Title: A mixed-methods convergent parallel study into the impact of emergency laparotomy for older adults living with frailty
Funder: Health Education England

Abstract: Background Emergency laparotomy is a big operation to open the abdomen. Older people are more likely to require emergency laparotomy but are at greater risk of adverse outcomes including death, especially if they are identified as frail on the Rockwood Clinical Frailty Scale (CFS)1,2,3. Current evidence focusses on clinical outcomes and follow up often ceases at 90-days. Longer-term outcomes are less well understood, and there is a paucity of research into patient experience following emergency laparotomy. No literature exists to inform holistic postoperative care that meets both patient need and expectation. As the average population age increases, the number of older people requiring emergency laparotomy will continue to rise4. There is an urgent need for a more comprehensive understanding of the impact of emergency laparotomy for older, frail people, to design effective, patient-centred services for this vulnerable group5-8. Aim To develop a comprehensive understanding of the experience and longer-term outcomes following emergency laparotomy for frail older people Methods This study will be conducted using a mixed-methods convergent parallel design, consisting of two distinct workstreams. The qualitative and quantitative data collection will be undertaken concurrently, independently and with equal weighting. Merging of the two strands will occur after separate data analysis, using a simultaneous bi-directional synthesis framework to develop completeness and provide insight into the characteristics, factors and perceptions that influence recovery for this group of patients in the context of objective clinical outcomes. Workstream one: Phase one: 30 participants aged 65 years and over with a CFS of 5+ who have undergone emergency laparotomy be recruited from a minimum of 11 hospital sites across the UK using maximum-variation purposive sampling. Semi-structured interviews will be undertaken at 3 weeks from the date of surgery. Reflexive thematic analysis will be used to identify key themes relating to the recovery process and patient perception of success. Phase two: 8-10 participants aged 65 years and over with a CFS of 5+ will be heterogeneously sampled to undertake semi-structured interviews at 3, 6 and 12-months. Longitudinal Interpretative Phenomenological Analysis will be used to develop an in-depth understanding of lived experience in the 12 months following surgery. Workstream Two: Data from the National Emergency Laparotomy Audit (NELA) will be linked to Office for National Statistics and Hospital Episode Statistics data to determine time-to-mortality and time-to-readmission following surgery. Approximately 7600 patients aged 65 years+ with CFS 5+ will be included, using records from the NELA dataset entered between March 2017 and March 2020. Outcome measures will be analysed using mixed-effects multivariable Cox proportional baseline hazards models and reported via a Kaplan-Meier survival plot. Anticipated impact and disseminationThe findings of the study will be published in high-impact surgical and geriatric medicine journals and presented at conferences nationally and internationally. They will also be shared with key organisations responsible for the planning and funding of peri-operative care delivery models. A comprehensive understanding of the implications of emergency laparotomy for older, frail patients will facilitate individualised care and recognition of areas for improvement to existing care pathways.

Lay abstract: This research aims to understand the impact of emergency laparotomy on older people living with frailty. An emergency laparotomy is a big operation that opens the abdomen. Reasons for an emergency laparotomy include a burst or blocked bowel.Every year 30,000 people in the UK have an emergency laparotomy. Half of these people are aged 65 years or above. Unfortunately, older adults are more likely to die or have problems following the surgery. These risks are even higher if that person is frail. Frailty is a chronic condition caused by a build-up of other health problems. People who are frail rely on others to help with day-to-day activities. A person can be mildly, moderately or severely frail. The more frail a person becomes, the less strength they have to recover from an illness or injury. A quarter of older people having an emergency laparotomy are frail and the risk of death afterwards is high. Those who survive tend to spend a long time in hospital. Many need carers or a move into a care home when discharged from hospital. Most research into emergency laparotomy only looks at first 90-days following the operation. We do not know what happens after this. We also do not know how the operation impacts on people's day-to-day lives once they leave hospital or how well they recover from the surgery. We need to know more so that we can improve the experience and reduce the risk of problems occurring at home. In this study, patients who have had an emergency laparotomy will be invited to be involved in telephone or face-to-face interviews. They will be asked to talk about their experience of emergency laparotomy. Some of these patients will be contacted every few months for a year after the surgery. Large hospital databases will also be used to determine how long people survive after this kind of operation, and whether they need to come back into hospital. This information will help us to better understand the experience of emergency laparotomy from the patient's point of view. It will help us to provide patients with information on what to expect after the surgery and what we can do to improve the recovery process. It is also important to be able to recognise which patients may not recover well after surgery. This will enable clinicians to provide additional support to try and reduce the risk of death or hospital admission. It will also help us to identify which people might benefit from palliative care input, like with other health problems such as cancer and heart disease. Older people living with frailty who had recently undergone emergency laparotomy were involved in developing this research proposal. They all felt it is an important area for research, and that it is essential to hear the patient's story. They all agreed to be involved in developing documents for the study and give further input on the study design in the future. They also agreed to help plan how to share the findings of the study. The research findings will be shared in nursing and medical journals. It will be presented at conferences and teaching events. I will apply to be supported by the Association of Surgeons of Great Britain and Ireland, the largest emergency laparotomy society in the UK, that will help share information to surgeons, other health professionals and patients. Written plain English summaries, presentations and social media will be used to share the research findings with patients and the public. This study findings will help organisations re-shape services to better meet the needs of older people living with frailty.

Research activity codes: 6.4 SURGERY;7.1 INDIVIDUAL CARE NEEDS
Health categories: GENERIC HEALTH RELEVANCE