scholarly journals Pre-NELA vs NELA – has anything changed, or is it just an audit exercise?

2016 ◽  
Vol 98 (8) ◽  
pp. 554-559 ◽  
Author(s):  
M Mak ◽  
AR Hakeem ◽  
V Chitre
Keyword(s):  
Critical Care ◽  
High Risk ◽  
Uneventful Recovery ◽  
Emergency Laparotomy ◽  
Mortality And Morbidity ◽  
High Risk Patients ◽  
Possum Score ◽  
Operative Severity Score ◽  
Risk Patients ◽  
Set Up

BACKGROUND Following evidence suggestive of high mortality following emergency laparotomies, the National Emergency Laparotomy Audit (NELA) was set up, highlighting key standards in emergency service provision. Our aim was to compare our NHS trust’s adherence to these recommendations immediately prior to, and following, the launch of NELA, and to compare patient outcome. METHODS This was a retrospective study of patients who underwent an emergency laparotomy over the course of 6 months – 3 months either side of the initiation of NELA. RESULTS There were 44 patients before the initiation of NELA (pre-NELA, PN group) and 55 in the first 3 months of NELA (N group). We saw a significant increase in the proportion of patients whose decision to operate was made by the consultant: 75.0% in the PN group vs 100% in N group (subsequent data presented in this order) (P < 0.001). The presence of a consultant surgeon (75.0% vs 83.6%, P = 0.321) and anaesthetist (100.0% vs 90.9%, P = 0.064) in theatres were comparable in both groups. Risk stratification based on Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (P-POSSUM) score showed no difference in high-risk patients in both groups (47.7% vs 36.4%, P = 0.306). With the NELA initiative, however, significantly more patients were admitted directly from theatres to the critical care unit, when compared with the pre-NELA period (9.1% vs 27.3%, P = 0.038). This also reflected a significant reduction in unexpected escalation to a higher level of care during this period (10.0% vs 0%, P = 0.036). Significantly more patients had uneventful recovery in the NELA period (52.3 vs 76.4%, P = 0.018), although there was no difference in 30-day mortality between the groups (2.3% vs 7.3%, P = 0.378). CONCLUSIONS This study demonstrated a greater degree of consultant involvement in the decision to operate during NELA. More high-risk patients have been identified preoperatively with diligent risk assessment and, hence, have been proactively admitted to critical care units following laparotomy, which may account for the significant reduction in unexpected escalation to level 2 or level 3 care and thus in overall better patient outcomes.

scholarly journals Decisions to operate: the ASA grade 5 dilemma

2011 ◽  
Vol 93 (5) ◽  
pp. 365-369 ◽  
Author(s):  
J Horwood ◽  
S Ratnam ◽  
A Maw
Keyword(s):  
High Risk ◽  
Scoring Systems ◽  
Apache Ii ◽  
Ageing Population ◽  
Mortality And Morbidity ◽  
High Risk Patients ◽  
Operative Severity Score ◽  
Grade 5 ◽  
Number Of Patients ◽  
Risk Patients

INTRODUCTION Deciding to operate on high risk patients suffering catastrophic surgical emergencies can be problematic. Patients are frequently classed as American Society of Anesthesiologists (ASA) grade 5 and, as a result, aggressive but potentially lifesaving intervention is withheld. The aim of our study was to review the short-term outcomes in patients who were classed as ASA grade 5 but subsequently underwent surgery despite this and to compare the ASA scoring model to other predictors of surgical outcome. METHODS All patients undergoing emergency surgery with an ASA grade of 5 were identified. Patient demographics, indications for surgery, intraoperative findings and outcomes were recorded. In addition to the ASA scores, retrospective Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (P POSSUM) and Acute Physiology and Chronic Health Evaluation II (APACHE II) scores were calculated and compared to the observed outcomes. RESULTS Nine patients (39%) survived to discharge. ASA grade was a poor predictor of outcome. P POSSUM and APACHE II scores correlated significantly with each other and with observed outcomes when predicting surgical mortality. The median stay for survivors in the intensive care unit was nine days. CONCLUSIONS In times of an ageing population, the number of patients suffering catastrophic surgical events will increase. Intervention, with little hope of a cure, a return to independent living or an acceptable quality of life, leads to unnecessary end-of-life suffering for patients and their relatives, and consumes sparse resources. The accuracy and reliability of ASA grade 5 as an outcome predictor has been questioned. P POSSUM and APACHE II scoring systems are significantly better predictors of outcome and should be used more frequently to aid surgical decision-making in high risk patients.

scholarly journals Post-operative Complications Following Emergency Laparotomy are Common and Associated with Increased Late Mortality – a Retrospective Multi-centre Study.

