MOY 1 Variation in decision making around high-risk emergency laparotomy over time

Abstract Background There have been huge improvements in the ten years of the National Emergency Laparotomy Audit (NELA), notably in the assessment and recognition of high-risk emergency laparotomy patients, with associated improvements in outcomes. However, guidance around emergency laparotomy multi-disciplinary decision making remains sparse. The aim of this work was to examine the NELA database for variation in emergency laparotomy patient demographics over time. Method All patients enrolled in the NELA database December 2012-2020 were included. Patients were grouped according to their year of entry into the database (Years 1-7) and were assessed for NELA score, futile surgery (death in <72 hours of emergency laparotomy), and their admitting hospital. Results A total of 161,337 patient enrolled in the database had a documented NELA risk score. The mean NELA score decreased over time: 11.6% in Year 1 compared to 8.9% in Year 7. The number of extreme-risk patients decreased accordingly; overall 3.2% (n=5196) had a 30-day mortality risk of ≥50%, accounting for 4.3% of surgeries in Year 1, and only 2.2% in Year 7 (p<0.001). Although extreme-risk laparotomies were carried out in 183 hospitals, 1 in 5 were carried out in just 16 participating hospitals. The number of futile surgeries also decreased over time from 5% (n=1034) in Year 1 to 3.2% (n=705) in Year 7 (p<0.001). Conclusion High-risk, extreme risk and futile surgeries have decreased significantly annually since NELA began auditing surgical outcomes, however the missing puzzle piece remains patients that do not have emergency laparotomy.