National Emergency Laparotomy Audit (NELA) Context Page

**Please note: updated information pending**

This page provides guidance to assist interpretation of the key metrics from the National Emergency Laparotomy Audit as selected by the National Institute of Academic Anaesthesia’s Health Services Research Centre on behalf of the Royal College of Anaesthetists. Full audits can be reviewed on the NELA audit website where it is necessary to further inform an inspection. A total of 179 ¹ NHS hospitals in England and Wales participated in the 2019 audit.

Metrics:

1. Case ascertainment

• Rationale: This metric shows the proportion of eligible cases within the hospital that were submitted to the audit. The comparison is made against Hospital Episode Statistics data. Case ascertainment describes the proportion of emergency laparotomy patients on whom data were received, compared to the total number of emergency laparotomies performed.
• Guideline/mapping: There is no national guideline related to case ascertainment; the audit is moving towards an aspirational standard of 95%.
• Graph/relative performance: Graph/relative performance: simple RAG scale; ‘green triangle’ means higher than 85% case ascertainment, ‘red circle’ means 0-54% case ascertainment, ‘amber box’ means 55-85% case ascertainment. A grey hexagon indicates insufficient data supplied.
• Quality improvement prompt question: Consider the other metrics in context of case ascertainment; particularly where ascertainment is low. If case ascertainment is low, this should prompt questions about data collection and engagement with the audit.

2. Crude proportion of cases with pre-operative documentation of risk of death (applicable to all patients)

• Rationale: Consistent documentation of an accurate estimate of risk of death is central to both providing informed consent for the patient and for ensuring that peri- and post-operative care needs are anticipated and met. This metric is known to vary across hospitals. Death, complications, long-term debilitation, and prolonged in-hospital recovery are far more common after emergency bowel surgery than after many other operations, including elective bowel surgery. Since the risks of adverse outcomes vary between individuals, and because the risks posed by an operation sometimes outweigh proposed benefits, it is essential that they are quantified and documented before surgery for every patient.
• Guideline/mapping: This metric maps exactly to the Royal College of Surgeons of England and Department of Health report on the Peri-operative Care of the Higher Risk General Surgical Patient 2011, recommendation 4²; the audit is moving towards an aspirational standard of 95%.
• Graph/relative performance: simple RAG scale to describe the proportion of cases with documentation; ‘green triangle’ means that more than 85% of cases had documentation; ‘red circle’ means that 0-54% of cases had documentation and ‘amber box’ means that 55-85% of cases had documentation.
• Quality improvement prompt question: ‘Red circle’ status should prompt questions about the quality of clinical review for emergency general surgical patients in the pre-operative period and what actions the hospital is taking to improve this.

3. Crude proportion of cases with access to theatre within a clinically appropriate time-frame (includes only those patients who required surgery within 18 hours, and excludes patients categorised as needing ‘expedited’ surgery [i.e. surgery not required within 18 hours])

• Rationale: Delay in receiving emergency surgery is associated with lower rates of survival. This metric is known to vary across hospitals. The following operative urgency categories are used in the NELA Patient Audit: 1 Immediate (<2 hours), 2A Urgent (2–6 hours), 2B Urgent (6–18 hours), 3 Expedited (>18 hours). This metric measures the percentage of patients in groups 1, 2A and 2B who receive surgery in the specified timeframe.
• Guideline/mapping: This metric maps approximately to the Royal College of Surgeons of England and Department of Health report on the Peri-operative Care of the Higher Risk General Surgical Patient recommendation 3²; mapping is approximate because the guideline applies to all emergency general surgery patients. The audit is moving towards an aspirational standard of 95%.
• Graph/relative performance: simple RAG scale to describe proportion of cases receiving appropriately expedient surgery; interpretation is as for metric 1.
• Quality improvement prompt question: ‘Red circle’ status should prompt inspectors to ask questions about the adequacy of operating theatre capacity for and appropriateness of prioritisation of emergency general surgery cases as well as actions which the hospital is taking to improve access.

4. Crude proportion of high-risk cases (≥ 5% predicted mortality) with consultant surgeon and consultant anaesthetist present in theatre

• Rationale: Outcomes for high-risk patients are likely to be improved when senior clinicians are directly involved in delivering care. This metric is known to vary across hospitals.
• Guideline/mapping: This metric maps exactly to the Royal College of Surgeons of England and Department of Health report on the Peri-operative Care of the Higher Risk General Surgical Patient 2011, recommendations 5 and 6²; the audit is moving towards an aspirational standard of 95%.
• Graph/relative performance: Graph/relative performance: simple RAG scale to describe proportion of cases with Consultant surgeon and anaesthetist present; interpretation is as for metric 1.
• Quality improvement prompt question: ‘Red circle’ status should prompt questions about the adequacy of consultant numbers and availability for high-risk emergency general surgery patients and what actions the hospital is taking to improve this.

5. Crude proportion of highest-risk cases (≥ 5% predicted mortality) admitted to critical care post-operatively

• Rationale: Intensive care requirements are considered for all patients needing emergency surgery. There should be close liaison and communication between the surgical, anaesthetic and intensive care teams perioperatively with the common goal of ensuring optimal safe care in the best interests of the patient.
• Guideline/mapping: 2018 guidance from RCS in ‘The High-Risk General Surgical Patient: Raising the Standard’ says: Patients should have their risk of in-hospital mortality reassessed and documented at the end of surgery, using available risk prediction tools and clinical judgement. Patients with an end-of-operation predicted hospital mortality of ≥ 5%, by any measure, should be transferred from theatre directly to critical care.
  
• Graph/relative performance: Graph/relative performance: simple RAG scale to describe proportion of high risk admitted to CCU post operatively; interpretation is as for metric 1.
• Quality improvement prompt question: ‘Red circle’ status should prompt questions about the adequacy of critical care support and capacity for high-risk emergency general surgery patients and what actions the hospital is taking to improve this.

6. Risk-adjusted 30-day mortality

• Rationale: Emergency laparotomy is a complex procedure and postoperative mortality is known to vary. This metric uses case-mix adjustment of patient demographic, surgical and physiological variables to ensure that hospitals dealing with sicker patients are compared fairly against those with a less complex case mix.
• Guideline/mapping: Individual organisations’ adjusted rates are compared against others and the national average (see Key). Adjusted scores take into account the differences in the case-mix of patients treated, adjusting for: age, sex, disease severity and co-morbidity. Lower values indicate better performance. Hospitals with high post-operative mortality identified as negative outliers are followed-up by the audit body as part of their outlier process.
• Graph/relative performance: The bar chart identifies positive and negative outliers at alert (2SD) and alarm (3SD).
• Quality improvement prompt question: Investigation of negative outliers should be a priority with formal action plans. Providers should ensure that national guidance is implemented at a local level, so that deaths are identified, screened and investigated, when appropriate, and that learning from deaths is shared and acted on. Emphasis must be given to engaging families and carers.

¹ National Emergency Laparotomy Audit, 2019