Having worked in the NHS for over 25 years it struck me, about 10 years ago that the mortality for emergency bowel surgery was extremely high. Higher than any mortality from any other surgery including cardiac. In my own hospital, the rate was 22%. This, to me, was unacceptable. I set about improving the care and reducing this high rate by using an evidence based care bundle and implemented it in 4 hospitals. Our team reduced the risk-adjusted mortality overall by 42% and the crude mortality by 25%.
Finding specific hospital mortality
- convincing surgical teams that the mortality was actually that high
- ensuring the quality improvement work for the care Bundle was adequately carried out
Using the audit department and collecting retrospective data on specific mortality rates helped find each hospital’s actual mortality rate. Regular meetings with surgeons, case presentations of specific patients and going through the ‘bereavement process’ of them coming to terms with the mortality rate. Time and regular presence was required. Regular meetings with the multidisciplinary teams involved one each of the 4 hospitals, telephone conference calls every two weeks, regular updating of data and ironing out issues helped with engagement. Also teaching about time series charts and QI basics helped. Engaging the executive board definitely helps with engagement with clinical staff. Regular meetings, finding out issues and updating teams with how they are doing helped with engagement.
Reduction of crude mortality by 25%
Reduction of risk-adjusted mortality by 42%
Being awarded a scaling up award by The Health Foundation to scale the original 4 hospital project to 30 hospitals in the UK Being contacted by a social franchising team to scale the project up to a national level.
The value that was achieved by this project is immeasurable. The mortality rate dropped dramatically. The quality of care the patient receives when been given the news that they need an emergency laparotomy is evidence based therefore the quality has increased further. Doctors see emergency surgery now as something they can reduce complications of rather than just the surgery that ‘no one wants to do.’ However as a result we did further analysis on the financial benefits of the project and we have shown that despite following the five point care bundle is more expensive, in terms of cost effectiveness it is better as patients suffer less complications.
The mortality rate for emergency surgery was far too high. After some research, in some hospitals the mortality rate was as high as 30%. This was the biggest driver for Nial. Patients should not have a risk on 1 in almost 3 of dying post emergency surgery. Using best practice that had been published by various bodies such as NCEPOD, the Royal College of Surgeons and the Royal College of Anaesthetists, the 5 point evidence based care bundle was formed: early recognition of sepsis and antibiotics within an hour if appropriate early surgery within 6 hours (including next slot CT scan using ‘Code Laparotomy’) consultant anaesthetist and consultant surgeon Perioperative goal directed fluid therapy during the operation and for 6 hours post-op Intensive care for all patients post operatively. This care bundle has followed Nial all the way through and he is consistently looking for new evidence/changes to evidence that may improve patient care.
Using this evidence based care bundle the initial 4 hospital project dropped crude mortality by 25% and risk-adjusted mortality by 42%. As a result, patients are dying less, so patient safety is increased as care is evidence-based. Nial worked extremely hard to ensure that the care bundle was being followed and that patient safety was improving and never compromised. Travelling to all 4 hospitals once a month and speaking to patients who had undergone this procedure with the care bundle was vital for him. As a result of the staggering results of the initial project, The Health Foundation awarded Nial a Scaling Up award to scale up his work from 4 hospitals to 30 across the South of England. He has also published his work to ensure everyone an learn from it and patients across the world can benefit.
Nial has consistently influenced behaviour throughout this project, and quite frankly throughout all of his working life. He was a constant presence in his own hospital to the surgical and anaesthetic teams and ensured that consultant surgeons and anaesthetists would attend any emergency laparotomy operation at any time of day or night. This is no mean feat when there are six professors at the Royal Surrey alone! He did this and learnt techniques of behaviour change along the way in 4 hospitals. This has all increased patient safety and outcomes. Nial goes round the world teaching and presenting his work to ensure spread of the original project. The four original hospitals he worked with have maintained a low mortality rate but his work was recognised as excellent, hence the award of half a million pounds by The Health Foundation to spread his work. He is now in talks with taking this excellent patient safety, quality improvement project to the next level: nationally.
Looking at the financial implications of this project it has been shown by a health economist that following the evidence based care bundle is more cost effective than ‘normal care.’ With the new Scaling up Project he has taken this one step further and reduced length of day by 1.5 days. This has resulted in over £1 million pounds in non-cash releasing savings. Therefore, there is an improved quality, safety and financial gain also.
Nial always involves all members of his team well. He enjoys working in the multi-disciplinary aspect of medicine and ensures that he has a full cohort of different professionals represented - from nurses, physios, radiographers and managers. He insists on discussing care with patients which he feels forms his learning even further and uses information and knowledge gained from them and his team to constantly adapt and change the way he works. Nial is extremely approachable in the way he works. He makes it very easy to raise concerns and regularly asks for opinion and ensures everyone is happy and all understand before something is carried out. I don’t think I have worked with anyone like Nial which is why I am recommending his for this award. He goes out of the way, above and beyond the call of duty to ensure staff and, more importantly, patients are cared for in the correct way.