* Please provide a brief outline of your work.
Emergency laparotomies (EL) carry a high risk of morbidity and mortality. Extended nursing roles are becoming increasingly more important and diverse within the general surgical team. A new role was developed, the first of its kind, specialist nursing care focusing solely on patients needing emergency surgery.
The aim of the role is to improve overall outcomes for this high-risk group of patients but to also improve the experience these patients have by coordinating their complex care needs through multidisciplinary interventions. We set out to assess whether the introduction of a NELA Nurse Specialist (NNS) had an impact on our results.
* Please describe the actions you took to achieve your result.
Reason role needed:
• 400+ emergency laparotomies per annum
• Mortality 10.2% (at the time the job advertised)
• Someone to provide pre/post-operative care
• Someone with in-depth knowledge in this specialist area
• Able to work autonomously and within a team
• Have good relationships with surgeons/anaesthetists/ward staff to coordinate care • Drive QI projects
NELA (National Emergency Laparotomy Audit) is a national mandatory audit. Data is collected about each emergency laparotomy carried out in the trust, but simple data collection is not enough unless the data collected is turned into actions to improve care for future patients.
NELA data can be used to empower the best decision making to provide the best quality care for these patients. A Band 7 Nurse Specialist recruited into post; the role required the individual to implement new ways of thinking and working and improve patient pathways.
During the time I have been in post I have identified several key areas in the management of emergency laparotomy patients that demanded improvement; patient experience, care of the elderly emergency patient and ensuring accurate data collection. The journey of the emergency surgical patient can be a frightening and traumatic one as these patients have many investigations and procedures in the first 24-48 hours of their admission.
The role has allowed for these patients to have a point of contact on any ward or in any department for any questions or queries they may have. This role has also given support to the ward teams to deal with a highly complex and unwell group of patients through daily reviews to support not only the patients and the ward teams but relatives also.
The introduction of the NNS has allowed for a multidisciplinary working by collaborating with elderly medicine specialists for management of complex conditions in older patients. Previously, specialist input from elderly medicine for surgical patients was sent via an email referral with average review time 48-72 hours.
I have developed a system to have elderly surgical patients reviewed by elderly medicine specialists on a weekly basis with focus around frailty specific medication reviews, discussions around DNACPR and escalation of care.
This notoriously difficult and neglected aspect of elderly surgical care has been addressed and an excellent example of collaborative multidisciplinary working. We have made great strides in improving care for these patients in only six months and I look forward to further developing this otherwise neglected part of the service.
* Please list the most significant results
Comparing 2015/16 data to 2016/17. Overall observed mortality improved from 9.3% to 7.3%. Median length of stay reduced from 11 to 9.5 days. Returns to theatre were reduced from 6.9% to 5%. Case ascertainment improved to 100% each month compared to 67.5% nationally. Elderly medicine specialist input improved from 20% to 73%.
“Kate provided a direct link to the surgeon and ward staff, she changed dressings expected of any nurse really, but most importantly, she helped me to come to terms with what had happened and for that I will be forever thankful” (JG)
* Describe how your project has spread to other teams, departments or organisations
There are 30,000 emergency laparotomies carried out in England and Wales each year with one of the highest risks of morbidity and mortality. Therefore having someone to focus solely on this large group of patients in each hospital would not only be beneficial for patient outcomes but also improves working relationships between departments. I would encourage other trusts to develop this role to drive quality improvement projects relevant to their hospitals.