Success of a Transdisciplinary Peri-Operative Pathway for Patients Undergoing Emergency Laparotomy During the COVID-19 Pandemic: A CUSUM Analysis.

Abstract

Background: Emergency laparotomy (EL) is associated with high post-operative morbidity. This study aims to evaluate the sustainability of our peri-operative pathway for EL (Emergency Laparotomy Pathway (ELAP)) during the COVID-19 pandemic.

Methods: This is a single-center retrospective study on patients who underwent EL following ELAP implementation from Jan 2019-Dec 2022. Exclusion criteria were EL for trauma or vascular surgery. The cohort was divided based on the COVID-19 pandemic (COVID was defined from 7 Feb 2020-25 Apr 2022). Cumulative sum (CUSUM) analysis was used to assess the chronologic performance of ELAP. Our primary outcomes were efficiency outcomes (time to surgery, presence of senior surgeon/anaesthetist in theatre and post-operative geriatric review). Our secondary outcomes were post-operative complications, major morbidity, and 30-day mortality.

Results: There were 564 patients (30.5% pre-COVID, 52.1% COVID, 17.4% post-COVID). The median age was 66.0 years, and 57.6% had ASA score ≥ 3. The commonest indication for EL was intestinal obstruction (56.9%). Overall major morbidity was 14.0%, and 30-day mortality was 2.8%. CUSUM analysis showed two phases-exploration phase (Case 1-158) and proficiency phase (Case 159-564); an inflection point was noted following the exploration phase, which showed a more sustained performance in achieving post-operative geriatric review and absence of post-operative complications or major morbidity. There was no observed relationship between COVID-19 and the performance of ELAP in both efficiency and clinical outcomes.

Conclusion: The good performance of ELAP was sustained at 4 years following its initial implementation despite the COVID-19 pandemic, which resulted in major disruptions to healthcare delivery.