A new Clinical Care Standard to improve emergency laparotomy outcomes

Each year, around 15 000 Australians undergo emergency laparotomy for time-critical conditions including bowel obstruction, peritonitis, haemorrhage and ischaemia. The surgery is high risk with a baseline in-hospital mortality in Australia of 6.9%. For older adults and those with serious comorbidities, mortality estimates reach 20% or higher.

Postoperative complications, extended hospital stays and unplanned readmissions are common, with a significant proportion of surviving patients experiencing poor outcomes, including functional decline and loss of independence. There is also considerable variation in outcomes between health services, which is related to a combination of case-mix and the standard of care provided, including the management of complications.

Those requiring an emergency laparotomy are critically unwell with life-threatening pathology that needs expedited management. Evidence-based clinical pathways for time-critical abdominal conditions are not embedded in practice in the same way they are for other emergency conditions like stroke or hip fracture. With growing evidence demonstrating the benefit of standardised approaches, the Australian Commission on Safety and Quality in Health Care recognised an opportunity to improve care. 

Developing the Emergency Laparotomy Clinical Care Standard

The Commission has published the Emergency Laparotomy Clinical Care Standard to support clinicians and healthcare services to consistently deliver best care and improve patient outcomes. The Standard was developed with guidance from a topic working group with multidisciplinary expertise including consumer lived experience. It builds on the work of the Australian and New Zealand Emergency Laparotomy Audit – Quality Improvement (ANZELA-QI), the registry introduced by the Royal Australasian College of Surgeons (RACS) and the Australian and New Zealand College of Anaesthetists (ANZCA) in 2018. 

The evidence to establish ANZELA-QI was based on England and Wales’ National Emergency Laparotomy Audit (NELA), which has seen postoperative mortality fall from 11.8% to 8.1% over ten years. The Standard describes nine key care components that are outlined in Box 1.

Time-critical management

Abdominal pain is one of the most common reasons people present to Australian emergency departments. Identifying those who are seriously ill and need urgent surgery can be challenging. However, for some people mortality risk may increase by the hour — particularly those with sepsis or ischaemia — so rapid clinical assessment including diagnostic imaging, resuscitation, surgical referral and access to theatre are essential. For Australians who live in rural or remote areas, decisions regarding safe and timely transfer to an appropriately resourced hospital must also be made when local facilities are unable to provide all of the required care.

Risk-informed decision making

Risk prediction tools such as the NELA risk calculator, used in combination with clinical judgment, facilitate informed decision-making for clinicians and patients, and allow treatment to be appropriately targeted, including identifying those who are high risk and are most likely to need postoperative critical care. Risk assessment — including consideration of frailty — can help inform difficult decisions for patients, families and medical teams, especially when surgical intervention may not align with the patient’s goals of care. 

Collaborative management of older people

Over half of Australians who undergo emergency laparotomy are aged 65 or above, an age at which the perioperative mortality of acute abdominal conditions begins to increase. Strong evidence demonstrates that comprehensive geriatric assessment and management reduces mortality and length-of-stay for elderly patients. 

A collaborative model, like the now well-embedded orthogeriatric pathway, should become routine for older people needing emergency abdominal surgery, with the Standard recommending early engagement of a geriatrician or other physician skilled in the perioperative care of older people. In rural settings, this might be an appropriately trained rural generalist or general practitioner.

Specialist clinician support for a new Standard

Associate Professor Matthew Burstow, Director of General Surgery at Logan Beaudesert Health Service, and member of the topic working group, believes a standardised approach to emergency laparotomy is overdue. ‘It is time for emergency surgery patients to be given the support, structure and institutional accountability that has been routine in elective surgery for some time,’ he stated. ‘The Standard is not just another set of indicators but instead provides a framework to support delivery of optimal clinical care to a high risk and vulnerable patient group.’

Dr Chuan-Whei Lee, Anaesthetist and Pain Medicine Specialist at Royal Melbourne Hospital, advocates for improved preoperative planning and structured decision making to improve the quality of care. ‘The Emergency Laparotomy Clinical Care Standard is crucial for supporting a coordinated, multidisciplinary approach that spans the entire perioperative journey,’ she said. ‘It defines expectations of rapid escalation and risk stratification for time-sensitive conditions, while embedding values-based practice, through shared decision making and setting goals-of-care, ensuring a patient-centred approach to treatment.’ 

Using the Standard

Along with the quality statements, the Standard contains a set of clinical indicators to enable health services to monitor care delivery and to support implementation of local quality improvement initiatives. The indicators are aligned with those of ANZELA-QI and NELA, to facilitate consistency in measurement efforts for health services adopting the Clinical Care Standard and participating in the clinical quality registry. 

While not mandatory, the role of Clinical Care Standards within the context of acute hospital accreditation provides a further incentive for uptake of the Standard. The combination of these initiatives provides an important opportunity for Australian health services, across a diverse range of contexts and settings, to improve both experiences and outcomes for people who require emergency abdominal surgery.

Dr Clare Skinner is an emergency physician in Northern Sydney. 

Professor David Watters AM OBE is a Distinguished (Alfred Deakin) Professor at Deakin University and Barwon Health, and Director of Surgery at Safer Care Victoria.

Dr Phoebe Holdenson Kimura is a Medical Advisor to the Australian Commission on Safety and Quality in Health Care and a general practitioner based in Sydney.