Department of Anesthesiology, Royal Surrey County Hospital, Guildford, United Kingdom.
Department of Anesthesiology, Keck School of Medicine, University of Southern California, Los Angeles.
JAMA Surg. 2019 May 1;154(5):e190145. doi: 10.1001/jamasurg.2019.0145. Epub 2019 May 15.
Patients undergoing emergency laparotomy have high mortality, but few studies exist to improve outcomes for these patients.
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.
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.
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.
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.
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.
接受急诊剖腹手术的患者死亡率很高，但很少有研究能够改善这些患者的预后。
评估实施 6 点护理包的协作方法是否与死亡率和住院时间的降低以及一组医院提供护理标准的改善相关。
设计、地点和参与者：紧急剖腹手术协作（ELC）是一项英国前瞻性质量改进研究，对 2015 年 10 月 1 日至 2017 年 9 月 30 日期间需要紧急剖腹手术的患者实施护理包。参与者为 28 家英国国家医疗服务体系医院和急诊外科患者，这些患者在这些医院接受治疗，并将其数据输入国家紧急剖腹手术审计（NELA）数据库。实施后 ELC 的结果与 2014 年 7 月 1 日至 2015 年 9 月 30 日的基线数据进行了比较。数据输入和收集是通过 NELA 进行的。
使用了一个 6 点、基于证据的护理包。该套餐包括及时测量血乳酸水平、早期评估和治疗脓毒症、在决定手术后按规定时间目标转移到手术室、使用目标导向液体治疗、术后入住重症监护病房以及高级临床医生在围手术期决策和护理方面的多学科参与。为 ELC 领导团队提供了变革管理和领导力辅导。
主要结果是住院死亡率，包括粗死亡率和朴茨茅斯生理和手术严重程度评分用于死亡率和发病率的枚举（P-POSSUM）风险调整后死亡率，以及住院时间。次要结果是护理包中单独指标实施后的变化。
共有 28 家医院参与了 ELC 并完成了该项目。基线组包括 5562 名患者（2937 名女性[52.8%]，平均[范围]年龄为 65.3[18.0-114.0]岁），而 ELC 后组有 9247 名患者（4911 名女性[53.1%]，平均[范围]年龄为 65.0[18.0-99.0]岁）。未调整的死亡率从基线时的 9.8%降至项目第 2 年的 8.3%，风险调整后的死亡率从基线时的 5.3%降至 ELC 后的 4.5%。第 1 年的平均住院时间从 20.1 天减少到第 2 年的 18.9 天。护理包中的 6 项指标中的 5 项都发生了显著变化。
使用质量改进方法和护理包的协作方法似乎可以有效降低急诊剖腹手术的死亡率和住院时间，这表明医院应采用这种方法以获得更好的患者预后和护理提供表现。
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