Organisational factors and mortality after an emergency laparotomy: multilevel analysis of 39 903 National Emergency Laparotomy Audit patients
| Autor: | Michael P.W. Grocott, Dave Murray, C.M. Oliver, T.E. Poulton, Mike G. Bassett, Suneetha Ramani Moonesinghe, I. D. Anderson |
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| Rok vydání: | 2018 |
| Předmět: |
Adult
Male medicine.medical_specialty Adolescent medicine.medical_treatment 030230 surgery 03 medical and health sciences Young Adult 0302 clinical medicine Case mix index Laparotomy Medicine Humans 030212 general & internal medicine Hospital Mortality Prospective Studies Prospective cohort study Aged Geriatrics Aged 80 and over Perioperative medicine business.industry Odds ratio Perioperative Middle Aged Anesthesiology and Pain Medicine Logistic Models Cohort Emergency medicine Multilevel Analysis Female Emergencies business |
| Zdroj: | British journal of anaesthesia. 121(6) |
| ISSN: | 1471-6771 |
| Popis: | Background Studies across healthcare systems have demonstrated between-hospital variation in survival after an emergency laparotomy. We postulate that this variation can be explained by differences in perioperative process delivery, underpinning organisational structures, and associated hospital characteristics. Methods We performed this nationwide, registry-based, prospective cohort study using data from the National Emergency Laparotomy Audit organisational and patient audit data sets. Outcome measures were all-cause 30- and 90-day postoperative mortality. We estimated adjusted odds ratios (ORs) for perioperative processes and organisational structures and characteristics by fitting multilevel logistic regression models. Results The cohort comprised 39 903 patients undergoing surgery at 185 hospitals. Controlling for case mix and clustering, a substantial proportion of between-hospital mortality variation was explained by differences in processes, infrastructure, and hospital characteristics. Perioperative care pathways [OR: 0.86; 95% confidence interval (CI): 0.76–0.96; and OR: 0.89; 95% CI: 0.81–0.99] and emergency surgical units (OR: 0.89; 95% CI: 0.80–0.99; and OR: 0.89; 95% CI: 0.81–0.98) were associated with reduced 30- and 90-day mortality, respectively. In contrast, infrequent consultant-delivered intraoperative care was associated with increased 30- and 90-day mortality (OR: 1.61; 95% CI: 1.01–2.56; and OR: 1.61; 95% CI: 1.08–2.39, respectively). Postoperative geriatric medicine review was associated with substantially lower mortality in older (≥70 yr) patients (OR: 0.35; 95% CI: 0.29–0.42; and OR: 0.64; 95% CI: 0.55–0.73, respectively). Conclusions This multicentre study identified low-technology, readily implementable structures and processes that are associated with improved survival after an emergency laparotomy. Key components of pathways, perioperative medicine input, and specialist units require further investigation. |
| Databáze: | OpenAIRE |
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