scholarly journals 61 Impact of Dedicated Geriatrician Involvement on National Emergency Laparotomy Audit Standards and Outcomes

2019 ◽  
Vol 48 (Supplement_3) ◽  
pp. iii1-iii16
Author(s):  
Roisin Coary ◽  
Kath Jenkins ◽  
Emma Mitchell ◽  
Anne Pullyblank ◽  
David Shipway
Keyword(s):  
Older Patients ◽  
Ad Hoc ◽  
Gastrointestinal Surgery ◽  
Emergency Laparotomy ◽  
Published Data ◽  
Mortality And Morbidity ◽  
The United Kingdom ◽  
Service Introduction ◽  
National Emergency ◽  
The Impact

Abstract Background Older patients undergoing emergency laparotomy (EmLap) have high levels of mortality and morbidity. The National Emergency Laparotomy Audit (NELA) in the United Kingdom records processes and outcome measures for patients undergoing EmLap. Recent data shows that geriatrician review is associated with reduced post-surgical mortality (Oliver C.M. et al., British Journal of Anaesthesia 2018). Geriatrician review of all patients aged ≥70 years is a NELA standard. However, the most recent national report shows only 23% compliance, falling short of the target of 80% and consistently the poorest performing standard. Methods In August 2018, we established a dedicated gastrointestinal surgery liaison service to replace ad hoc geriatrician reviews. We evaluated the impact on NELA standard compliance and patient outcomes. Data were extracted from the local NELA database on all patients aged ≥70 years, for the first six months of the service (September to February). These were compared to the same time period in the preceding year prior to service launch. Results Following service introduction, increased numbers of patients aged ≥70 years underwent EmLap: 50 (2018-9) vs 31 (2017-8). Geriatrician review occurred in 86% (n=43) in 2018-9, compared to 16% (n=5) in 2017-8. Inpatient mortality fell from 23% (n=7) in 2017-8 to 14% (n=7) in 2018-9. Discharge to own home rose to 76% (n=38) in 2018-9 from 68% (n=21) in 2017-8. One patient in each cohort was newly discharged to a nursing home. Mean length of stay was 17.9 days in 2018-9 (range 3-75), versus 17.6 in 2017-8 (range 3-94). Conclusion Introduction of a dedicated geriatric surgical liaison service is associated with increased compliance with NELA standards. Despite more emergency laparotomies being performed on older patients, this was associated with improved mortality and rates of home discharge, consistent with published data. Targeted investment in surgical liaison services may therefore be warranted.

scholarly journals 670 Documentation and Communication of National Emergency Laparotomy Audit (NELA) Mortality and Morbidity Scoring with Patients Prior To Consenting: Are We Following the Best Practice?

2021 ◽  
Vol 108 (Supplement_6) ◽  
Author(s):  
M Barghash ◽  
J Rehman ◽  
F Salimi ◽  
M Mansour
Keyword(s):  
Best Practice ◽  
District General Hospital ◽  
Management Plan ◽  
Emergency Laparotomy ◽  
Mortality And Morbidity ◽  
Retrospective Audit ◽  
Risk Of Mortality ◽  
The Uk ◽  
National Emergency ◽  
Management Alternatives

Abstract Aim Patients presenting as an emergency have a greater risk of dying than those admitted electively. The ability to stratify risk and calculate a percentage chance of death, not only gives the clinical team a common language to be able to formulate a management plan but also enables them to communicate this with patients and their families. This includes a full explanation of potential risks, benefits, a ceiling of care and management alternatives. In this project, we assessed if the NELA score has been properly calculated, documented prior to surgery for every emergency laparotomy patient and whether such patients were aware of NELA risk predictions prior to consenting. Method This was a retrospective audit based on the NELA guidelines of pre-operative risk stratification and the fifth report NELA recommendations. We assessed 50 case notes of patients who had laparotomies from January 2019 to April 2020 in a busy district general hospital in the UK. Results We noted that NELA risk prediction score was not utilised/documented in most of the patients with compliance of only 26%. We also found that, in the majority of notes, no NELA score discussion with the patient/family was documented, even with patients who had their NELA score calculated preoperatively. Compliance was only 14% in relation to this category. Conclusions A formal assessment of the risk of mortality and morbidity should be made explicit to each patient and should be recorded clearly in the consent form and medical record.

