ACUTE abdomen, if not assessed and treated expeditiously, can lead to mortality rates higher than those for heart attack and stroke, and yet Australian emergency departments (EDs) do not have a fast-track pathway for severe abdominal pain.
While evidence-based standards do exist for the management of a patient with acute abdomen and potential sepsis – a sepsis screen on arrival at the ED, blood cultures, antibiotics, lactate testing, computed tomography scans, a risk assessment to escalate care as appropriate, and post-operative admission to a critical care unit – it is the initial assessment on presentation that lacks the appropriate alarm bells.
According to the authors of a Perspective published today by the MJA, the overall predictive mortality of acute abdomen is 8–15%, and double that for patients aged 80 years and over.
“The consequences [of delayed assessment and treatment of acute abdomen] are actually worse [than for heart attack and stroke],” Dr Katherine Broughton, a co-author on the MJA article, told MJA InSight in an exclusive podcast.
“The mortality rate for a patient having an emergency laparotomy is much higher than the chance that a patient dies following a heart attack or stroke.
“The potential diagnoses are multiple, there is no single blood test. It’s a higher risk group and we should be putting more attention into managing these patients, and that is why we need these pathways.”
In the UK, findings of a 14.9% 30-day mortality rate for emergency laparotomies prompted the National Health Service to set up the National Emergency Laparotomy Audit (NELA) across England and Wales, with data collection commencing in 2012 and the third report published in 2017.
“Improved care, as demonstrated by a reduction in average length of stay of almost 3 days, represented a cost saving of £30 million per annum in bed days alone,” the authors of the MJA Perspective wrote.
Dr Broughton said that Australia had much to learn from NELA.
“We’ve been a bit slow on the uptake of some of the work done in the UK in regards to … improving the care of patients with emergency laparotomies – 5–7 years behind,” she said.
“It’s a difficult group of patients to look at … but it is very clear that there are standards of care that we should be meeting. It’s often the simple things – early antibiotic treatment, getting them early to the operating theatre in the appropriate timeframe, making sure the right people are operating on them.”
Dr Broughton was a colorectal fellow at Sir Charles Gairdner Hospital in Perth, and now works at Western General Hospital in Edinburgh. Late in 2016, along with co-author Dr Robert J Aitken, a Perth colorectal surgeon, and a group of surgical colleagues at Sir Charles Gairdner, she undertook a 12-week prospective multihospital audit using inclusion and exclusion criteria similar to those of the Emergency Laparotomy Network. The audit included compliance with a care bundle and a documented prospective risk assessment, similar to NELA’s.
“The audit recorded a low 30-day mortality rate (6.6%); however, as almost three-quarters of the emergency laparotomies were performed in a principal referral hospital, the results may not be typical of Australia,” Broughton and Aitken wrote.
Dr Broughton told MJA InSight that despite the low mortality rate, WA “failed to meet standards of care across the board”.
“That dichotomy is a little difficult to understand,” she said.
“It may be a cultural difference in selecting patients who are actually going to survive an operation. I think Australia is better at acknowledging the patient who’s not going to benefit from surgery and is going to die regardless.
“We’re better at talking to patients and their families frankly about it, and actually selecting the right patients [for surgery].”
As a result of the WA audit, the Royal Australian College of Surgeons and the Royal Australian and New Zealand College of Anaesthetists are setting up a binational audit and quality improvement project which will – hopefully – get started in the middle of 2018.
“We saw that we very clearly needed some national data, and … we needed prospectively collected, high quality data and, at the same time, we need to look at quality improvement,” Dr Broughton said.
Apart from improved outcomes for patients, the WA audit also highlighted the financial benefits of developing a fast-track pathway for acute abdomen.
“Most of the cost estimations are based on reducing length of stay in hospital,” Dr Broughton said.
“A night in hospital is expensive. What really makes a difference is getting patients home earlier, appropriately so. NELA reduced length of stay by 2 days between the first and third years.”
The bottom line for Australia?
“If we reduce length of stay by one day, then based on the cost of one night in hospital, we could save $34 million in a year.”
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