Anaesthesia 2020, 75, 1321–1330 doi:10.1111/anae.

15088

Original Article

Sustaining better care for patients undergoing emergency

laparotomy*
L. C. Jordan,1 T. M. Cook,1,2 S.-C. Cook,3 S. J. Dalton,4 K. Collins,5 J. Scott6 and C. J. Peden7

1 Consultant, 5 Senior Operating Department Practitioner, Department of Anaesthesia and Critical Care, 4 Consultant,
Department of Surgery, 6 Chief Executive, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
2 Honorary Professor, University of Bristol, Bristol, UK
3 Consultant, Department of Critical Care, University Hospital of Wales, Cardiff, UK
7 Professor, Department of Anesthesiology, Keck Medicine, University of Southern California, Los Angeles, CA, USA

Summary
Emergency laparotomy is associated with high mortality. Implementation of an evidence-based care bundle has
been shown to improve patient outcomes. A quality improvement project to implement a six-component care
bundle was undertaken between July 2015 and May 2018. As part of this project, we worked with 27 hospitals in
the Emergency Laparotomy Collaborative. Previous pilot implementation of the same bundle in our hospital
between December 2012 and July 2013 had shown marked improvement, maintained until April 2014, but then
deterioration. Understanding the reasons for this deterioration informed our work to re-implement the bundle
and sustain improvement. A cohort of 930 consecutive patients requiring emergency laparotomy between
October 2014 and April 2019 were included. Baseline data were collected between October 2014 and June
2015, and the bundle was re-implemented in July 2015. Thirty-day mortality decreased from 11% in the
baseline group to 7.3% after bundle implementation. Hospital length of stay decreased from 19.5 to 17.9 days.
Full bundle compliance improved from < 60% to > 80% for all patients, with improvement in application of all
individual bundle components. This study provides further evidence that outcomes for high-risk surgical
patients can be improved with an evidence-based care bundle, but attention must be paid to maintaining
bundle compliance. Issues around sustaining improvement must be considered from project initiation.

.................................................................................................................................................................
Correspondence to: L. C. Jordan
Email: lesleyjordan@btinternet.com
Accepted: 15 April 2020
Keywords: care bundle; emergency laparotomy; quality improvement; sustainability
*Presented in part at the Association of Anaesthetists’ Winter Scientific Meeting, London, UK, January 2019.
Twitter: @drlesleyjordan; @doctimcook; @SaraCatrinCook; @daltonsurgeon; @PedenCarol

Introduction whether improvement is sustained, or indeed how to sustain

Emergency laparotomy is one of the highest risk operations
performed, with much greater morbidity and mortality than
similar elective procedures [1–7]. Several studies have been
undertaken recently in an attempt to improve outcomes for
these patients [8–14], and there is now increased focus on
this group of patients worldwide [15]. Whereas some
studies have shown improvement in delivered processes
and outcomes [8–10, 13], there is little information about
improvement in this high-risk patient group.
The Royal United Hospitals Bath NHS Foundation Trust
(RUH) has a long-standing interest in emergency
laparotomy surgery, and has contributed to raising
awareness of its importance [5, 6, 8, 16–18]. Our hospital
was one of four in the emergency laparotomy pathway
quality improvement care study (ELPQuIC) in 2012–2013
[8], which demonstrated that implementation of an