scholarly journals EP.FRI.763 Impact of COVID-19 on the rates of emergency laparotomies at an acute general hospital in the United Kingdom

2021 ◽  
Vol 108 (Supplement_7) ◽  
Author(s):  
Curtis Wright ◽  
Simon Kirkham ◽  
Alex Millward ◽  
Robert MacAdam
Keyword(s):  
Critical Care ◽  
United Kingdom ◽  
High Risk ◽  
Observational Study ◽  
Best Practice ◽  
Emergency Laparotomy ◽  
Single Centre ◽  
The United Kingdom ◽  
The Uk ◽  
National Emergency

Abstract Aims The aim of this study was to analyse if the COVID-19 pandemic had any effect on the number of emergency laparotomies performed each month at a single NHS Foundation Trust. Methods This single-centre retrospective observational study included all patients that underwent an emergency laparotomy that was registered as part of the National Emergency Laparotomy Audit (NELA) at Whiston Hospital in Merseyside, UK, between January 2019 and October 2020. The rates recorded throughout March and April 2020 (COVID) were then compared to the preceding 12 months until the first COVID death was recorded in the UK on March 5th, and the 6 months following the initial national lockdown. Results The number of emergency laparotomies performed each month declined from an average of 14.7 (95% CI 13.2 – 16.1) in the preceding 12 months to 5 during COVID (95% CI 5 – 5); a decrease of 65.9%. Following the easing of lockdown rules in early May, this decline was partly reversed with an average of 9.7 (95% CI 8.9 – 10.5) performed each month until October 2020, reflecting a 34.1% reduction from the pre-COVID baseline. The percentage of patients that achieved the NELA best practice tariffs also fell during COVID to 71% from an average of 79.3% (95% CI 76.0 – 82.7) due to fewer high risk laparotomies being admitted to Critical Care post-operatively. Conclusions During the COVID-19 pandemic, emergency laparotomy rates fell and have only partially recovered to pre-pandemic rates. Post-operative admission to critical care for high risk laparotomies also declined during this period. 

scholarly journals Scoring Systems May be Effective in Predicting Mortality Associated with Palliative Emergency Gastrointestinal Surgery: A Retrospective Observational Study

2021 ◽  
Author(s):  
M. Laitamäki ◽  
I. Alamylläri ◽  
M. Kalliomäki ◽  
J. Laukkarinen ◽  
M. Ukkonen ◽  
...  
Keyword(s):  
Patient Population ◽  
Operative Mortality ◽  
Gastrointestinal Surgery ◽  
Scoring Systems ◽  
Morbidity And Mortality ◽  
Emergency Laparotomy ◽  
Improvement Program ◽  
Mortality And Morbidity ◽  
Asa Score ◽  
Acs Nsqip

Abstract Background Palliative emergency gastrointestinal surgery is associated with significant morbidity and mortality and weighing up the benefits and harms during the decision-making may be challenging. There are very few studies on surgery in palliative patient population. The aim of this retrospective study was to evaluate morbidity and mortality after palliative emergency gastrointestinal surgery and the usability of scoring systems in predicting the outcome. Methods Consecutive adult patients undergoing palliative emergency surgery at a tertiary hospital during the period 2015 to 2016 were included. Pre- and post-operative functional status, morbidity and mortality of patients were assessed. The predictive value of the American Society of Anesthesiologists (ASA) classification, the American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator (ACS NSQIP SRC) and Palliative index (PI) in estimating morbidity and mortality were determined. Results A total of 93 patients (age 69 [28–92] years, 51% female) were included. Typical indications for surgery were bowel obstruction (52%) and securing food intake (30%). Pre-operatively two patients (2.2%) were totally dependent in daily activities, while post-operatively the respective share was 34% at discharge from hospital. The incidence of post-operative complications was 37% and 14% died during the hospital stay. One-, three-month and one-year mortality rates were 41%, 63% and 87%, respectively. While ASA score, PI score and ACS NSQIP did not predict post-operative morbidity, both ASA score and ACS NSQIP SRC predicted post-operative mortality. Conclusions Palliative emergency laparotomy is associated with significant post-operative mortality and morbidity. Scorings, such as ASA score and ACS NSQIP SRC predict mortality in this patient population.

