National Emergency Laparotomy Audit (NELA) - care must improve to avoid risking patients' lives

National Emergency Laparotomy Audit (NELA) - care must improve to avoid risking patients lives

The latest report from the National Emergency Laparotomy Audit (NELA) warns that care of patients needing emergency abdominal surgery must improve if hospitals are to avoid unnecessarily risking patients’ lives.

Key areas needing improvement included delays in getting patients to theatre, delays in antibiotic treatment for sepsis, and failure to categorise patients needing emergency surgery as high risk. However, within its key messages the report also contains an alert to the NHS that further improvements in care and patient outcomes in emergency surgical care may only be possible with system-wide investment or redesign.

What is NELA?

The National Emergency Laparotomy Audit (or NELA) collects information from 179 hospitals in England and Wales about eligible patients’ perioperative care. It is funded by NHS England and the Welsh government. The audit highlights processes and specific areas of care relating to patients undergoing emergency laparotomy surgery which need investment or improvement. NELA’s stated aim is

“to ensure every person who needs emergency laparotomy surgery consistently receives the right care, from the right people, at the right time, regardless of where they may live”

NELA’s Fifth Patient Report was carried out on behalf of the Royal College of Anaesthetists. It is based on data from December 2017 to November 2018.

What is a laparotomy?

Laparotomy is the medical name for an open operation involving a surgical incision into the abdominal cavity. It is usually carried out to allow the surgeon to examine the abdominal organs to help diagnose and surgically treat any problems in that area. 

Someone might need emergency abdominal surgery if they have a perforation in the bowel or intestine, an abdominal abscess, an abdominal bleed, obstruction or poor blood supply to the bowel.

Care failings in emergency laparotomy

An emergency laparotomy is a high-risk procedure with one of the highest associated rates of death of all types of surgery. NELA reports that the mortality rate after emergency laparotomy has not improved and remains at 9.6%.

Prompt diagnosis and treatment is imperative in people undergoing emergency bowel surgery. Despite this, NELA found that care surrounding emergency laparotomy often falls short of the clinical and care processes that most elective (non-emergency) patients receive.

Decisions about the need for emergency surgery often have to be taken quickly, and whilst very few patients (1.4%) were found to have had unnecessary surgery resulting in no abnormal findings, the audit found that delays in getting patients to theatre often depended on:

  • their route of admission - gastroenterology patients waited on average 30 hours - twice as long as other patients - to go to theatre;
  • level of urgency – the group of patients requiring the most urgent surgery (within two hours) are still the least likely to arrive in theatre within the stated time (over a quarter of patients in this category experienced delay);
  • the time of day – greater delays occur where the decision for surgery is made in morning than if made overnight or at other times.

Emergency surgery was no riskier out of hours than at any other time. The importance of having a consultant surgeon’s assessment was a balancing factor in considering the reasons for delay.

Laparotomy, peritonitis and sepsis

Peritonitis

Peritonitis (infection of the inner lining of the abdomen which covers the internal organs) and sepsis are closely associated with laparotomy (open abdominal surgery). When a person suffers an injury in the abdominal area, there is a risk of peritonitis and a higher risk of then developing sepsis.

Patients with peritonitis or sepsis require prompt treatment with intravenous (IV) antibiotics to treat potentially life-threatening infection.

The recent NELA audit found that 21% of patients who had peritonitis on admission received antibiotics in 4½ hours. This shows an improvement in treatment time from the six hour finding of the first NELA audit, but as peritonitis can lead to sepsis, it is important the treatment timescales continue to be improved.

Sepsis

Sepsis is a potentially life-threatening condition. It occurs when the body’s immune system responds to overwhelming infection by attacking its own tissues and organs. Approximately 25,000 to 30,000 patients each year have an infection in the abdominal area which leads to sepsis.

Symptoms of sepsis may include:

  • slurred speech or confusion
  • extreme shivering or muscle pain
  • passing no urine in a day
  • severe breathlessness
  • feeling you are going to die
  • mottled or discoloured skin

Why must sepsis be treated promptly?

The Health Service Ombudsman has identified sepsis as one of the main causes of avoidable death. The Sepsis Action Plan (2015) suggested that better treatment could reduce mortality and morbidity associated with sepsis, and that 10,000 deaths a year could be prevented. Sepsis kills but research by the UK Sepsis Trust has found that 40% of sepsis survivors suffer permanent and life-changing after-effects.

How is sepsis treated?

Sepsis should be treated with antibiotics to try to overcome the source of the infection. This may be difficult to identify without the patient having a CT or MRI scan, but in cases where there is concern about the bowel and where surgery might be needed, antibiotics should be given as a precaution.  

The audit found that a very large percentage (45%) of patients undergoing emergency laparotomy surgery had signs of sepsis. However, despite research showing that treatment is time-critical as the chance of survival reduces for each hour’s delay in treatment, and increased awareness of the sepsis treatment pathway, NELA found that only 19% of patients with suspected sepsis received antibiotics within an hour. This finding has not improved over five years.

Who is at risk during an emergency laparotomy procedure?

The older generation have a higher mortality rate with this type of operation. They are more likely to have other underlying health issues and suffer more complications from surgery. It is important that these patients have an effective risk assessment prior to surgery and their aftercare is carefully and appropriately managed.

The NELA audit highlighted that an assessment of frailty is not routinely performed in patients who are over 65 before surgery and, given their high-risk status, recommended that this needs to be addressed.

In fact, NELA recommended that all patients undergoing emergency laparotomy should be treated as high risk unless clinically assessed as low-risk by a consultant.

How Boyes Turner can help

Boyes Turner’s top-rated medical negligence team have helped recover substantial compensation for clients suffering from severe injury caused by negligent surgery and delayed or inadequate treatment of post-surgical complications, infection, peritonitis and sepsis. We have experience of helping clients with a wide range of disabilities related to negligent peri-operative care, including multiple amputations, bowel injury, liver damage, incontinence, impaired mobility, long term pain and psychological injury. Compensation can help replace lost earnings, pay for domestic help and assistance, medical treatment, adapted accommodation, specialist equipment and aids, therapies and counselling, and personal care.

If you have suffered severe injury as a result of medical negligence and would like to find out more about making a claim, contact us by email on mednegclaims@boyesturner.com.

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I would also like to express my thanks to you for your dedication in chasing the defendant's insurance company especially where COVID-19 made an impact. 

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