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evidence-based care bundle for patients undergoing
emergency laparotomy resulted in a significant reduction in
risk-adjusted 30-day mortality. During this 8-month project,
we achieved 60% full bundle compliance and crude
mortality fell from 14.6% to 12.5%. Bundle compliance
continued after the study, and the crude mortality
decreased further to 5% over the next 6 months [16]. Mean
hospital length of stay fell from 19 to 17 days.
Improvement was supported by care bundle
implementation using several innovative processes such as
the ‘Bath boarding card’ [19], staff engagement, and timely
sharing of results. Six months later, we believed that the new
processes were embedded. However, key members of staff
then left, including data collectors, and at the beginning of
2015 it was apparent that bundle compliance had fallen. We
re-measured bundle compliance and outcomes during
October–December 2014, which confirmed a fall in
compliance with all measures and a rise in mortality to 11%.
In response, we aimed to relaunch the bundle using quality
improvement (QI) methods, but with particular emphasis on
sustainability. We also joined the Emergency Laparotomy
Collaborative in September 2015, which scaled up the
ELPQuiC project across 28 Hospitals [13]. Participating in
the Emergency Laparotomy Collaborative ensured
organisational support and prioritisation, with the Trust’s
Chief Executive Officer becoming the project’s executive
sponsor.
In this paper, we share our experiences and the lessons
learned in this process. These have widespread relevance as
this patient group is both large and high risk, with many
challenges to improving care [1–7].
Methods
The RUH is a 759-bed general hospital providing acute
services to a population of 500,000. We defined an
emergency laparotomy using the inclusion and exclusion
criteria in the UK National Emergency Laparotomy Audit
(NELA) [14]. All consecutive patients who underwent
emergency laparotomy were included in the study. Patients
were followed until discharge or death. Mortality was
defined as death within 30 days of surgery.
In April 2015, we had identified a decline in
performance in our emergency laparotomy care bundle,
confirmed by full review of all emergency laparotomies
between October and December 2014. This was associated
with a rise in mortality from 5% to the national average of
11%. We therefore undertook an analysis of the reasons
behind both our decreased bundle compliance and
increased mortality, including interviews with
multidisciplinary team members. Based on our findings, we
1322
established a re-engagement plan using the structure of the
National Health Service sustainability model [20].
We re-established an emergency laparotomy QI team
in July 2015 with the aim of sustaining full bundle
compliance in 80% of patients. We also aimed for a 25%
reduction in 30-day crude mortality from 11% to 8%, and a
decreased hospital length of stay by 2 days, to be achieved
by December 2017. A multidisciplinary steering group was
established consisting of an overall lead and leads from the
anaesthetic, surgical, ICU, care of the elderly, operating
theatre and ward departments, who each had defined roles
and responsibilities. The team also included a
representative of the trust QI team and the Trust’s Chief
Executive Office as executive sponsor.
We presented information on what had been
achieved, and how the gains were lost with poor bundle
compliance, to all clinical teams, emphasising the need to
take action to reverse this situation. The care bundle was
prominently displayed in all relevant clinical areas and
circulated to all relevant teams (Fig. 1). Tools developed
locally during the ELPQuIC [8] study to generate
engagement with the bundle and to ensure compliance
were relaunched, and further developed using the Model
for Improvement [21] with repeated small-scale tests of
change. Changes to routine practice were not made until
multiple tests had been performed with feedback from
staff.
Following our analysis of the reasons for failure to
sustain improvement, the changes introduced included:
1 The relaunch of the Bath boarding card [19] to assist
with adherence to risk assessment, lactate
measurement, rapid decision-making and timely
transfer of patients to the operating theatre. This
developed into the ‘emergency laparotomy passport’,
including guidance on postoperative care and routine
critical care admission.
2 The Bath boarding card triggered a multidisciplinary
team discussion before offering surgery if the
predicted mortality risk was > 20%.
3 A Rockwood frailty assessment [22] of each patient was
added to the Bath boarding card. If debilitating frailty
(score ≥ 6) was identified, this triggered a
multidisciplinary team discussion before surgery was
offered.
4 Prompt identification and management of sepsis was
highlighted as a key improvement objective.
5 The ‘code laparotomy’ term was agreed with radiology
services to prioritise patients, ensuring a CT scan was
performed within an hour of request.
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Emergency laparotomy bundle

lactate and screen for sepsis.

P-POSSUM and

frailty 6 or more

bo

go

Figure 1 Royal United Hospital emergency laparotomy bundle. NEWS, National Emergency Warning Score; NELA, National
Emergency Laparotomy Audit; MDT, multidisciplinary team meeting; LiDCO, lithium dilution cardiac output; TT, tracheal tube;
NG, nasogastric; NJ, nasojejenal.