2021 ◽  
Author(s):  
shivam sharma ◽  
Joseph Alderman ◽  
Dhruv Parekh ◽  
David Thickett ◽  
Jaimin Patel
Keyword(s):  
High Risk ◽  
Length Of Stay ◽  
Pulmonary Complications ◽  
High Risk Group ◽  
University Hospital ◽  
Emergency Laparotomy ◽  
Multi Centre Study ◽  
Mortality And Morbidity ◽  
High Risk Patients ◽  
Risk Patients

Abstract BackgroundThe first National Emergency Laparotomy Audit (NELA) highlighted that morbidity and mortality from emergency surgery remains elevated especially in high-risk patients defined as a P-POSSUM mortality ≥ 5% and ASA ≥ 3. The incidence of postoperative pulmonary complications (PPCs) are thought to be high following emergency laparotomy but no recent studies have evaluated the incidence or consequences of PPC following emergency laparotomy in the UK.MethodsA retrospective cohort study was conducted at University Hospital Birmingham and Heartlands Hospital, Birmingham, to investigate the incidence of PPCs following emergency laparotomy. The NELA databases from the two Trusts were used to identify patients. Patients were retrospectively screened for the development of PPCs using the validated Melbourne Group Scale. Data was analysed using Chi-squared test for categorical data and continuous data displayed as medians with statistical analysis from a Mann–Whitney U test. Results A total of 362 correctly coded patients were identified. High-risk patients accounted for 62% (226) of the cohort. These patients were older (p < 0.001) and had higher baseline lactate (p = 0.04) and creatinine levels (p = 0.003). Median P-POSSUM mortality was 10.6% (5.6–31.4%) with 76.4% of patients having an ASA ≥ 3. These patients had an increased length of stay (p < 0.001) and accounted for nearly all the deaths (42 vs. 2; p < 0.001). The incidence of PPCs was 37%, again the incidence was greater in the high-risk group (37% vs. 6% p < 0.001). Development of a PPC was associated with an increased length of stay (17 d vs. 9 d; p < 0.001) as well as a 90, 180 and 360 day mortality.DiscussionThis study demonstrates that the sub-group of patients deemed ‘high-risk’ are at greatest risk of developing a PPC and consequently have an increased length of stay and an increased 90, 180 and 360 day mortality. This allowed us to identify a group of patients at high risk of PPC who we can target with potential novel therapies such as high-flow nasal cannulae oxygen in clinical trials to reduce mortality and morbidity.

scholarly journals EP.FRI.974 NELA 30 day mortality: A single centre experience

2021 ◽  
Vol 108 (Supplement_7) ◽  
Author(s):  
M A Gok ◽  
O Shams ◽  
F Ftaieh ◽  
U A Khan
Keyword(s):  
High Risk ◽  
Survival Curve ◽  
Emergency Laparotomy ◽  
Single Centre ◽  
High Risk Patients ◽  
Single Centre Experience ◽  
Risk Patients ◽  
The Uk ◽  
National Emergency

Abstract Aims National emergency laparotomy audit (NELA) developed in 2014 in the UK, aims to improve of quality of care of patients undergoing emergency laparotomy. NELA highlights the importance of identifying high risk patients for potential significant morbidity and mortality. The aim of this study is to review the NELA 30 day mortality at a single centre. Methods This is a retrospective review of all 30 day NELA mortality patients since 2014 carried out at East Cheshire NHS Trust until January 2020. The NELA survivors beyond 30 days were used as controls. Results Conclusion The overall NELA 30 day mortality rate was 9.8 %. NELA deaths occurred in the older, frail, multi-comorbid & high ASA status patients. Most NELA deaths occur within 90 days, whereas patient survival curve appears to plateau out beyond 90 days. P possum can be used to identify high risk patients, where early collaborative senior assessment by consultant surgeons, anaesthetists and intensivists may identify and allocate appropriate surgical intervention. 

