Minutes of the Liverpool Society of Anaesthetists Meeting
20th Novemeber 2015
‘What have we learnt from NELA?’
Dr Matt Oliver, London
The meeting was opened by the President, Dr Ewen Forrest, who set the scene and introduced the speaker, Dr Matt Oliver who has been the RCA NELA fellow at the Health Services Research Centre.
Dr Oliver started his talk by looking at the problem. More than 30,000 emergency laparotomies were performed in England and Wales every year. The overall mortality at 30 days was 15%, at one year, 22% and at two years, more than 25%. He then showed a figure from the British Journal of Anaesthesia (109 (3): 368-75 (2012)) which revealed the variations in mortality across different hospitals after emergency laparotomy. This was in the form of a funnel plot and demonstrated both the average of 15% as well as a difference in outcomes and numbers of procedures in different hospitals. These variations may be due to either patients or processes. The problem was therefore understood however, the quality of the data was uncertain. Consequently, the NHS commissioned a national audit of emergency laparotomy to clarify the figures.
Dr Oliver described the problems. Firstly, there are those associated with individual patients, such as the primary pathology and patient co-morbidity and secondly, ones associated with the process. Examples of the latter may be the rapidity at which antibiotics were administered or the speed at which a patient can be taken to the operating theatre. Standards of expected care have been previously published and Dr Oliver showed a slide of their adherence in different hospitals. He pointed out that only one hospital had any postoperative input from physicians in elderly medicine for this group of often elderly patients.
Dr Oliver looked at the first patient report, published in July 2015. In it, the details of over 20,000 patients from 192 hospitals had been reported. Approximately 50% of patients were over the age of 70 years with an ASA status of 3 or 4, requiring surgery in less than 6 hours. Inpatient 30 day mortality was 11% which seemed an improvement in the generally accepted figure of 15% both from this country and a larger study from the United States. He thought that perhaps the improved figure was as a result of parallel quality improvement projects such as EPOCH and the Hawthorne effect. This is the way that individuals modify or improve an aspect of their behaviour in response to their awareness of being observed.
Dr Oliver demonstrated the clear association between age and outcome and described an approximately 5% increase in mortality for every 10 years in age. He discussed the public perception of what is considered ‘high risk’. He cited cardiac surgery, for example, which lay people felt was high risk and had a mortality of below 5%. In view of the NELA figures, emergency laparotomies can virtually all be seen as high risk procedures.
Dr Oliver discussed the processes around emergency laparotomy. In particular, he looked at risk assessment. Scoring systems such a p-POSSUM are widely available but their use in this group is poorly documented. Indeed, 44% of patients had no risk assessment score of any kind. He showed figures demonstrating that p-POSSUM was a reasonably accurate risk assessment scoring tool. The importance of this calculation was to make anaesthetists and surgeons more aware of the calculated risk which may be a driver for better quality care and decision making. The Royal College of Surgeons’ guidelines state that a consultant surgeon and consultant anaesthetist should be present for all cases with predicted mortality of greater than 10% and ideally for cases with predicted mortality of greater than 5%, except in specific circumstances where adequate experience and manpower is otherwise assured. Dr Oliver showed the recoded figures which demonstrated that consultants were present for 75% of operations during the day, but the figure dropped off in the evenings and at night. The presence of consultant surgeons was higher than that of their consultant anaesthetist colleagues. The numbers of cases undertaken in the evening or overnight were smaller than day time cases however their predicted mortality was much higher perhaps reflecting the urgency and severity of a patient’s condition. These figures were worse at weekends.
Dr Oliver then looked at the specific issues of elderly patients undergoing emergency laparotomy. Nearly half of patients undergoing this procedure are 70 years or older and only 10% were assessed at any point post-operatively by a care of the elderly physician. This is an area that he thought needed significant improvement in the years ahead.
Dr Oliver looked to the future and hoped when figures from the Office of National Statistics would become available, information about mortality at 1 and 2 years after surgery, would be more accurate. This would also allow individual hospital data to be compared with national averages. Data continues to be collected and he hoped that improvements in figures would continue following quality improvement initiatives such as EPOCH. The analysis of Year 2 data is currently underway, and there would be a second annual report next year.
Dr Oliver finished his talk with pictures of Dave Brailsford who put forward the concept of marginal gains, with small improvements in all areas leading to a much greater overall improvement in performance. He also showed a slide of Dr Atul Gawande, who, in his recent Reith lectures, looked at the fallibility of systems and doctors and how these could be improved.
Dr Oliver took some questions from the floor and Dr Lawrence Wilson gave the vote of thanks.
Liverpool Society of Anaesthetists