The National Emergency Laparotomy Audit (NELA) Registry standards recommend Consultant Surgeon and Consultant Anaesthetist input for the sickest emergency laparotomy patients and those undergoing complex surgical operative procedures. The rationale is that more experienced clinicians provide better decision-making and therefore clinical outcome for the sickest of patients undergoing an emergency laparotomy.
This includes patients whose pre-operative risk score (The American Society of Anaesthesiologists grading system) is determined to be ASA 3E or higher.
Data of all patients admitted to Whipps Cross University Hospital requiring an emergency laparotomy are submitted to the NELA Registry.
Data from the NELA Registry was analysed to determine the level of Consultant input/supervision for such cases. This enabled us to ascertain if the standards were being met for patients with an ASA 3E grade or higher had Consultant Surgeon and Consultant Anaesthetist input and decision-making in their peri-operative care.
This standard only necessitates Consultant involvement peri-operatively. The operating surgeon and anaesthetist may be a trainee/non-Consultant grade, so long as they are being supervised/led during the emergency laparotomy by a Consultant in their respective specialty.
We analysed data from the NELA Registry for our hospital between 1/1/2013 and 31/12/2016. 266 patients were submitted to the NELA Registry during this period for whom there was a complete dataset entered within the NELA Registry.
Analysis of all 266 patients undergoing an emergency laparotomy was undertaken.
Patient ASA and grade of the most senior surgeon and anaesthetist present treating the patient during their emergency surgery was recorded for each patient and evaluated to identify if the NELA standards were being met
For an equal gender distribution (male 51%, female 49%) and age range 18-94 (mean 60 years), there were 27 cases in total [10.2%] which did not meet the guidance of having Consultant Surgeon and Anaesthetist level input for patients with an ASA33 requiring an emergency laparotomy.
The senior-most surgeon present was non-Consultant grade for 11 patients [ASA 3E - 4%] and 8 patients [ASA 4E - 3%] respectively undergoing emergency laparotomy.
Similarly, there were 3 patients [ASA 3E - 1.1%], 4 patients [ASA 4E – 1.5%] and 1 patient [ASA 5E – 0.4%] where the senior-most anaesthetist present for the emergency laparotomy was not of Consultant grade.
In all cases at least either the most senior surgeon or anaesthetist present during the laparotomy was of Consultant grade.
The NELA standard was not always met as some patients who underwent emergency laparotomy with an ASA 3E grade or higher did not have input/supervision from a Consultant Surgeon and Anaesthetist during their emergency laparotomy.
This is partly explained by the presence of senior surgical trainees (peri-Consultant/post-CCT level) performing the laparotomy or the presence of a highly experienced non-Consultant grade anaesthetist (e.g. Associate Specialist).
However, these occurrences were historic and identification of these issues in the latter half of the period under review has resulted in changes to rectify this problem.
This has been achieved by educating all departmental staff members of the national guidelines and ensuring adherence to these (irrespective of the seniority and/or experience of the non- Consultant grade clinician present).
Subsequent ad hoc analysis of this has demonstrated much better compliance with the national NELA guidelines.