Some authorities believe that patients’ protective reflexes are impaired at any level of sedation, and indeed sedation merges into anaesthesia in a continuum of loss of consciousness. All anaesthetists should understand the definition of ‘conscious sedation’, and be aware of the concepts of ‘deep sedation’ and ‘monitored anaesthesia care’, which are prevalent in the USA. This paper discusses, in particular, dental sedation guidelines and, more generally, safe sedation practice for other procedures in which sedation is given.

The population in the UK is growing older and the number of elderly patients cared for on intensive care units (ICU) is increasing. This study was designed to identify risk factors for mortality in critically ill patients of80 yr of age after surgery.We identified 275 patients, aged 80 yr or greater, admitted to the ICU after surgery. After exclusions, 255 were selected for further analysis. Multivariate analysis was then performed to determine the covariates associated with hospital mortality.The overall ICU and hospital mortality was 20.4% and 33.3%, respectively. Patients who received i.v. vasoactive drugs on days 1 and 2 had hospital mortality of 54.4% and 60.5%, respectively. Multivariate analysis showed that requirement for i.v. vasoactive drugs within the first 24 h on ICU [odds ratio (OR) 4.29; 95% CI, 2.35-7.84, P0.001] and requirement for i.v. vasoactive drugs for a further 24 h (OR 3.63; 95% CI, 1.58-8.37, P0.01) were associated with hospital mortality. The requirement for i.v. vasoactive drugs was also strongly associated with hospital mortality in all the subgroups studied (elective surgery, emergency surgery, and emergency laparotomy).For patients aged 80 yr and more, admitted to ICU after surgery, the requirement for i.v. vasoactive drugs in the first and second 24 h was the strongest predictor of hospital mortality.

Objective: This study aims to use the Dr Foster Global Comparators Network (GC) database to examine differences in outcomes following high-risk emergency general surgery (EGS) admissions in participating centres across 3 countries and to determine whether hospital infrastructure factors can be linked to the delivery of high-quality care. Design: A retrospective cohort analysis of high-risk EGS admissions using GC’s international administrative data set. Setting: 23 large hospitals in Australia, England and the USA. Methods: Discharge data for a cohort of high-risk EGS patients were collated. Multilevel hierarchical logistic regression analysis was performed to examine geographical and structural differences between GC hospitals. Results: 69 490 patients, admitted to 23 centres across Australia, England and the USA from 2007 to 2012, were identified. For all patients within this cohort, outcomes defined as: 7-day and 30-day inhospital mortality, readmission and length of stay appeared to be superior in US centres. A subgroup of 19 082 patients (27%) underwent emergency abdominal surgery. No geographical differences in mortality were seen at 7 days in this subgroup. 30-day mortality (OR=1.47, p

We describe a case of a 19-year-old man who developed traumatic pulmonary pseudocysts after a rollover road traffic crash. These were associated with significant pulmonary haemorrhage requiring a period of mechanical ventilation, but resolved without specific intervention. Review of the literature confirms that this rare complication of blunt chest trauma occurs usually in young adults and, although normally benign, can be associated with life-threatening haemoptysis and secondary infection.

Summary The feasibility of clay ease laparoscopic cholecystectomy was assessed in unselected patients using a standard anaesthetic protocol. Postoperative pain and nausea were assessed at 6 and 24 h postoperatively (visual analogue scale, range 0-10). Thirty-two patients were studied (23 female. 9 male, mean age 49.6 years). The mean duration of surgery was 68 mitt. At 6 h after surgery, 10 patients (31%) had no pain at rest. For the group as a whole, the median pain score was 3 at rest (range 0-6), 4 on movement (0 9), and 5 on coughing (0 9) and eight patients (25%) were nauseated. At 24 It, 15 (46.9%) had no pain at rest. For the group as a whole, the median pain score was I at rest (0-7), 3 (0-6) on movement and 3 on coughing (0 9). The same eight patients were nauseated. Ten patients (31.3%) were judged fit for discharge at 6h, and 28 (87.5%) by 24h. There was no statistical difference in mean age or duration of surgery in those judged fit for early discharge compared to the study group as a whole. Nausea was an important factor in those unfit for discharge at 24 It. Selection criteria might improve these figures. Front the results of our study, 24 h admission is a more realistic goal and will be suitable for most patients requiring laparoscopic cholecystectomy.

Introduction The Dr Foster Global Comparators Network (GC) aims to improve quality in healthcare by promoting inter-hospital collaboration through sharing of outcome data and benchmarking standards. This study aims to utilise the GC database to establish whether geographical differences in outcomes exist following high-risk emergency general surgery (EGS) admissions, whilst determining if structural differences between healthcare systems can be linked to high-quality care. Method Discharge data for a cohort of EGS patients were collated using a pre-determined protocol. Hierarchical logistic regression analysis was performed to examine geographical and structural differences between GC hospitals. Results 69,490 patients, admitted to 23 centres across Australia, England and the USA with high-risk EGS diagnoses from 2007–2012 were identified. Outcomes including: seven/thirty-day mortality, readmission and length of stay were all superior in the USA. 19,082 patients (27%) underwent emergency abdominal surgery. No geographical differences in mortality were seen at seven-days in this subgroup. Thirty-day mortality (OR = 1.47) readmission (OR = 1.42) and length of stay (OR = 1.98) were all worse in the UK. Across this cohort, patient factors, (age, pathology and co-morbidity) were significantly associated with worse outcome as were structural factors including: low ITU bed ratios, high unit volume and inter-hospital transfers. Having dedicated EGS teams cleared of elective commitments with formalised handover of patients was associated with shorter length of stay. Conclusion Post-operative outcomes were similar at seven but not at thirty-days. This may be attributable to better infrastructure and resource allocation towards EGS in the US. The costs associated with this healthcare gain were not measured. Disclosure of interest None Declared.