scholarly journals Development and Application of Nursing Risk Management Evaluation System

2021 ◽  
Author(s):  
Li Xiaoyu ◽  
Li Jinxue ◽  
Jiang Fengqiong ◽  
Zhu Yan ◽  
Ye Qiaohua
Keyword(s):  
Risk Assessment ◽  
Risk Management ◽  
High Risk ◽  
Evaluation System ◽  
Assessment System ◽  
High Risk Patients ◽  
Clinical Nurses ◽  
Standard Management ◽  
Risk Patients ◽  
Set Up

Objective: to construct an integrated nursing risk management assessment system, standardize nursing risk assessment and management process, and improve the implementation rate of nursing risk assessment and nursing safety quality. Methods: a special team was set up to construct an integrated nursing risk management and assessment system, including management personnel, clinical nurses and information engineers, to analyze the problems existing in the old nursing risk assessment and design an integrated nursing risk management and assessment system. Results: the integrated nursing risk management assessment system was applied in all wards of the hospital from July 2019 to September 2019, and 25,778 cases were evaluated. It has the advantages of intelligence, integration, convenient operation, historical score query, guiding standard management of high-risk patients. Conclusion: the intelligence, integration and standardization of the integrated nursing risk management assessment system can improve nursing efficiency, standardize nursing risk management, improve nursing staff satisfaction, and reduce the incidence of nursing adverse events in high-risk patients.

O20 Quick, simple and just as effective—comparing pm: L3 ratio to NELA, P-POSSUM and NSQIP scores in assessing mortality risk for emergency laparotomy

2021 ◽  
Vol 108 (Supplement_5) ◽  
Author(s):  
J Y Ming ◽  
M Holmes ◽  
P Pockney ◽  
J Gani
Keyword(s):  
Risk Assessment ◽  
High Risk ◽  
Assessment Tool ◽  
Risk Assessment Tool ◽  
Emergency Laparotomy ◽  
Routine Practice ◽  
High Risk Patients ◽  
Acs Nsqip ◽  
Psoas Muscles ◽  
Risk Patients

Abstract Introduction Multiple tools (NELA, P-POSSUM, ACS-NSQIP) are available to assess mortality risks in patients requiring emergency laparotomy(1–3), but they are time-consuming to perform and have had limited uptake in routine clinical practice in many countries(4). Simpler measures, including psoas muscle: L3 vertebrae (PM: L3) ratio(5,6), may be useful alternates. This measure is quick to perform, requiring no special skills or equipment apart from basic CT viewing software. Method We performed an analysis on all patients in the Hunter Emergency Laparotomy Audit (HELA) database, from January 2016 to December 2017. HELA is a retrospective review of all emergency laparotomy undertaken in a discrete area in NSW, Australia. Patients with an available CT abdomen were included (N = 500/562). A single slice axial CT image at the L3 endplate level was analysed using ImageJ® software to measure the area of L3 and bilateral psoas muscles. This can be done using normal PACS software in routine practice. Result PM: L3 ratios in this cohort have a mean of 1.082 (95%CI 1.042–1.122; range 0.141–3.934). PM: L3 ratio is significantly lower (P &lt; 0.00001) in those patients who did not survive beyond 30 days (mean 0.865 [95% CI 0.746–0.984]) and 90 days (mean 0.888 [95%CI 0.768–1.008]) compared to patients that survived these periods (30 day mean 1.106 [95% vs. 1.033–1.179], 90 day mean 1.112 [95% CI 1.070–1.154]). These associations are similar to those calculated by established risk assessment models. Conclusion PM: L3 ratio is a reliable, quick and easy risk assessment tool to identify high risk patients undergoing emergency laparotomy. Take-home Message PM: L3 ratio is a reliable, quick and easy risk assessment tool to identify high risk patients undergoing emergency laparotomy. It is comparable to NELA, P-POSSUM and ACS-NSQIP.

