Nurses developing new roles to improve laparotomy care

The call comes as the NHS prepares for the introduction of a new best practice tariff for emergency laparotomy this month, which will see hospitals that meet set criteria earn more money.

“Specialist nurses could really help these patients have a better time in hospital”

Sarah Hare

An emergency laparotomy is a major emergency surgical procedure used to investigate the cause of severe abdominal pain, performed under general anaesthetic.

Since 2013-14, information on patients who undergo the procedure has been gathered through the National Emergency Laparotomy Audit (NELA), led by the Royal College of Anaesthetists and commissioned by the Healthcare Quality Improvement Partnership.

The audit has been at the heart of efforts to improve care for this vulnerable group of patients who are the highest risk group of surgical patients, with 9.5% dying within 30 days, according to the latest NELA data from 2016-17.

Nurses can play a key part in supporting this important work and a handful of trusts have even developed specialist roles.

However, those behind the audit said they were keen to see many more organisations harness the expertise of nurses, especially when it comes to boosting recovery and patients’ overall experience of care, and hope the new tariff could provide an incentive for organisations to invest in extra nursing support.

“Specialist nurses could really help these patients have a better time in hospital,” said Dr Sarah Hare, consultant anaesthetist and clinical lead for NELA.

“This is a group of patients who are absolutely under-represented,” she said. “There are charities and marathons run for people with sepsis, diabetes and cancer but you barely ever hear about emergency laparotomy patients despite the fact they are our highest risk group and a significant number will die.”

“They don’t really fit in one particular pocket, so they almost get forgotten when they go to a ward”

Sarah Hare

She said nurses could not only support the timely collection of data for NELA but also help improve all aspects of care for this “hidden” group of patients.

“It might be that a hospital is not very good at getting patients to theatre in a timely fashion or that post-operatively they identify that patients don’t have analgesia, or there is a problem with returns to theatre or unplanned admissions to critical care – often caused by a failure to recognise deteriorating patients,” she said.

“Their role could be much like a critical care outreach nurse but specialising in the problems of an emergency surgical patient,” said Dr Hare.

She highlighted key areas where she believed nurses could make a real difference including ensuring continuity of care and providing emotional support for patients and families.

“One of the most frightening bits for patients after emergency laparotomy surgery is when they get stepped down from intensive care or moved to a ward and they suddenly feel completed isolated,” she said.

“They have a heterogenous bunch of conditions, but they don’t really fit in one particular pocket, so they almost get forgotten when they go to a ward,” she noted.

“Nurses can also help improve overall patient experience because these poor patients often just go home into the ether with no support,” said Dr Hare.

She said the new best practice tariff could provide an opportunity to invest in additional nursing support.

“Feedback from patients showed they were frustrated with having to repeat themselves”

Kate Varley

Under the split tariff, trusts will be paid at a higher rate if 80% of high risk patients have a consultant surgeon and consultant anaesthetist present during surgery and are admitted to critical care.

“The enhanced best practice tariff is about £700 per patient so if you were to move onto a higher rate that could work out as quite a significant amount of money for hospitals doing 100 or so emergency laparotomies a year,” said Dr Hare.

At Medway Maritime Hospital, where she works, the hope is that money earned by achieving the enhanced tariff could be re-invested in a new emergency laparotomy nurse practitioner role to help co-ordinate care, run a follow-up clinic and set up a patient support group.

Another organisation leading the way is St James’s University Hospital in Leeds, which consistently performs more emergency laparotomies than another other hospital in England and Wales, with 465 carried out in 2017-18.

As part of efforts to ensure the best care, NELA leads at the organisation decided to appoint a nurse co-ordinator.

Kate Varley, who was a sister on a general surgical and colorectal ward, took up the post in June 2017 and has since become what is understood to be the UK’s first “emergency laparotomy nurse specialist”.

She told Nursing Times that when she started there was no real job description, so she went on to create the role “out of thin air” starting by looking at the hospital’s NELA data and identifying areas for improvement.

One area that needed improving was patient flow, with patients who need emergency laparotomies generally passing through five or six different areas before they land on a ward.

