A new national Standard will improve care for more than 15,000 Australians each year who are among the sickest patients in a hospital and need urgent surgery for life-threatening abdominal conditions.
The Australian Commission on Safety and Quality in Health Care is launching the first Emergency Laparotomy Clinical Care Standard at the Royal Australasian College of Surgeons Annual Scientific Congress in Perth today, with the aim of driving a coordinated approach to care.
The Standard focuses on emergency laparotomy for urgent conditions affecting the gastrointestinal tract, like a bowel obstruction, perforation or serious internal bleeding.
Unlike other life-threatening medical emergencies such as stroke or cardiac events, evidence-based clinical pathways for urgent abdominal conditions are not consistently embedded in practice. This is despite emergency laparotomy being one of the highest-risk surgical procedures, with recovery taking weeks or months, and patient outcomes varying significantly.
In Australia, the mortality rate for people undergoing the procedure is almost 7% overall, and it is substantially higher for people who have sepsis or who are older or are frail.[i]
Survival, recovery and the long-term impact on quality of life can be significantly improved with better pathways of care for critically unwell patients.
Commission Medical Advisor Dr Phoebe Holdenson Kimura said the Standard is a call to action for health services to consider the entire patient journey, from when a critically ill patient presents and is assessed in the emergency department, through to surgery, postoperative care and discharge.
“Timeliness is crucial, and so is understanding the patient’s level of risk. The use of risk scores can create a common language and support decision-making to help ensure patients receive appropriate care. For high-risk patients, this includes having a consultant surgeon and consultant anaesthetist for their surgery and will often mean admission to ICU after their operation;” she said.
“Older people have the highest risk. More than half of emergency laparotomy patients are over 65 years old, and many are frail. For these patients, involving a geriatrician to help manage co-morbidity is shown to reduce mortality and length of their hospital stay.
“We’ve seen excellent outcomes for hip fracture patients using an orthogeriatric model of care. The Standard highlights the same opportunity for collaborative management in older people who have had emergency abdominal surgery. This will support better decisions, fewer complications and give patients the best chance of a good recovery,” Dr Holdenson Kimura explained.
Professor David Watters, a surgeon with Deakin University and Safer Care Victoria, said an hour or two can make a big difference to the chances, or degree, of recovery after emergency laparotomy.
“I’ve seen first-hand how patients can suffer because of late presentation, delayed diagnosis or referral, late recognition of complications, or failure to manage their other medical conditions,” he said.
“The Clinical Care Standard is important because it offers a comprehensive approach to providing the best care across the whole patient journey.
“All health services, even those already delivering many of these aspects of care, will find the Standard offers an opportunity to reduce variation by ensuring consistency in how to provide the best care to the right patients at the right time and in the right place.”
Dr Holdenson Kimura added: “Unfortunately for some high-risk emergency laparotomy patients, the risks of surgery outweigh the benefits. The care team must quickly assess the situation and involve the patient and their family in treatment decisions, especially when surgery may not be beneficial.
“These discussions can be difficult, but it is so important that skilled clinicians help these patients and their families to understand the risks, including the likely impacts on their quality of life. Understanding what matters to the patient is essential in ensuring that treatment choices are well-informed, realistic and consistent with patients’ preferences and values.”
Dr Holdenson Kimura looks forward to better outcomes for patients with the new Standard.
“There is robust evidence in Australia and internationally that when we provide the care described in the new Standard, it is a better outcome for everyone – with lower mortality rates, shorter hospital stays and a higher likelihood of patients returning home to their normal life and activity,” she said.
The Standard was developed in collaboration with key stakeholders including the Clinical Quality Registry, the Australian and New Zealand Emergency Laparotomy Audit – Quality Improvement (ANZELA-QI), which is updating their data collection and key indicators in line with the Standard.