6 A ‘traffic light’ system was devised that prompted a trolley was highlighted to theatre staff and
standardised team response when emergency theatre anaesthetists.
capacity was inadequate for the cases booked. This 10 We re-engaged the ICU consultants with an agreement
empowered theatre staff to implement actions to for routine critical care admission for all emergency
prioritise emergency patients over elective cases, laparotomies receiving active treatment
including cancelling elective surgery cases in other postoperatively, irrespective of predicted risk.
theatres (Fig. 2). Intensive care bed capacity was increased, in part to
7 Metrics on time to theatre for all emergency cases were facilitate this change in practice. If no ICU bed was
collected as a balancing measure, to ensure other available, a structured recovery pathway was
emergency conditions were not disadvantaged. implemented that provided invasive monitoring in the
8 Use of goal-directed fluid therapy as part of the bundle recovery ward, mandatory regular medical review, and
was facilitated by the anaesthetic assistants senior review and decision-making at 6 hours to
automatically setting up goal-directed fluid therapy determine whether the patient could return to the
equipment for all emergency laparotomy cases. ward or should await ICU bed availability.
9 A ‘laparotomy trolley’ was introduced that included 11 Re-instatement of a structured review of all emergency
ICU-specific tracheal tubes, feeding tubes and goal- laparotomy deaths to identify deficiencies in bundle
directed fluid therapy disposables. The use of the compliance and any areas for improvement.

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Anaesthesia 2020, 75, 1321–1330 Jordan et al. | Sustaining better care for emergency laparotomy

Figure 2 Royal United Hospital emergency theatre traffic light system. SAU, surgical assessment unit.

Staff were supported to learn QI methodologies by
attending the comprehensive trust QI programme, and to
attend the Emergency Laparotomy Collaborative meetings
[13].
Collection of data was facilitated by provision of a
dedicated tablet computer in the emergency theatre. Data
were entered directly into the NELA database [14] by the
teams at the time of surgery. Reliable case ascertainment
and completion of data was facilitated, and pursued if
missing, by the trust QI team. Relevant postoperative data
were routinely collected until discharge, enabling timely
data retrieval, review and feedback.
Primary outcome measures were crude- and risk-
adjusted in-hospital 30-day mortality and length of stay.
Secondary outcomes were compliance with specific
elements of the care bundle. Baseline data were collected
between October 2014 and June 2015, and
implementation data between July 2015 and April 2019.
The number of procedures performed per quarter was
recorded to ensure accurate case ascertainment, and to
provide reassurance that any improvements in outcome
resulted from real process improvement and not more
stringent patient selection.
All data were exported from the NELA database and
converted into run charts for analysis, facilitated by a run
chart tool provided by the Emergency Laparotomy
Collaborative team [13]. Data were available on the NELA
database immediately after they had been entered,
downloaded regularly, and reviewed each month. The run
charts consisted of monthly compliance, displayed in time-

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series graphs. These were inspected for special cause Results

variation from external factors [23]. Significant
improvements or deteriorations were based on the seven-
point rule of consecutive values above or below the median
[24]. This is a common method for demonstrating
improvement in processes in real-world QI projects where
control of all variables is not possible, as it is in more
traditional research experiments. Run charts were also
inspected for decrease in variation in measures over time,
demonstrating reliability of process integration.
Performance was reported to the teams each month using
the run charts and an infographic newsletter (Fig. 3). Patient
stories were recorded and fed back to clinical staff and the
trust board.
Our hospital collects data for the NELA database [14],
which is part of the UK Healthcare Quality Improvement
Program and has national ethical approval for that dataset.
Additional data collection during the Emergency
Laparotomy Collaborative were assessed under UK national
ethical guidance [25], which confirmed that the project fell
outside the definition of research and required no further
ethical approval or informed consent. As a participant
centre in the Emergency Laparotomy Collaborative study,
the work was registered with the local research and ethics
panel. This report includes only those data routinely
collected for the above purposes, and those used to
monitor clinical performance. The study was structured and
reported in-line with the SQUIRE guidance for quality
improvement projects [26].
Results from 930 patients undergoing emergency
laparotomy between October 2014 and April 2019 were
analysed, including baseline data from 153 patients
between October 2014 and June 2015, and data from 777
patients between July 2015 and April 2019 after relaunch of
the bundle.
The characteristics of the patients in the two periods
were similar (Table 1). The key findings of interviews and
investigation into our failure to sustain bundle compliance,
and areas on which we focused action, are summarised in
Table 2.
The mean number of laparotomies remained
consistent at 51 per quarter. The statistical process control
chart demonstrates only normal variation, with no decrease
in activity that might suggest a change in the rate of surgery
for high-risk patients following relaunch of the bundle
(Fig. 4). Crude 30-day mortality, our primary outcome
measure, fell from 11% to 7.3%, and this improvement was
sustained over an extended period of 46 months up until
April 2019 (Fig. 5). Risk-adjusted mortality decreased from
6.7% to 3.7% after January 2016.
Mean hospital length of stay of survivors decreased by
1.6 days from 19.5 days to 17.9 days.
Following relaunch of the bundle in July 2015, both
individual process components and overall bundle
compliance rose (Figs. 6 and 7). By May 2017, the
proportion of patients receiving all components of the
bundle had risen from < 60% to > 80%. Variation in month-