“I am nearly two years into the job now and still fighting that battle”

Kate Varley

This has not changed but now Ms Varley, who is alerted as soon as the decision is made that an emergency laparotomy is needed or when the patient is booked for theatre, is there to provide all-important continuity of care, ensure key information is passed on and support early discharge planning.

“Feedback from patients showed they were frustrated with having to repeat themselves over and over again with different sets of physios, nurses and pharmacists all asking them the same questions in each department,” she said.

“They come in ridiculously unwell and were then having to have the same conversations over and over again,” said Ms Varley.

She added: “I am there as a friendly face for that patient to say ‘okay – I know you are in a new scary environment but you know me’, providing continuity from the minute the decision is made to have an operation to when they go home.”

Since getting the job, she has qualified as a non-medical prescriber and learned how to site stomas in order to reduce delays in patients getting to surgery or receiving medication and IV fluids.

NELA guidance states all patients over the age of 70 should have input from a specialist in elderly medicine and Ms Varley has also strived to improve the hospital’s performance in this area.

She identified a registrar in elderly medicine to do a weekly ward round and provide ongoing support with complex medical issues to advanced nurse practitioners and others in the surgical department.

“Unlike our elective patients, our emergency laparotomy patients are really sick”

Anne Livesey

Meanwhile, the hospital’s NELA team has successfully made the case for a Proactive care of Older People undergoing Surgery (POPS) consultant role in surgery due to start this summer.

Part of her role also includes chasing up people to ensure they fill in NELA data at the earliest opportunity.

“I am nearly two years into the job now and still fighting that battle,” said Ms Varley.

“It’s an audit document to fill out and people don’t like doing it, which was a real eye-opener for me because I’m a nurse and when we’re told to do an audit we just get on and do it,” she said.

Other areas she is working with colleagues to improve include ensuring A&E patients get antibiotics on time and that the highest risk patients are routinely admitted to critical care.

Since she started two years ago, the hospital has seen a drop in mortality rates and average length of stay for emergency laparotomy patients.

When data collection began in 2013-14 there was a 10.2% mortality risk, which dropped to 9% in 2015-16 and was down to 8.6% in 2016-17.

Raw, unpublished data for 2017-18 suggests this may have dropped further with an observed mortality rate of 7.2%. Meanwhile, length of stay has dropped from 11 to nine days.

“Our mortality has come down, our length of stay has come down and we have improved patient safety”

Anne Livesey

Ms Varley said her vision was for the hospital to employ two more emergency laparotomy nurse specialists in order to ensure a year-round, seven-day a week service.

She believed many trusts would benefit from employing nurses in roles similar to hers to ensure emergency surgical patients got the same level of care as those coming in for elective surgery.

“If other hospitals can’t justify the expense for the volume they are doing then I would encourage them to add it on to an existing clinical nurse specialist role,” she said.

Ms Varley said she felt “honoured” to do her job, which involved “all the good bits” of nursing.

“I get to see people at their worse but I don’t have the time constraints and the pressure the ward staff do,” she said.

She added: “I get to meet the families and counselling and psychological support is a massive part of my role.

“I came into the job two years ago wanting to fix everything really quickly and realising that in such a huge trust it doesn’t happen like that. But this is definitely somewhere you can make a huge difference over time,” she said.

“It doesn’t have to be an enhanced recovery nurse – there are lots of specialist nurses out there”

Anne Livesey

Anne Livesey, enhanced recovery lead nurse at East Lancashire Hospitals NHS Trust, knows this only too well having spearheaded efforts to improve care for emergency laparotomy patients.

“Unlike our elective patients, our emergency laparotomy patients are really sick when they come in and often in a life-threatening position that needs treatment and management within a timescale,” she said.

However, she said initial NELA data revealed variation in the care patients received in different departments – as well as between trusts.

“Our main aim is to bring mortality down and when we first started our mortality was higher than the national average,” she said.

Her trust took part in the Enhanced Peri-Operative Care for High-risk patients – or EPOCH – trial which used NELA data to test the effectiveness of a variety of interventions when it came to improving outcomes for emergency laparotomy patients.

The organisation has since built on this work, with nurses playing a key role in devising and implementing quality improvement strategies with support from lead consultants and the quality improvement team.

This has included improving risk assessment of patients before they go into theatre and developing information packs for patients and their families, which include steps people can take to boost recovery.