The past year has seen a number of reports discussing the future possibilities of image-guided surgery and interventional radiology. One of the most exciting developments is intra-operative magnetic resonance imaging. The anaesthesiologist plays a central role in these developments, ensuring that patients undergoing procedures in the radiology department are adequately monitored and safely maintained.

Results. Data from 1853 patients were collected from 35 NHS hospitals. The unadjusted 30 day mortality was 14.9% for all patients and 24.4% in patients aged 80 or over. There was a wide variation between units in terms of the proportion of cases subject to key interventions that may affect outcomes. The presence of a consultant surgeon in theatre varied between 40.6% and 100% of cases, while a consultant anaesthetist was present in theatre for 25‐ 100% of cases. Goal-directed fluid management was used in 0‐63% of cases. Between 0% and 68.9% of the patients returned to the ward (level one) after surgery, and between 9.7% and 87.5% were admitted to intensive care (level three). Mortality rates varied from 3.6% to 41.7%. Conclusions. This study confirms that emergency laparotomy in the UK carries a high mortality. The variation in clinical management and outcomes indicates the need for a national quality improvement programme.

To ensure systems in hospitals improve to make patient care safer, learning must occur when things go wrong. Incident reporting is one of the commonest mechanisms used to learn from harm events and near misses. Only a relatively small number of incidents that occur are actually reported and different groups of staff have different rates of reporting. Nationally, junior doctors are low reporters of incidents, a finding supported by our local data. We set out to explore the culture and awareness around incident reporting among our junior doctors, and to improve the incident reporting rate within this important staff group. In order to achieve this we undertook a number of work programmes focused on junior doctors, including: assessment of their knowledge, confidence and understanding of incident reporting, education on how and why to report incidents with a focus on reporting on clinical themes during a specific time period, and evaluation of the experience of those doctors who reported incidents. Junior doctors were asked to focus on incident reporting during a one week period. Before and after this focussed week, they were invited to complete a questionnaire exploring their confidence about what an incident was and how to report. Prior to "Incident Reporting Week", on average only two reports were submitted a month by junior doctors compared with an average of 15 per month following the education and awareness week. This project highlights the fact that using a focussed reporting period and/or specific clinical themes as an education tool can benefit a hospital by promoting awareness of incidents and by increasing incident reporting rates. This can only assist in improving hospital systems, and ultimately increase patient safety.

Cerebral morbidity is a problem after cardiac surgery. Although neuropsychological tests and imaging techniques have been applied to cardiac patients, the relationship between them has not been considered. In the preliminary investigation, we studied 15 patients (11 male, mean age 59 years) having coronary artery bypass graft (CABG) surgery. Before surgery, patients had magnetic resonance (MR) imaging and neuropsychological assessment with a battery of 10 tests. During surgery, cardiopulmonary bypass was maintained at 28 degrees C with a flow rate of 2.4 L/m2/min-1 and at a mean arterial pressure of 50-70 mm Hg. Bubble or membrane oxygenators with in-line filters were used. Arterial blood gases were maintained using a pH-stat protocol. Fourteen of the 15 patients showed MR abnormalities before surgery. One week after surgery, four patients had additional MR changes. Six patients had significant postoperative neuropsychological deficit in memory (verbal and nonverbal) and attention. The four patients with new MR abnormalities all had significant neuropsychological deficit. In addition to corroborating previous observations that a high proportion of patients undergoing elective CABG have MR abnormalities before surgery, these preliminary data suggest a promising concordance between structural brain changes and cerebral function after CABG.

Ten patients underwent a laparoscopic surgical technique for thoracic and cervical dissection of the oesophagus during oesophagogastrectomy. Thoracotomy was avoided with potential benefits to the patient. To facilitate surgical access the right lung was collapsed using a double-lumen bronchial tube and carbon dioxide was insufflated into the right pleural cavity to compress the lung. Changes in haemodynamic and respiratory variables occurred. In the majority of the patients airway pressure and end-tidal CO2 increased, despite alterations in ventilation. In five patients systolic blood pressure decreased suddenly by between 15 and 35 mmHg, and in four patients SpO2 decreased to 91% or less, despite an FIO2 of 1.0. If carbon dioxide was insufflated too fast, or the lung failed to deflate adequately, the clinical picture was that of a tension pneumothorax. One patient developed surgical emphysema and a contralateral pneumothorax. Postoperatively two patients had recurrent laryngeal nerve damage. Suggestions are made to minimise the changes in haemodynamic and respiratory variables during carbon dioxide insufflation into the thorax.