“It showed how we can improve and approach any obstacles/ problems in delivering the bundle of care and how to plan better to implement the ELC bundle.”
Participating hospital partner

Overview

KSSThe Emergency Laparotomy Collaborative (ELC) is an AHSN-led programme funded by the Health Foundation as one of seven national ‘Scaling Up Improvement Awards for 2015’. The programme involves the spread and adoption of the evidence-based Emergency Laparotomy Pathway Quality Improvement Care (ELPQuiC) bundle, from four hospitals to 28 hospitals/ 24 NHS trusts within three AHSN regions: Kent Surrey Sussex, Wessex, and West of England.

Our ambition is to improve standards of care for patients undergoing emergency laparotomy surgery, reduce mortality rates, complications and hospital length of stay, while encouraging a culture of collaboration across the regions and embedding quality improvement skills to ensure sustainability of change.

The programme regularly brings 100+ staff from emergency departments, radiology, acute admission units, theatres, anaesthetics and intensive care together through a series of collaborative learning events using the IHI Breakthrough Series Collaborative Model for Achieving Breakthrough Improvement (Institute for Healthcare Improvement, 2003).

Key outcomes achieved so far include significant reductions in mortality rate and length of stay:

  • Risk adjusted mortality rate fell by 18% in the first three months. We are looking to see if this reduction is sustained.
  • Length of stay has fallen by 8.5% (1.5 days), equating to non-cash releasing savings of £1.3m in the first nine months.

Challenge/ problem identified

Emergency laparotomy is a major surgical procedure, with 30,000 – 50,000 performed annually in the UK (Barrow et al., 2013). However, 14.9% of patients are reported to die within 30 days of surgery, rising to 24.4% for those over the age of 80 years (Saunders et al., 2012). It is a costly procedure too, with over 25% of patients remaining in hospital for more than 20 days after surgery, costing the NHS over £200m a year in ward care (NELA, 2016, p. 9).

To address this problem, an evidence-based emergency laparotomy care bundle was developed by the Royal Surrey County Hospital NHS Foundation Trust. After implementing the care bundle in four UK hospitals, data collected over an eight month period found crude 30 day mortality for all patients was reduced by 25% and risk-adjusted hospital mortality rate reduced by 42% (Huddart et al., 2014).

Actions taken

The ELC programme uses Quality Improvement methodology to support the scaling-up of the ELPQuiC care bundle (now known as the ELC care bundle) across the three AHSN regions.

We have developed a suite of tools and delivered a training programme consisting of the generation and interpretation of run-charts, SPC charts and a comparative dashboard. The training programme also covers subjects such as PDSA cycles, process mapping and human factors.

National Emergency Laparotomy Audit (NELA) only reports progress on key measures annually, so to provide more frequent access to performance data, we distribute a comparative dashboard showing adherence to the ELC care bundle and patient outcome measures on a quarterly basis. This allows hospital teams participating in our programme to use the data to improve quality of care and patient outcomes. Trusts also share their progress at our collaborative learning events, enabling open dialogue, group reflection and celebration of successes.

Impacts/ outcomes

KSS infographicPatient impact to date includes:

  • Risk adjusted mortality rate fell by 18% in the first three months. We are looking to see if this reduction is sustained.
  • Length of stay has fallen by 8.5% (1.5 days).
  • Of the 4,165 patients who had an emergency laparotomy at a participating hospital between 1st October 2015 and 30th September 2016, over 98% received have at least one aspect of the care bundle.
  • Consultant led care has improved by 14.5% meaning 4 out of 5 patients now have a senior surgeon and anaesthetist present in theatre.
  • Three quarters of the sickest patients are now in theatre within 2 hours of decision to operate.

Financial impact to date:

The observed length of stay improvements mentioned above equate to non-cash releasing savings of £1.3m in the first nine months. We have also undertaken a piece of health economics analysis and based on initial findings, our interim report suggests every £1 spent will result in approximately £4.50 benefit to the wider health and social economy.

Collaboration:

With three AHSNs and 24 NHS trusts (incorporating 28 hospitals) working as partners, the Emergency Laparotomy Collaborative is arguably the largest AHSN-led spread and adoption programme to date.

Our ELC programme was mentioned in NHS National Director of Patient Safety Dr Mike Durkin’s opening speech at the Patient Safety Congress in 2016. We have also presented and spoken about the ELC programme at the 2016 IHI Conference in Gothenburg, at the Royal College of Anaesthetists, and at the 2016 Evidence Based Perioperative Medicine (EBPOM) Congress. The ELC programme has been published in the report Patient Safety Collaboratives – Making Care Safer for All. These presentations and publications not only promote the good work of participating NHS trusts and regions, but will help with further spread and adoption in the future.

“It’s important because you will make sure that we took all the possible care that we could to improve the patient outcome.”
Participating hospital partner

Plans for the future

Although the programme will be completed at the end of August 2017, we expect the relationships between clinicians in participating hospitals will continue to develop, allowing collaborative work to extend beyond an emergency laparotomy focus to other aspects of care, particularly emergency surgery, A&E and acute care. We believe the QI training delivered through the ELC programme has also contributed to the development of a culture of continuous improvement within the participating hospitals teams. We hope this will result in improvements being sustained and encourage teams to apply their learning to other improvement initiatives within their organisations.

As a programme team, we are inspired by our early success and plan to scale-up the ELC care bundle further to other regions and hospital teams using our collaborative model for improvement. We are currently discussing opportunities for scaling with interested parties and are open to being approached by others (UK or abroad). We intend to use a train-the-trainer approach, transferring our team’s learning and experience to adopters, whilst also providing mentoring, guidance and support throughout implementation. This will allow our delivery model to be replicated whilst taking advantage of the local system knowledge adopters will have.

Which national clinical or policy priorities does this example address?

  • Care and Quality
  • Funding and Efficiency
  • Health and Well Being
  • Driving Economic Growth.

Find out more

Start and end dates

March 2015 – August 2017

Contact for help and advice

Sadie Leack, Senior Programme Manager, Kent Surrey Sussex Academic Health Science Network (KSS AHSN)
E: sadie.leack@nhs.net

Rick Fell, Communications Lead, Kent Surrey Sussex Academic Health Science Network
E: rickfell@nhs.net