UK National Surgical Research Collaborative. Multicentre observational study of adherence to Sepsis Six guidelines in emergency general surgery

Prediction of complications associated with general surgery using a Bayesian network

BACKGROUND

Numerous attempts have been made to identify risk factors for surgery complications, but few studies have identified accurate methods of predicting complex outcomes involving multiple complications.

METHODS

We performed a prospective cohort study of general surgical inpatients who attended 4 regionally representative hospitals in China from January to June 2015 and January to June 2016. The risk factors were identified using logistic regression. A Bayesian network model, consisting of directed arcs and nodes, was used to analyze the relationships between risk factors and complications. Probability ratios for complications for a given node state relative to the baseline probability were calculated to quantify the potential effects of risk factors on complications or of complications on other complications.

RESULTS

We recruited 19,223 participants and identified 21 nodes, representing 9 risk factors and 12 complications, and 55 direct relationships between these. Respiratory failure was at the center of the network, directly affected by 5 risk factors, and directly affected 7 complications. Cardiopulmonary resuscitation and sepsis or septic shock also directly affected death. The area under the receiver operating characteristic curve for the ability of the network to predict complications was >0.7. Notably, the probability of other severe complications or death significantly increased when a severe complication occurred. Most importantly, there was a 141-fold higher risk of death when cardiopulmonary resuscitation was required.

CONCLUSION

We have created a Bayesian network that displays how risk factors affect complications and their interrelationships and permits the accurate prediction of complications and the creation of appropriate preventive guidelines.

Trauma Team Activation: Which Surgical Capability Is Immediately Required in Polytrauma? A Retrospective, Monocentric Analysis of Emergency Procedures Performed on 751 Severely Injured Patients

There has been an ongoing discussion as to which interventions should be carried out by an “organ specialist” (for example, a thoracic or visceral surgeon) or by a trauma surgeon with appropriate general surgical training in polytrauma patients. However, there are only limited data about which exact emergency interventions are immediately carried out. This retrospective data analysis of one Level 1 trauma center includes adult polytrauma patients, as defined according to the Berlin definition. The primary outcome was the four most common emergency surgical interventions (ESI) performed during primary resuscitation. Out of 1116 patients, 751 (67.3%) patients (male gender, 530, 74.3%) met the inclusion criteria. The median age was 39 years (IQR: 25, 58) and the median injury severity score (ISS) was 38 (IQR: 29, 45). In total, 711 (94.7%) patients had at least one ESI. The four most common ESI were the insertion of a chest tube (48%), emergency laparotomy (26.3%), external fixation (23.5%), and the insertion of an intracranial pressure probe (ICP) (19.3%). The initial emergency treatment of polytrauma patients include a limited spectrum of potential life-saving interventions across distinct body regions. Polytrauma care would benefit from the 24/7 availability of a trauma team able to perform basic potentially life-saving surgical interventions, including chest tube insertion, emergency laparotomy, placing external fixators, and ICP insertion.

Guidelines for Perioperative Care for Emergency Laparotomy Enhanced Recovery After Surgery (ERAS) Society Recommendations: Part 1-Preoperative: Diagnosis, Rapid Assessment and Optimization

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.

Effectiveness of the sepsis six bundle in the management of acute adult sepsis in the UK

There are up to 11 million sepsis-related deaths worldwide each year. Management of sepsis requires early recognition, appropriate antibiotic treatment and careful management of haemodynamic status. In 2006, the UK Sepsis Trust introduced the sepsis six care bundle to simplify the guidelines for managing sepsis and identify actions for management that were more accessible to junior clinicians. This article reports findings from a literature review that explored the effectiveness of the sepsis six bundle in the management of adult sepsis patients in the UK and assessed the level of clinician compliance in UK clinical settings. The effectiveness of sepsis six was based on patient mortality during hospital stay, rate of intensive care unit admissions and length of hospital stay, all of which were found to have improved since the introduction of the tool.

Three wound-dressing strategies to reduce surgical site infection after abdominal surgery: the Bluebelle feasibility study and pilot RCT

BACKGROUND

Surgical site infection (SSI) affects up to 20% of people with a primary closed wound after surgery. Wound dressings may reduce SSI.

OBJECTIVE

To assess the feasibility of a multicentre randomised controlled trial (RCT) to evaluate the effectiveness and cost-effectiveness of dressing types or no dressing to reduce SSI in primary surgical wounds.

DESIGN

Phase A - semistructured interviews, outcome measure development, practice survey, literature reviews and value-of-information analysis. Phase B - pilot RCT with qualitative research and questionnaire validation. Patients and the public were involved.

SETTING

Usual NHS care.

PARTICIPANTS

Patients undergoing elective/non-elective abdominal surgery, including caesarean section.

INTERVENTIONS

Phase A - none. Phase B - simple dressing, glue-as-a-dressing (tissue adhesive) or 'no dressing'.

MAIN OUTCOME MEASURES

Phase A - pilot RCT design; SSI, patient experience and wound management questionnaires; dressing practices; and value-of-information of a RCT. Phase B - participants screened, proportions consented/randomised; acceptability of interventions; adherence; retention; validity and reliability of SSI measure; and cost drivers.

DATA SOURCES

Phase A - interviews with patients and health-care professionals (HCPs), narrative data from published RCTs and data about dressing practices. Phase B - participants and HCPs in five hospitals.