Figure 3 Infographic newsletter.

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Table 1 Patient characteristics before and after relaunch of Since we relaunched our emergency laparotomy
the emergency laparotomy care bundle. Values are mean programme, we have improved and sustained compliance
(SD) or number (proportion). with a bundle of six components at > 80%, which aligns with
Before After the decrease in mortality and an 8% reduction in hospital
relaunch relaunch
length of stay. We have also noted increased reliability in
n = 153 n = 777
delivery of our standard process, shown by a marked
Age; years 65 (17.4) 64 (17.2)
reduction in the month-to-month variation in bundle
Pre-operative P-Possum 15 (20.4) 15 (20.2)
performance. Bundles are a small group of evidence-based
mortality risk
interventions that, when applied together, may result in
Pre-operative P-Possum 65 (24.3) 66 (24.9)
morbidity risk better outcomes than when implemented individually. In
ASA grade the ELPQuIC study that included our hospital [8], there was a
1 12 (8%) 67 (9%) significant increase in the use of goal-directed fluid therapy
2 52 (34%) 273 (35%) in all four study sites, and an increase in patient admission to
3 58 (38%) 281 (36%) ICU in three of the four sites, associated with the reduction in
4 25 (16%) 144 (19%) mortality. The same bundle was applied across 28 hospitals
5 6 (4%) 12 (2%) in the Emergency Laparotomy Collaborative study, with a
significant improvement in five of the six bundle
components and a corresponding reduction in mortality
and length of stay [13]. The one component that did not
by-month compliance decreased, implying reliable improve was timely administration of antibiotics. While it
implementation. may be appealing to try to isolate the most effective
Postoperative critical care admission increased from components of a bundle, this is not advised; applying
70% to > 90% in all patients, and to 100% for those with a P- bundle science concerns promoting teamwork and
Possum predicted mortality risk of > 5%. redesigning processes to deliver care reliably in different
Emergency laparotomy patients who require surgery in domains [27]. The other sustainability processes described
< 6 h are classed as category B. The average time from in this paper, such as the traffic light system, were not
booking till arrival in theatre for these cases was 3 h. The components of the bundle but were designed to support
improved time to reach theatre for these patients did not and prompt bundle utilisation.
have an impact on non-laparotomy emergency cases of The aim of reliably recording the mortality risk and the
similar urgency, of whom 90% arrived within the intended Rockwood Frailty assessment was to promote consultant
time-frame. involvement and critical care admission for high-risk cases,
as well as to increase the quality of patient and family
Discussion involvement and shared decision-making. There has been
The mortality for our patients undergoing emergency no change in our policy with regard to operating on high-
laparotomy reduced by 30% to well below the national risk cases since relaunch of the bundle, except that
average [14], and better than that achieved in the consultant involvement is mandated. This is demonstrated
Emergency Laparotomy Collaborative [13]. These by similar proportions of ASA 4-5 cases before and after
improvements have been sustained now for nearly bundle re-implementation, as well as the number of
4 years. The changes were achieved by regular feedback laparotomies performed. Rather, the Bath boarding card
of outcomes, process and bundle compliance to theatre facilitated accurate assessment of risk and frailty and has
teams. Although not measurable, it was apparent that this driven improvement in consultant-delivered care, timely
led to improved engagement of staff and enthusiasm to surgery and admission for postoperative critical care.
cooperate with pathway processes. Using QI Since 2012, we have now twice reduced our local
methodology to test ideas, and involve the staff in hospital mortality for a high-risk group of patients to almost
implementing changes, led to ownership of the work by half of the national mortality rate. Hospital length of stay has
the clinical teams. Regular meetings and review of the also reduced on each occasion. These clinically-relevant
data enabled identification and prompt actions to resolve improvements have been achieved on both occasions by
issues underlying process concerns, such as shortage of involvement of multidisciplinary teams in a program of
boarding cards on wards or shortage of goal-directed change supported by robust QI processes including
fluid therapy equipment. colleague engagement, care bundle implementation,