scholarly journals SP3.2.12 Do the National Emergency Laparotomy Audit (NELA) performance indicators correlate with mortality? A retrospective analysis of years 4-6

2021 ◽  
Vol 108 (Supplement_7) ◽  
Author(s):  
Lachlan Dick ◽  
Stefan Tucker ◽  
Fiona Bairstow ◽  
James Green ◽  
Jamie Young
Keyword(s):  
Critical Care ◽  
Performance Indicators ◽  
Performance Indicator ◽  
Average Rate ◽  
Multivariable Analysis ◽  
High Standard ◽  
The Elderly ◽  
Emergency Laparotomy ◽  
National Emergency ◽  
The Impact

Abstract Aims Emergency laparotomy continues to carry significant morbidity and mortality. The National Emergency Laparotomy Audit (NELA) publishes individual hospital reports, detailing key performance indicators. We aimed to determine the impact of performance indicators on mortality. Methods NELA aggregate hospital reports from years 4 to 6 were used to extract data relevant to the study aims. Linear regression was used to determine if any of the reported variables could be used as predictors of mortality. Results An analysis of 559 hospital aggregates, totalling 73075 laparotomies was carried out. Overall, the average rate of mortality was 9.6%. There was no significant correlation between mortality with any common variable across years 4-6 data, including risk documentation before surgery, arrival in theatre appropriate to urgency, consultant review preoperatively and supervision in theatre, admission to critical care, care of the elderly assessment, unplanned return to theatre or admission to critical care and length of stay. Conclusion No single performance indicator alone appears to correlate significantly with mortality. Multivariable analysis may identify some performance indicators, however, given that across all the hospitals there is a high standard of performance for each of the reported variables, the variation in mortality is likely influenced by other factors not evaluated by the hospital aggregate reports.

Tolerance and Response to Initial Systemic Therapy In Older Patients with Follicular Lymphoma (FL): Observations From 186 Unselected Recent Cases In the Practices of US-Based Medical Oncologists (MOs).

Blood ◽  
2010 ◽  
Vol 116 (21) ◽  
pp. 3842-3842
Author(s):  
Neil Love ◽  
Stephanie A. Gregory ◽  
Bruce D. Cheson ◽  
Myron S. Czuczman ◽  
Melanie Elder ◽  
...  
Keyword(s):  
Side Effects ◽  
Board Of Directors ◽  
Older Patients ◽  
Age Groups ◽  
Treatment Selection ◽  
Phase Iii ◽  
Published Data ◽  
Advisory Committees ◽  
Presenting Symptoms ◽  
The Impact