scholarly journals Early Outcome of on Pump Beating Heart CABG Surger

2019 ◽  
Vol 12 (1) ◽  
pp. 13-19
Author(s):  
Md Mainul Kabir ◽  
AM Asif Rahim ◽  
ASM Iftekher Hossain ◽  
Nazmul Hossain ◽  
Syed Monirul Islam ◽  
...  
Keyword(s):  
High Risk ◽  
Myocardial Ischemia ◽  
Artery Bypass ◽  
Operation Time ◽  
Beating Heart ◽  
Total Blood ◽  
Mortality And Morbidity ◽  
High Risk Patients ◽  
Postoperative Ventilation ◽  
Risk Patients

Background: Current cardioplegic technique during conventional coronary artery bypass grafting (CABG) does not consistently avoid myocardial ischemic damage in high risk patients. Alternatively revascularization without CPB is not always technically feasible. The on-pump beating technique eliminates global myocardial ischemia and thus reduce the mortality and morbidity in high risk patients. This study evaluates the early surgical outcomes of on-pump beating-heart CABG in comparison to conventional CABG. Methods: In this prospective study 60 high risk patients with EURO-SCORE of 6 and above were prospectively allocated into two groups in non-randomized way. Among them 30 patients underwent on-pump beating-heart CABG and 30 patients underwent conventional CABG. The early surgical clinical outcomes were compared between the groups. Results: On-pump beating heart CABG significantly reduced the duration of operation time, cardiopulmonary bypass time, postoperative ventilation time and intensive care unit (ICU) stay. Total blood loss and transfusion requirement were less with reduced Peak Creatine-Kinase level in On-pump beating heart CABG. 30 day mortality was less in On-pump beating heart CABG group (6.7% versus 13.3%). No significant differences between the groups were found in morbidity regarding stroke, renal failure, mediastinitis and atrial arrhythmia. Conclusion: On-pump beating heart CABG can be performed safely in high risk patients. It is still associated with the detrimental effect of CPB but eliminates intra-operative global myocardial ischemia. Cardiovasc. j. 2019; 12(1): 13-19

scholarly journals Evaluation of the validity of POSSUM and P-POSSUM score in predicting the risk of morbidity and mortality respectively in patients undergoing emergency laparotomy

2020 ◽  
Vol 7 (10) ◽  
pp. 3224
Author(s):  
Vivian Anandith Paul ◽  
Agnigundala Anusha ◽  
Alluru Sarath Chandra
Keyword(s):  
Mortality Rate ◽  
Linear Method ◽  
Morbidity And Mortality ◽  
Emergency Laparotomy ◽  
Medical Sciences ◽  
Mortality And Morbidity ◽  
Possum Score ◽  
Operative Severity Score ◽  
Significant Difference ◽  
Predicted Values

Background: Aim of this study is to examine the efficacy of Physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM) and Portsmouth predictor modification (P-POSSUM) equations in predicting morbidity and mortality in patients undergoing emergency laparotomy, to study the morbidity and mortality patterns in patients undergoing emergency laparotomy at Malla Reddy Institute of Medical Sciences, Hyderabad. Methods: The study was conducted for a period of 2 years from February 2018 to February 2020. 100 Patients undergoing emergency laparotomy were studied in the Department of General surgery MRIMS, Hyderabad. POSSUM and P-POSSUM scores are used to predict mortality and morbidity. The ratio of observed to expected deaths (O:E ratio) was calculated for each analysis. Results: The study included total 100 patients, 83 men and 17 women. Observed mortality rate was compared to mortality rate with POSSUM, the O:E ratio was 0.62, and there was no significant difference between the observed and predicted values (χ²=10.79, 9 degree of freedom (df) p=0.148). Observed morbidity rates were compared to morbidity rates predicted by POSSUM, there was no significant difference between the observed and predicted values (χ²=9.89, 9 df, p=0.195) and the overall O:E ratio was 0.91. P-POSSUM predicted mortality equally well when the linear method of analysis was used, with an O:E ratio of 0.65 and no significant difference between the observed and predicted values (χ²= 5.33, 9 df, p= 0.617).Conclusion: POSSUM and P-POSSUM scoring is an accurate predictor of mortality and morbidity following emergency laparotomy and is a valid means of assessing adequacy of care provided to the patient. 

