"It showed how we can improve and approach any obstacles / problems in delivering the bundle of care and how to plan better to implement the ELC bundle."
Participating hospital partner
Overview

The Emergency Laparotomy Collaborative (ELC) is an AHSN-led programme funded by the Health Foundation as one of seven national ‘Scaling Up Improvement Awards for 2015’. The programme involves the spread and adoption of the evidence-based Emergency Laparotomy Pathway Quality Improvement Care (ELPQuiC) bundle, from four hospitals to 28 hospitals / 24 NHS trusts within three AHSN regions: Kent Surrey Sussex, Wessex, and West of England.

Our ambition is to improve standards of care for patients undergoing emergency laparotomy surgery, reduce mortality rates, complications and hospital length of stay, while encouraging a culture of collaboration across the regions and embedding quality improvement skills to ensure sustainability of change.

The programme regularly brings 100+ staff from emergency departments, radiology, acute admission units, theatres, anaesthetics and intensive care together through a series of collaborative learning events using the IHI Breakthrough Series Collaborative Model for Achieving Breakthrough Improvement (Institute for Healthcare Improvement, 2003).

Key outcomes achieved so far include significant reductions in mortality rate and length of stay:

  • Risk adjusted mortality rate fell by 18% in the first three months. We are looking to see if this reduction is sustained.
  • Length of stay has fallen by 8.5% (1.5 days), equating to non-cash releasing savings of £1.3m in the first nine months.
Challenge/problem identified

The Emergency Laparotomy Collaborative (ELC) was an AHSN-led programme originally funded by the Health Foundation as one of seven national ‘Scaling Up Improvement Awards for 2015’. The programme involved the spread and adoption of the evidence-based Emergency Laparotomy Pathway Quality Improvement Care (ELPQuiC) bundle, from four hospitals to 28 hospitals / 24 NHS trusts within three AHSN regions: Kent Surrey Sussex, Wessex, and West of England.

ELC’s ambition was to improve standards of care for patients undergoing emergency laparotomy surgery, reduce mortality rates, complications and hospital length of stay, while encouraging a culture of collaboration across the regions and embedding quality improvement skills to ensure sustainability of change.

The programme connected 100+ staff from emergency departments, radiology, acute admission units, theatres, anaesthetics and intensive care together through a series of collaborative learning events using the IHI Breakthrough Series Collaborative Model for Achieving Breakthrough Improvement (Institute for Healthcare Improvement, 2003).

Key outcomes achieved include significant reductions in mortality rate and length of stay, for example:

Risk adjusted mortality rate fell by 18% in the first three months.

Length of stay has fallen by 8.5% (1.5 days), equating to non-cash releasing savings of £1.3m in the first nine months.

Actions taken

The ELC programme used Quality Improvement methodology to support the scaling-up of the ELPQuiC care bundle (now known as the ELC care bundle) across the three AHSN regions.

ELC developed a suite of tools and delivered a training programme consisting of the generation and interpretation of run-charts, SPC charts and a comparative dashboard. The training programme also covered subjects such as PDSA cycles, process mapping and human factors.

National Emergency Laparotomy Audit (NELA) reports progress on key measures annually, so to provide more frequent access to performance data, ELC distributed a comparative dashboard showing adherence to the ELC care bundle and patient outcome measures on a quarterly basis. This allowed hospital teams participating in our programme to use the data to improve quality of care and patient outcomes. Trusts also shared their progress at ELC collaborative learning events, enabling open dialogue, group reflection and celebration of successes.

The initial project’s evaluation was published in JAMA, March 2019:

Evaluation of the Collaborative Use of an Evidence-Based Care Bundle in Emergency Laparotomy | Surgery | JAMA Surgery | JAMA Network

https://jamanetwork.com/journals/jamasurgery/fullarticle/2728194

Impacts/outcomes

Patient impact included:

Risk adjusted mortality rate fell by 18% in the first three months.

Length of stay reduced by 8.5% (1.5 days).

Of the 4,165 patients who had an emergency laparotomy at a participating hospital between 1st October 2015 and 30th September 2016, over 98% received at least one aspect of the care bundle.

Consultant led care improved by 14.5%, meaning four out of five patients had a senior surgeon and anaesthetist present in theatre.

Three quarters of the sickest patients reached theatre within two hours of decision to operate.

Financial impact:

The observed length of stay improvements mentioned above equate to non-cash releasing savings of £1.3 million in the first nine months. Health economics analysis based on initial findings, suggested that every £1 spent will result in approximately £4.50 benefit to the wider health and social economy.

Collaboration:

The ELC programme was mentioned in NHS National Director of Patient Safety Dr Mike Durkin’s opening speech at the Patient Safety Congress in 2016. ELC programme was presented at the 2016 IHI Conference in Gothenburg, at the Royal College of Anaesthetists, and at the 2016 Evidence Based Perioperative Medicine (EBPOM) Congress. The ELC programme has been published in the report Patient Safety Collaboratives – Making Care Safer for All.

The evidence supported the selection of ELC intervention as an AHSN Network national programme between April 2018-March 2020. All AHSNs committed to supporting trusts in their regions to implement the Emergency Laparotomy Collaborative care bundle.

At the end of the AHSN Network national programme 97% of eligible sites had adopted the bundle and more than 50,000 patients benefited over the course of the programme (figures from April 2018-March 2021).

Start and end dates

March 2015 – August 2017.

Contact for help and advice

Jo Wookey, Senior Programme Manager, Kent Surrey Sussex AHSN: E: jowookey@nhs.net

Rick Fell, Communications Lead, Kent Surrey Sussex AHSN: E: rickfell@nhs.net