Abstract Abstract 3842 Background: Advanced-stage FL is generally considered incurable, but the disease often responds to systemic anticancer treatment (SAT). A number of factors influence the selection of a specific SAT, which must be administered judiciously to older patients, particularly those with known comorbidities. A paucity of information exists to document which SATs are chosen for this population in clinical practice and the resultant clinical outcomes. We attempted to address this issue by aggregating and examining clinical information on individual patients receiving initial treatment for FL. Methods: US community-based MOs were recruited from a database of past participants in our CME activities to provide anonymous information on the presenting symptoms, diagnostic workup, treatment selection, side effects and clinical antitumor responses for all patients in their practices with a new diagnosis of FL since January 1, 2008. Modest, per-patient honoraria were provided to each MO for this work. Results: From April 14 to July 9, 2010, 38 MOs entered a total of 186 cases of FL into a web-based data bank (minimum 1 case, maximum 15, median 4.5). The median age was 66, with 45% under age 65, 26% from 65 to 74 and 29% age 75 and older. 53% of the patients were women. 42% of patients were minimally symptomatic or asymptomatic at diagnosis (Table 1), and across each of the three age groups the presence of various symptomology was similar. A number of SATs were initiated, including R-CHOP (26%), RCVP (25%), and rituximab monotherapy (13%). 15% of patients were observed without SAT. For patients first treated in 2010, an increase in the use of bendamustine/rituximab was observed, representing 8 of 26 patients (31%) versus 3 out of 80 patients (4%) in 2009. The choice of regimen differed by age, with, for example, more R-CHOP (37%) used for patients under age 65 and more R-CVP (38%) and rituximab monotherapy (28%) selected for patients age 75 and older. Overall, these treatments resulted in complete clinical responses in 57% of patients and “things went very well with expected or fewer toxicities” in 58%. These outcomes are similar to what has been reported in published data from randomized Phase III trials of these regimens. No major differences were observed in the levels of efficacy and side effects between the three age groups (Table 1). Conclusions: This unselected case series produced, in a rapid manner, information addressing a variety of clinical issues in newly diagnosed FL, including the impact of age on treatment selection and resultant outcomes. These data suggest that MOs are able to individualize SATs for older patients and match the short-term outcomes and tolerability of the therapies selected for younger patients. This risk-benefit differential is of particular palliative importance as this dataset demonstrates a majority of patients present with clinically significant tumor-related symptoms at diagnosis. Additional work of this kind is needed to better understand how physicians adjust the dose and schedule of SATs to prevent and ameliorate toxicity, particularly in older patients. Disclosures: Gregory: Cephalon Inc: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Amgen Inc: Consultancy; Genentech BioOncology: Consultancy, Speakers Bureau; Novartis Pharmaceuticals: Consultancy; Spectrum Pharmaceuticals: Consultancy. Cheson:Celgene Corporation: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Cephalon Inc: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; GlaxoSmithKline: Membership on an entity's Board of Directors or advisory committees; Millenium Pharmaceuticals Inc: Membership on an entity's Board of Directors or advisory committees; Pfizer Inc: Membership on an entity's Board of Directors or advisory committees. Czuczman:Amgen Inc: Membership on an entity's Board of Directors or advisory committees; Biogen Idec: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Celgene Corporation: Membership on an entity's Board of Directors or advisory committees; Cephalon Inc: Membership on an entity's Board of Directors or advisory committees; Genentech BioOncology: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; GlaxoSmithKline: Membership on an entity's Board of Directors or advisory committees; Lilly USA LLC: Membership on an entity's Board of Directors or advisory committees; Millenium Pharmaceuticals Inc: Membership on an entity's Board of Directors or advisory committees; Novartis Pharmaceuticals Corporation: Membership on an entity's Board of Directors or advisory committees.

scholarly journals Older patients undergoing emergency laparotomy: observations from the National Emergency Laparotomy Audit (NELA) years 1–4

2020 ◽  
Vol 49 (4) ◽  
pp. 656-663 ◽  
Author(s):  
Rachel M Aitken ◽  
Judith S L Partridge ◽  
Charles Matthew Oliver ◽  
Dave Murray ◽  
Sarah Hare ◽  
...  
Keyword(s):  
Older Patients ◽  
Care Home ◽  
Mortality Data ◽  
Emergency Laparotomy ◽  
Data Set ◽  
Process Measures ◽  
Younger Patients ◽  
Age Cohorts ◽  
National Emergency ◽  
Over Time