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Table 2 Analysis of reasons for decreased bundle compliance in 2014–2015.

Problem identified
Single data-collection nurse
left with no replacement or
funding
No ownership by teams of
NELA data collected
Trainee project lead left
Senior clinical lead left
Changeover in all staff in
clinical teams (anaesthesia,
critical care and surgery and
operating rooms) bundle
memory decayed
NELA, National Emergency Laparotomy Audit; CEO, Chief Executive Officer.
Consequence
No routine or reliable
collection of data, no
individual responsible
Data not believed
Timely feedback to teams lost
No awareness of decreasing
performance
Lost oversight of the project
Innovative practices lost and
returned to pre-ELPQuIC [8]
status quo
Corrective action
A robust measurement strategy was developed to ensure full case
ascertainment in the NELA database
Tablet computer placed in emergency theatre and data entered at
time of surgery by the clinical team. Patients followed up until
discharge by hospital QI team and complete data collection
finalised promptly so available for review and timely feedback
Embedded an effective communication strategy to ensure staff were
aware of processes and outcomes, particularly targeted at
changeover of staff. Performance regularly fed back in timely
manner
New multidisciplinary leadership of the project established with a
steering group
Hospital CEO engaged to ensure organisational support, visibility of
project and alignment of goals
Alignment of processes to make it easier to ‘do the right thing’.
Standardisation of processes and equipment
Visible feedback of performance data
Regular review of performance by multi-disciplinary team identified
issues and promptly addressed decreases in bundle compliance

measurement of compliance and feedback. The fact that
bundle compliance increased during both periods of
improvement in mortality, and mortality rose dramatically
when bundle compliance waned, strongly suggests that the
mortality improvement is a direct result of the QI processes
undertaken. Our experience highlights the fact that quality
improvement may only be temporary if active efforts to
sustain improvements are not made. It is important
therefore to refocus efforts from quality improvement to
quality improvement and maintenance.
To maintain our improvement, care bundle compliance
continues to be monitored and results are fed back
regularly. As part of computerising our emergency theatre
booking process, we are embedding an electronic
boarding card that triggers and mandates care bundle
actions on the ward before an emergency laparotomy can
be booked into the operating theatre. Care bundle
compliance is routinely reviewed at surgical governance
meetings and is displayed in the operating theatre. A formal
standard operating procedure (SOP) has been established
for all emergency laparotomy patients. This SOP is
presented to all new surgical and anaesthetic team
members as part of their induction, and will soon be
supported by a video to ensure that new staff understand
processes and expectations.
On both occasions that we re-applied the bundle, we
did not work in isolation. Our improvements in 2013–2014
were achieved during and after involvement with three
other hospitals in the ELPQuIC study [8], while our 2017–
2019 improvements coincided with our joining the

Figure 4 Statistical process control chart of number of patients receiving emergency laparotomy per quarter October 2014–
March 2019. Black line – number of patients; red line – mean number of patients; blue line – upper and lower control limits (2SD);
arrow – relaunch of bundle.

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Anaesthesia 2020, 75, 1321–1330 Jordan et al. | Sustaining better care for emergency laparotomy

Figure 5 Run chart of 6-monthly emergency laparotomy mortality rate at Royal United Hospital April 2012–April 2019. Black
line – mortality rate; red line – median mortality rate; red arrow – ELPQuIC study; yellow arrow – relaunch of bundle.

