UCL Division of Surgery and Interventional Science, London, UK; UCLH Surgical Outcomes Research Centre, Department of Anaesthesia and Perioperative Medicine, University College London Hospitals NHS Foundation Trust, London, UK; National Emergency Laparotomy Audit, Royal College of Anaesthetists, London, UK; Health Services Research Centre, National Institute for Academic Anaesthesia, Royal College of Anaesthetists, London, UK.
National Emergency Laparotomy Audit, Royal College of Anaesthetists, London, UK; Health Services Research Centre, National Institute for Academic Anaesthesia, Royal College of Anaesthetists, London, UK; UCL Department of Applied Health Research, London, UK; Manchester University NHS Foundation Trust, Manchester, UK.
Br J Anaesth. 2018 Dec;121(6):1346-1356. doi: 10.1016/j.bja.2018.07.040. Epub 2018 Oct 3.
Studies across healthcare systems have demonstrated between-hospital variation in survival after an emergency laparotomy. We postulate that this variation can be explained by differences in perioperative process delivery, underpinning organisational structures, and associated hospital characteristics.
We performed this nationwide, registry-based, prospective cohort study using data from the National Emergency Laparotomy Audit organisational and patient audit data sets. Outcome measures were all-cause 30- and 90-day postoperative mortality. We estimated adjusted odds ratios (ORs) for perioperative processes and organisational structures and characteristics by fitting multilevel logistic regression models.
The cohort comprised 39 903 patients undergoing surgery at 185 hospitals. Controlling for case mix and clustering, a substantial proportion of between-hospital mortality variation was explained by differences in processes, infrastructure, and hospital characteristics. Perioperative care pathways [OR: 0.86; 95% confidence interval (CI): 0.76-0.96; and OR: 0.89; 95% CI: 0.81-0.99] and emergency surgical units (OR: 0.89; 95% CI: 0.80-0.99; and OR: 0.89; 95% CI: 0.81-0.98) were associated with reduced 30- and 90-day mortality, respectively. In contrast, infrequent consultant-delivered intraoperative care was associated with increased 30- and 90-day mortality (OR: 1.61; 95% CI: 1.01-2.56; and OR: 1.61; 95% CI: 1.08-2.39, respectively). Postoperative geriatric medicine review was associated with substantially lower mortality in older (≥70 yr) patients (OR: 0.35; 95% CI: 0.29-0.42; and OR: 0.64; 95% CI: 0.55-0.73, respectively).
This multicentre study identified low-technology, readily implementable structures and processes that are associated with improved survival after an emergency laparotomy. Key components of pathways, perioperative medicine input, and specialist units require further investigation.
在多个医疗体系中，研究表明在接受紧急剖腹手术后，医院间的生存率存在差异。我们假设这种差异可以通过围手术期流程的提供、支撑组织结构和相关医院特征方面的差异来解释。
我们利用国家紧急剖腹手术审计组织和患者审计数据集进行了这项全国性、基于登记的前瞻性队列研究。结局指标是全因术后 30 天和 90 天死亡率。我们通过拟合多水平逻辑回归模型，估计了围手术期流程以及组织结构和特征的校正比值比（OR）。
队列纳入了 185 家医院的 39903 例手术患者。在控制病例组合和聚类后，大量医院间死亡率差异可通过流程、基础设施和医院特征方面的差异来解释。围手术期护理路径[OR：0.86；95%置信区间（CI）：0.76-0.96；OR：0.89；95%CI：0.81-0.99]和急诊外科病房[OR：0.89；95%CI：0.80-0.99；OR：0.89；95%CI：0.81-0.98]分别与降低 30 天和 90 天死亡率相关。相反，不频繁的由顾问提供的术中护理与增加 30 天和 90 天死亡率相关（OR：1.61；95%CI：1.01-2.56；OR：1.61；95%CI：1.08-2.39）。术后老年医学审查与老年（≥70 岁）患者死亡率显著降低相关（OR：0.35；95%CI：0.29-0.42；OR：0.64；95%CI：0.55-0.73）。
这项多中心研究确定了一些低技术、易于实施的结构和流程，这些结构和流程与接受紧急剖腹手术后的生存率提高有关。路径、围手术期医学投入和专科病房的关键组成部分需要进一步研究。
