Title: The BCAE Study: Best Care for Abdominal Emergencies
Funder: Department of Health and Social Care

Abstract: Research question What is the best care for patients with abdominal emergencies? Background Abdominal emergencies are common, involving perforation, obstruction or ischaemia of the bowel, often needing life-saving emergency surgery, with a large incision to access the abdominal cavity called &ldquo;laparotomy&rdquo;. This procedure is high risk with 10% mortality rate. 30,000 emergency laparotomies are performed each year in England and Wales. Since 2013, the National Emergency Laparotomy Audit (NELA) has set standards of care and monitored outcomes for emergency laparotomy, which has reduced mortality from 11.8 to 9.5%. However, patients who do NOT have a laparotomy are not well characterised and do not receive the prioritised care patients having surgery do, even though their condition is no less severe. Initial research has shown a surprisingly large group of patients (32%) with an intestinal emergency do not have surgery and have 30-day mortality of 63%. There are two additional groups of patients admitted with abdominal emergencies: patients having keyhole surgery and patients for whom any treatment would be futile and would benefit most from an end of life care pathway. Clearly further work is needed to investigate the management of ALL patients with intestinal emergency, to optimise care for each group of patients. Aims and Objectives The aim of this study is to improve care for all patients with an intestinal emergency, irrespective of whether they have surgery. The objectives are to: Identify all patients with conditions qualifying for emergency abdominal surgery, both laparotomy and keyhole (laparoscopic) procedures, regardless of whether they had surgery or not. Provide mortality rates for different treatment options, and analysis of short- and long-term outcomes. Define patient sub-groups with similar health characteristics based on clinical data and an established risk index. Use statistical analysis to predict the risk of death for each patient group and treatment option, which will allow us to identify the best care pathways for each cluster. Methods This is a retrospective cohort study utilising electronic hospital records. We will identify patients with a qualifying condition for emergency abdominal surgery using diagnosis and procedure codes. We will extract relevant demographic data, blood tests, vital signs, diagnosis and procedure codes. Data will be pseudonymised on extraction. Statistical tests and logistic regression modelling will be used to calculate robust mortality estimates for each care option and to identify each patient group s significant characteristics. Additionally, we will investigate the correlation between demographic and clinical parameters and outcomes to identity the optimal treatment based on patient characteristics. Timelines for delivery Over 18 months, we will perform the data extraction and analysis, repeatedly consult with patient representatives and communicate and disseminate results to stakeholders, including the public. Impact and Dissemination We will gather the information needed to create new care pathways using Quality Improvement methodology based on our findings. Initially disseminate our findings through the Wessex Emergency Laparotomy Collaborative. Results will provide evidence for the benefits of each approach, not only benefiting patients but significantly reducing length of stay and, hence, hospital costs.

Lay abstract: Problem Intestinal emergencies are common and potentially life-threatening. Patients frequently need emergency abdominal surgery, involving a large cut to access the abdomen called a laparotomy. Emergency laparotomy has a high (10%+) risk of death, and is more dangerous than open-heart surgery. In recent years, a national audit has set high standards of care, leading to better laparotomy outcomes. Recently, keyhole surgery (laparoscopy) instead of laparotomy has been introduced and early data from Portsmouth Hospitals NHS Trust suggests patients may do better with this approach. For various reasons, 1 in 3 patients admitted with an intestinal emergency do NOT have a laparotomy. There are currently no documented, evidence-based care pathways providing alternatives to laparotomy, even though risk of death may be 5 times higher. This problem originates from a lack of information on other treatments and their risks. Without this information, it is difficult for surgeons to advise patients and relatives on the merits of other treatments compared to laparotomy. As a result, these patients do not routinely receive the same quality of care. Understanding this group more clearly may result in identifying patients who could in fact have done better with surgical or non-surgical treatments (for example, have infection drained under X-ray or ultrasound) instead of just limited or end of life care. PPI priorities Our PPI representatives identified 3 key needs: patients lack of awareness of the real risks of laparotomy, limited information on alternative treatments, and how to communicate this clearly in a high-stress situation. Aim Therefore, our aim is to find the best care for all patients with an abdominal emergency by: 1. understanding the outcomes for all patients admitted with an intestinal emergency including those who do not have surgery, and 2. identifying patient and admission characteristics of the 4 groups of patients (laparotomy, laparoscopy, non- surgical treatments, and end of life care), in order for surgeons to be better informed when discussing the choices and risks with their patients. Methods To achieve this, we have a wealth of electronically-collected data in PHT over 6 years on approximately 2500 patients, giving us a large sample size. Data include comorbidities, routine blood tests, vital signs, diagnoses, procedures and outcomes. Dissemination This data will be analysed by a health modelling team looking at factors that could predict the best care for these patients. This will inform the creation of clear, evidence-based patient information and the development of care pathways that we will share and publish. Finally, this study will provide evidence to justify a proposed larger multi-centre study to follow, where we intend to further develop and test the four care pathways and help select patients for best care based on admission data.

Research activity codes: 7.3 MANAGEMENT AND DECISION MAKING
Health categories: ORAL AND GASTROINTESTINAL