Abstract Background older patients aged ≥65 years constitute the majority of the National Emergency Laparotomy Audit (NELA) population. To better understand this group and inform future service changes, this paper aims to describe patient characteristics, outcomes and process measures across age cohorts and temporally in the 4-year period (2014–2017) since NELA was established. Methods patient-level data were populated from the NELA data set years 1–4 and linked with Office of National Statistics mortality data. Descriptive data were compared between groups delineated by age, NELA year and geriatrician review. Primary outcomes were 30- and 90-day mortality, length of stay (LOS) and discharge to care-home accommodation. Results in total, 93,415 NELA patients were included in the analysis. The median age was 67 years. Patients aged ≥65 years had higher 30-day (15.3 versus 4.9%, P < 0.001) and 90-day mortality (20.4 versus 7.2%, P < 0.001) rates, longer LOS (median 15.2 versus 11.3 days, P < 0.001) and greater likelihood of discharge to care-home accommodation compared with younger patients (6.7 versus 1.9%, P < 0.001). Mortality rate reduction over time was greater in older compared with younger patients. The proportion of older NELA patients seen by a geriatrician post-operatively increased over years 1–4 (8.5 to 16.5%, P < 0.001). Post-operative geriatrician review was associated with reduced mortality (30-day odds ratio [OR] 0.38, confidence interval [CI] 0.35–0.42, P < 0.001; 90-day OR 0.6, CI 0.56–0.65, P < 0.001). Conclusions older NELA patients have poorer post-operative outcomes. The greatest reduction in mortality rates over time were observed in the oldest cohorts. This may be due to several interventions including increased perioperative geriatrician input.

The Challenges of Managing Older Patients with Acute Lymphoblastic Leukemia

2015 ◽  
pp. e343-e351 ◽  
Author(s):  
David I. Marks
Keyword(s):  
United Kingdom ◽  
Acute Lymphoblastic Leukemia ◽  
Older Patients ◽  
Lymphoblastic Leukemia ◽  
Therapeutic Modality ◽  
Published Data ◽  
Curative Intent ◽  
Cell Therapies ◽  
The United Kingdom ◽  
Therapeutic Decisions

Acute lymphoblastic leukemia (ALL), predominantly a disease of children, has a second incidence peak in older adults. Patients older than age 50 but younger than age 65 may be included in trials of intensive treatment with curative intent, but their outcome is poor with high nonrelapse mortality (NRM), high relapse rates, and low overall survival. Using limited published data from the United Kingdom ALL XII and HOVON trials, this manuscript explores the reasons for the high transplant-related mortality (TRM) and presents early data from the United Kingdom ALL 60+ and United Kingdom ALL XIV studies. Factors affecting therapeutic decisions for older patients are discussed. A case study illustrates some of the issues involved in managing these patients and the need to individualize therapy and consider all options. There may be a role for reduced intensity allografting in selected, fitter patients older than age 50; this article presents preliminary transplant data from United Kingdom ALL XIV that prospectively assesses this therapeutic modality. Detailed discussion of tyrosine kinase inhibitors and the potential place of novel targeted antibodies and immune T-cell therapies will be not discussed in detail. Finally, there is a description of the major outstanding issues and the trials that are needed to inform decision making and improve outcome in this challenging group of patients.

SAGE & THYME

2017 ◽  
Author(s):  
Michael Connolly
Keyword(s):  
United Kingdom ◽  
Communication Skills ◽  
Health Workers ◽  
Published Data ◽  
New Approach ◽  
Patients With Cancer ◽  
The United Kingdom ◽  
Communication Behaviours ◽  
The Impact ◽  
Practice Patient

Unhelpful communication behaviours by nurses are known to block patients with cancer from thinking for themselves and so a new approach to training emotional support has emerged from practice. Foundation-level communication skills, including patient-centredness, are being taught in the United Kingdom within a three-hour workshop. Within it, teachers of communication skills are attempting to bridge the gap between published knowledge and clinical practice, using a structured and sequential model known as SAGE & THYME. The model is described as a starter kit to help health workers to listen carefully and practice patient-centred care. The elements of the model and the workshop are described. Published data of self-reported outcomes from workshop participants suggest that learning happens, beliefs change, confidence grows, and willingness to discuss emotional concerns increases. Dissemination of the workshop throughout the United Kingdom appears to be practical, though further research into the impact on patient outcomes is needed.

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