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Do we need an NHS network for emergency laparotomy in the elderly?

Do we need an NHS network for emergency laparotomy in the elderly?. Dave Murray James Cook University Hospital Middlesbrough Dave.murray@stees.nhs.uk. 10 years ago…. Over 90 years old 30 day mortality 93% non-elective surgery Hemiarthroplasty 24% Hip Screw 23% Laparotomy 13%

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Do we need an NHS network for emergency laparotomy in the elderly?

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  1. Do we need an NHS network for emergency laparotomy in the elderly? Dave Murray James Cook University Hospital Middlesbrough Dave.murray@stees.nhs.uk

  2. 10 years ago….. • Over 90 years old • 30 day mortality • 93% non-elective surgery • Hemiarthroplasty 24% • Hip Screw 23% • Laparotomy 13% • Amputation 4%

  3. Jin, BJA 2001,87,608-14

  4. Jin, BJA 2001,87,608-14 NCEPOD

  5. Prevalence of comorbidity NICE

  6. Prevalence of comorbidity NICE NCEPOD

  7. Fluid management The seniority of clinicians Delays in surgery Anaesthetic management Acute Pain Management Post Operative Cognitive Dysfunction Use of Critical Care Nutrition Comorbidites Medications Thromboembolism prophylaxis Consent Peri-operative Hypothermia 10 years on, have we got any better? Elective and Emergency Surgery in the Elderly

  8. 10 years on, have we got any better?

  9. 10 years on, have we got any better? EWTD MRSA NICE

  10. 3-year survival following laparotomy for bowel cancer NORCAG 7th annual report

  11. What would a network achieve? • Collaboration • Data collection • Sharing of good practice and EBM • Benchmarking • Improved coordination of care

  12. Evidence • PubMed citations • Hip # 14500 • Emergency laparotomy 1390 • AAA presentations • 2009 • 2008 5/7 hip#, • 2007 …..

  13. emergency+laparotomy+elderly

  14. Since 1999 • Increasing elderly population means more evidence available • The elderly are no longer constitute a one off admission to ITU • Sepsis care bundles • CO monitoring • Stenting for colonic tumours • Need for collaboration and dissemination of EBM

  15. What would a network achieve? • Collaboration • Data collection • Sharing of good practice and EBM • Benchmarking • Improved coordination of care

  16. Benefits of benchmarking • Hip # in NSF • Business plan approved for orthogeriatrician • Increased trauma theatre provision • Weekend consultant trauma sessions

  17. Hip #s • Single diagnosis • Presenting complaint obvious • get to correct speciality • Diagnostic imaging straightforward • By definition, all require surgery • or palliation • Easy to define timescales

  18. Common themes • Lack of theatres • Lack of pre-op investigation • Lack of adequate resus • Comorbidity • Time pressures • Hip #, late surgery associated with worse outcome • Laparotomy, disease process

  19. Laparotomy • Multiple pathologies • Multiple presentations • Multiple investigations • Multiple treatment options • Multiple specialities

  20. Multiple pathologies • Cancer • Diverticular disease • Inflammatory bowel disease • Perforated DU/PU • Adhesions • Volvulus • Strangulated hernias

  21. Multiple presentations • 30% admitted with non-GI symptoms • Obstruction • Sepsis • GI bleed • Toxic megacolon • Gas under diaphragm • Pneumonia  coughing hernia  strangulates  dead bowel  sepsis  laparotomy

  22. Multiple investigations • CXR • USS • CT • Ba enema • Biopsy • Endoscopy

  23. Multiple treatment options • 15% need surgery • Drip and suck • Stent • Palliation • Bridge to surgery • Surgery • Endoscopy • (Diagnostic laparotomy)

  24. Multiple specialities • Medicine • Surgery • Endoscopy • Radiology • Anaesthesia • ITU

  25. Emergency laparotomy • More complicated……

  26. Emergency laparotomy • More complicated.….. …… or too complicated? • Hip # network, ~5% are non-anaesthetists

  27. 10 years on, have we got any better? • Still cant say • Lack of denominator figures: network might allow that • EESE may provide some answers, catalyst rather than driving force • Network may be the way forward • Do you want to be involved?

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