“We’re trying to use every opportunity we have – even if it’s just a small one – to say ‘when you wake up this is what will help to stop chest infections or reduce the risk of pneumonia’,” she said.

“The reason we have been able to implement things has been because I am on the ward”

Anne Livesey

Ms Livesey and a nurse colleague also developed a sticker that is placed on the anaesthetic chart to remind anaesthetists of the key things they need to bear in mind during an emergency laparotomy, including the need to re-assess risk at the end of an operation if a patient is going on to a ward.

Crucially, they spearheaded the creation of an emergency laparotomy enhanced recovery guideline, developed with consultants, which sets out a clear pathway of care.

“It’s a good aide memoire for the nurses, physios, surgeons and dieticians and is all about us working as a multi-disciplinary team to achieve the same goals,” she said.

As a result of this work, the trust saw a significant drop in mortality from 13.2% in 2014-15 to 9.7% in 2015-16.

“In this trust, that equated to seven patients surviving so that was big news for us at the time,” said Ms Livesey, who said mortality rates continue to be below the national average.

She added: “Our mortality has come down, our length of stay has come down and we have improved patient safety, because we now have standardised, high quality care.”

While NELA is consultant-led, she said consultant surgeons and anaesthetists did not always have time to implement improvement programmes and this is where nurses came into their own.

“The reason we have been able to implement things has been because I am on the ward, have a good relationship with the nurses and doctors and just put myself out there,” she said.

“I have got time to do it because it is part of my job. I think it is vital to involve nursing staff who can see how much you can do to change things and actually stop people from dying,” said Ms Livesey.

“It doesn’t have to be an enhanced recovery nurse – there are lots of specialist nurses out there such as emergency co-ordinators and theatre co-ordinators and this could fit in with what they do quite easily,” she said.

One of the key areas where many trusts are not meeting NELA recommendations is when it comes to the management of older patients.

The latest audit data shows that in 2016-17 just 23% of patients aged over 70 were assessed by a care of the elderly specialist.

“We know that cognitive impairment is directly related to post-operative delirium”

Jason Cross

Jason Cross is an advanced nurse practitioner at Guy’s and St Thomas’ NHS Foundation Trust, where he is the lead nurse for the POPS team and has been involved in efforts to improve the care of patients undergoing emergency laparotomies.

“There is lots of national data that shows that if you are older and have an emergency laparotomy you do really badly,” he said. “If you are over 80 then the chance of you surviving is probably about 2 in 10 or 15%.”

His team aims to ensure every patient aged 65 and over who has had the procedure is seen by an elderly care specialist and local data shows this now happens in 95% of cases.

Mr Cross, who is on the steering group for the Royal College of Nursing’s Perioperative Forum, said ensuring patients received a comprehensive geriatric assessment was crucial and nurses could play a key role in the assessment process and in reducing post-operative complications.

For example, when it came to ensuring the best care for this vulnerable group, he said picking up on mild or undiagnosed cognitive impairment as early as possible was an important element.

“We know that cognitive impairment is directly related to post-operative delirium and acute confusion is related to worse outcomes,” he said.

“Highlighting that a patient might have delirium allows us to put in place very simple nurse-led interventions to help reduce the duration or severity,” he added.

“Nurses have a specific skillset that means…they have it within them to effect change early on in this patient group”

Jason Cross

Crucially, he said nurses could help improve the aspects of care and recovery that matter most to those on the receiving end – including supporting patients and families to make difficult decisions like not putting very ill and frail elderly patients through an operation in the first place.

“What I think a nurse brings to the role is the ability to really have an impact on patient-reported outcomes and supporting patients at all stages of their care to make the decision that is tailored to them,” he said. “Sometimes those are difficult decisions and supporting those patients is quite hard.”

He told Nursing Times he would like to see more nurses involved in work to improve care for emergency laparotomy patients because they could help make a real difference.

“The first thing you are taught at nursing college is about holistic assessment and nurses are good at putting patients at the centre,” he said.

“I don’t think you need to be a perioperative nurse specialist,” noted Mr Cross.

“Nurses have a specific skillset that means with the right tools and education they have it within them to effect change early on in this patient group, including helping to streamline care and support patients and families at their most vulnerable,” he added.