Emergency Laparotomy Collaborative with 27 other care and improvement in outcomes for emergency
hospitals across the South of England [13]. The recently laparotomy patients showed no change in 90-day mortality
published trial by Peden et al. [11, 12] was deemed by some and improvement in only about one-third of processes.
to be unsuccessful [28], as attempts to engender change in Ethnographic study of the trial by Peden et al. suggested

(a) (d)

(b) (e)

(c) (f)

Figure 6 Run charts demonstrating compliance with individual components of the Royal United Hospital emergency
laparotomy bundle. Proportion of patients having (a) pre-operative risk-assessment (b) pre-operative lactate measurement (c)
goal-directed fluid therapy (d) care by consultant anaesthetist (e) care by consultant surgeon (f) postoperative critical care
admission. Black line – proportion of patients; red line – median proportion of patients; yellow arrow – relaunch of bundle; black
arrow – fluid optimisation in emergency laparotomy (FLOELA) study; orange arrow – RUH sepsis campaign.

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Jordan et al. | Sustaining better care for emergency laparotomy
Figure 7 Run chart of the time to arrival in the operating theatre for patients requiring emergency laparotomy within 6 h of
decision to operate (RUH category B). Black line – median time per month for all patients; red line – average median time till
marked intervention; yellow arrow – relaunch of bundle; red arrow – traffic light implementation.
that teams did not have enough time for improvement, and
struggled with the social aspects of change [12]. In contrast,
the Emergency Laparotomy Collaborative had longer to
achieve change, much more opportunity for teams to
interact and learn from each other, more QI support, and
more support for change management [13]. Our results
provide further evidence of the ability of QI processes to
make an important impact on both processes and outcomes
for this very high-risk group of patients, and reinforce the
concept that the social aspects of change and a supportive
environment are also key.
Sustainability can be defined as “ensuring gains are
maintained beyond the life of the project, or the
institutionalisation or routinisation of programs into
organisational systems” or “when new ways of working
become the norm” [29, 30]. The Institute for Healthcare
Improvement identified key components that are present in
organisations that successfully sustain major change [30].
These are: supportive management; structures to fool-proof
the change; robust transparent feedback systems; a shared
sense of what needs to be improved; a culture of
improvement; a deeply engaged staff; and formal capacity-
building programs. In addition, a seminal Harvard Business
Review report on why transformation efforts fail identified
‘declaring victory too soon’ and ‘not anchoring changes in
the culture’, as two of eight principal reasons for failure to
achieve long-term change [31]. Our experience supports
these findings, and we would emphasise the importance of
supportive senior management (in this case led by the CEO)
and the importance of a culture of change (in our case
previous successful efforts in emergency laparotomy care
were followed by the embarrassment of reversal). The NHS
sustainability model adds further components to be
considered [20]. Sustainability requires considerable work
after initial changes have been achieved, and this can be
particularly challenging when a research or QI project ends
[32]. New national drivers in England, such as financial
incentives for emergency laparotomy performance [33],
© 2020 Association of Anaesthetists
Anaesthesia 2020, 75, 1321–1330
may help sustain change through ensuring focus by senior
management and awareness of financial risk.
A weakness of this study is that it is a retrospective
analysis from a single centre. We have now demonstrated
twice that implementation of a standardised bundle of care
is effective in improving outcomes from emergency
laparotomy. The challenges we faced, and our analysis of
what went wrong, are well described in the literature on
sustainability. Our solutions were based on recommended
interventions.
In conclusion, we describe fluctuation in outcomes
from emergency laparotomy linked to a quality
improvement project. Our results, both of improvement and
deterioration, strongly suggest that improvements in
outcome are related to our QI processes.
Acknowledgements
Miss S. Short, Miss S. Richards, all other RUH surgeons,
anaesthetists, intensivists and operating room staff. The
ELPQUiC study was supported by a Shine grant, and the
Emergency Laparotomy Collaborative study was supported
by a ‘scaling up improvement’ grant, from the Health
Foundation, UK. S-CC was the National Emergency
Laparotomy Audit (NELA) Research Fellow in 2018/19,
funded by the RUH, Bath, UK. CP received funding from the
Health Foundation UK for a quality improvement Fellowship
at the Institute for Health Care Improvement, Cambridge,
MA, USA. CP is a consultant to the Improving Care and
Surgical Recovery AHRQ grant with the American College of
Surgeons and the Johns Hopkins Armstrong Institute. No
other external funding or competing interests declared.
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