RESULTS

Phase A - we interviewed 102 participants. HCPs interpreted 'dressing' variably and reported using available products. HCPs suggested practical/clinical reasons for dressing use, acknowledged the weak evidence base and felt that a RCT including a 'no dressing' group was acceptable. A survey showed that 68% of 1769 wounds (727 participants) had simple dressings and 27% had glue-as-a-dressing. Dressings were used similarly in elective and non-elective surgery. The SSI questionnaire was developed from a content analysis of existing SSI tools and interviews, yielding 19 domains and 16 items. A main RCT would be valuable to the NHS at a willingness to pay of £20,000 per quality-adjusted life-year. Phase B - from 4 March 2016 to 30 November 2016, we approached 862 patients for the pilot RCT; 81.1% were eligible, 59.4% consented and 394 were randomised (simple, n = 133; glue, n = 129; no dressing, n = 132); non-adherence was 3 out of 133, 8 out of 129 and 20 out of 132, respectively. SSI occurred in 51 out of 281 participants. We interviewed 55 participants. All dressing strategies were acceptable to stakeholders, with no indication that adherence was problematic. Adherence aids and patients' understanding of their allocated dressing appeared to be key. The SSI questionnaire response rate overall was 67.2%. Items in the SSI questionnaire fitted a single scale, which had good reliability (test-retest and Cronbach's alpha of > 0.7) and diagnostic accuracy (c-statistic = 0.906). The key cost drivers were hospital appointments, dressings and redressings, use of new medicines and primary care appointments.

LIMITATIONS

Multiple activities, often in parallel, were challenging to co-ordinate. An amendment took 4 months, restricting recruitment to the pilot RCT. Only 67% of participants completed the SSI questionnaire. We could not implement photography in theatres.

CONCLUSIONS

A main RCT of dressing strategies is feasible and would be valuable to the NHS. The SSI questionnaire is sufficiently accurate to be used as the primary outcome. A main trial with three groups (as in the pilot) would be valuable to the NHS, using a primary outcome of SSI at discharge and patient-reported SSI symptoms at 4-8 weeks.

TRIAL REGISTRATION

Phase A - Current Controlled Trials ISRCTN06792113; Phase B - Current Controlled Trials ISRCTN49328913.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 39. See the NIHR Journals Library website for further project information. Funding was also provided by the Medical Research Council ConDuCT-II Hub (reference number MR/K025643/1).

Challenges of one-year longitudinal follow-up of a prospective, observational cohort study using an anonymised database: recommendations for trainee research collaboratives

BACKGROUND

Trainee research collaboratives (TRCs) have pioneered high quality, prospective 'snap-shot' surgical cohort studies in the UK. Outcomes After Kidney injury in Surgery (OAKS) was the first TRC cohort study to attempt to collect one-year follow-up data. The aims of this study were to evaluate one-year follow-up and data completion rates, and to identify factors associated with improved follow-up rates.

METHODS

In this multicentre study, patients undergoing major gastrointestinal surgery were prospectively identified and followed up at one-year following surgery for six clinical outcomes. The primary outcome for this report was the follow-up rate for mortality at 1 year. The secondary outcome was the data completeness rate in those patients who were followed-up. An electronic survey was disseminated to investigators to identify strategies associated with improved follow-up.

RESULTS

Of the 173 centres that collected baseline data, 126 centres registered to participate in one-year follow-up. Overall 62.3% (3482/5585) of patients were followed-up at 1 year; in centres registered to collect one-year outcomes, the follow-up rate was 82.6% (3482/4213). There were no differences in sex, comorbidity, operative urgency, or 7-day postoperative AKI rate between patients who were lost to follow-up and those who were successfully followed-up. In centres registered to collect one-year follow-up outcomes, overall data completeness was 83.1%, with 57.9% (73/126) of centres having ≥95% data completeness. Factors associated with increased likelihood of achieving ≥95% data completeness were total number of patients to be followed-up (77.4% in centres with < 15 patients, 59.0% with 15-29 patients, 51.4% with 30-59 patients, and 36.8% with > 60 patients, p = 0.030), and central versus local storage of patient identifiers (72.5% vs 48.0%, respectively, p = 0.006).

CONCLUSIONS

TRC methodology can be used to follow-up patients identified in prospective cohort studies at one-year. Follow-up rates are maximized by central storage of patient identifiers.

Evaluation of the Collaborative Use of an Evidence-Based Care Bundle in Emergency Laparotomy

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.

Securing the Appendiceal Stump During Emergency Appendicectomy: Options and Influencing Factors in Current UK Surgical Practice

INTRODUCTION

The aim of our study was to identify the most commonly employed methods and influencing factors for securing the appendiceal stump in current NHS practice.

METHODS

An electronic survey of the Scottish Surgical Research Group network, invitation extended to the UK National Research Collaborative.

RESULTS

A total of 111 responses were received from 32 surgical centers; 28 (25.2%) consultants, 66 (59.5%) specialty trainees and 12 (10.8%) core trainees. Endoscopic ligatures were the preferred method in 96 (86.5%) with no difference in those with the greatest operative experience (P=0.79), 12 (10.8%) preferred polymeric clips. Ease of application (70.3%) and severity of stump inflammation (65.8%) had the greatest influence on the method chosen. Cost was a factor in 36.0%.

CONCLUSIONS

The preferred method for securing the appendiceal stump in UK practice is endoscopic ligatures regardless of operative experience. Factors with the greatest influence on the method employed include the ease of application and severity of stump inflammation. Our findings are likely to be representative of current NHS practice in Scotland.