scholarly journals 812 Mortality Risk prediction in Emergency Laparotomy (ORIEL) Study Outcomes at Wythenshawe Hospital

2021 ◽  
Vol 108 (Supplement_6) ◽  
Author(s):  
C Carey ◽  
B Pittam ◽  
S Mobarak ◽  
R Varley ◽  
J Kingston ◽  
...  
Keyword(s):  
High Risk ◽  
Operative Mortality ◽  
Scoring Systems ◽  
Mortality Rates ◽  
National Study ◽  
Emergency Laparotomy ◽  
Mortality And Morbidity ◽  
Mortality Risks ◽  
Acs Nsqip ◽  
Risk Patients

Abstract Aim Emergency laparotomy is a high-risk procedure with significant morbidity and mortality. ORIEL is a multi-centre national study aiming to compare the 30-day mortality predictions generated by NELA, P-POSSUM, ACS-NSQIP and SORT risk calculators with observed 30-day mortality rates in patients undergoing emergency laparotomies. We present the data collected from Wythenshawe hospital. Method Data were collected retrospectively on adult patients undergoing an emergency laparotomy between 01/12/2017 to 30/11/2019 at Wythenshawe hospital from the online NELA database. The median pre-operative mortality risks were calculated using the four risk calculators for all patients. Mortality and morbidity were compared with data reported in the Sixth NELA report. Results The median predicted pre-operative mortality (IQR) for all patients studied using NELA, P-POSSUM, ACS-NSQIP and SORT were: 4.3 (13.0), 5.2 (14.2), 3.4 (8.2) and 2.9 (9.3) respectively. Among patients who were alive 30 days post-operatively, the median predicted mortalities (IQR) were: 3.8 (8.5), 4.8 (11.0), 2.6 (6.9) and 2.8 (7.1) respectively, and among those who died were: 30.8 (18.9), 30.3 (63.4), 16.9 (13.9) and 20.3 (16.2). Compared to the national average, mortality rates at Wythenshawe were lower (9% v 9.3%), the median length of stay in hospital was lower (12 days v 15.4 days) and the percentage of high-risk patients admitted to critical care was higher (93% v 85%). Conclusions Similar values were generated with all the scoring systems among all patients. Wythenshawe hospital reports lower mortality rates and shorter stays in hospital despite operating on higher risk patients (ASA grades 3-5).

scholarly journals Efficacy of the P-POSSUM scoring system in prediction of post-operative mortality and morbidity in patients undergoing emergency laparotomy in a tertiary institute

2018 ◽  
Vol 5 (7) ◽  
pp. 2523 ◽  
Author(s):  
Sivakumar Thirunavukkarasu ◽  
Atreya M. Subramanian
Keyword(s):  
Scoring System ◽  
P Value ◽  
Emergency Laparotomy ◽  
Accurate Predictor ◽  
Mortality And Morbidity ◽  
South Indian ◽  
Possum Score ◽  
Operative Severity Score ◽  
Indian Setting ◽  
A Prospective Study

Background: The Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) scoring system and its modification P-POSSUM (Portsmouth-POSSUM) has been studied in various clinical settings, with varied results. Due to its simplicity and wide application, the efficacy must be verified in individual settings. We wish to assess the system’s efficacy among emergency laparotomies in a south Indian clinical scenario.Methods: A prospective study was undertaken with a sample size of 50. All cases taken for emergency laparotomy were included. 12 physiological and 6 intra-operative characteristics were taken and according to the equation the predicted rates of mortality and morbidity were predicted. This was compared with the observed rates. With these results, the efficacy of the scoring system was assessed.Results: Of the 50 cases included 5 expired (10%) and 29 (58%) experienced some form of morbidity. The P-POSSUM score was found to be an accurate predictor of mortality (x2 =1.174, d.f=8) with a p-value of 0.997.  The POSSUM score was not found to be an accurate predictor of morbidity (x2 =16.949, d.f=8) with a p-value of 0.0403, as the p-value was <0.05.Conclusions: The P-POSSUM scoring system produced accurate results even in the setting of emergency laparotomies in a south Indian setting. It has proved to be a useful tool for predicting mortality, though not completely accurate to assess post-operative morbidity (POSSUM) due to post-operative factors playing a major role in its determination.

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