New National Standard Set to Transform Emergency Laparotomy Care in Australia

The Australian Commission on Safety and Quality in Health Care has published the Emergency Laparotomy Clinical Care Standard, the first national framework aimed at standardizing care for patients undergoing emergency abdominal surgery. Approximately 15,000 Australians undergo this procedure each year for time-critical conditions.

Background and Scope

Emergency laparotomy is performed for urgent intra-abdominal conditions such as bowel obstruction, perforation, peritonitis, hemorrhage, and ischemia. The patient population is predominantly older adults, with over half of patients aged over 65.

The standard applies to patients aged 18 and over. Current baseline data indicates:

• In-hospital mortality is approximately 7% overall, rising to 20% or higher for older adults and patients with serious comorbidities.
• More than one in five patients have sepsis on presentation.
• The average hospital stay is nearly 13 days.
• Only 59% of patients currently receive surgery within recommended timeframes.
• Postoperative complications, extended hospital stays, and unplanned readmissions are common.

Standard Content

The standard comprises nine quality statements:

1. Rapid assessment and escalation: For patients with symptoms of time-critical intra-abdominal conditions, including use of sepsis pathways.
2. Diagnostic imaging: Timely access to appropriate imaging.
3. Assessment of risk: Consistent preoperative risk and frailty assessments to guide care pathways.
4. Shared decision making and goals of care: Discussions involving patients and families, with senior clinician involvement when surgery may not be beneficial.
5. Timely access to surgery: Prompt access to theatre, currently achieved for only a minority of patients.
6. Presence of consultant doctors during surgery: Consultant surgeon and anaesthetist present for high-risk patients.
7. Postoperative critical care: Appropriate critical care placement after surgery.
8. Proactive assessment and collaborative management of the older patient: Involvement of geriatricians or other clinicians skilled in perioperative care.
9. Transition from hospital care: Detailed individualized care plan at discharge covering medications, wound management, nutrition, rehabilitation, potential complications, and contact details for the surgical team, with coordination with general practitioners.

Implementation and Monitoring

The standard includes clinical indicators aligned with the Australian and New Zealand Emergency Laparotomy Audit – Quality Improvement (ANZELA-QI) registry, allowing health services to monitor care and benchmark nationally. The national rollout is underway.

The standard was informed by international evidence, including the UK's National Emergency Laparotomy Audit (NELA), which was associated with a reduction in postoperative mortality from 11.8% to 8.1% over ten years in England and Wales.

Stakeholder Statements

Dr. Phoebe Holdenson Kimura, GP and medical advisor to the Australian Commission on Safety and Quality in Health Care, stated that the standard aims to equip GPs for their role in early assessment, escalation, and ongoing recovery. She expressed hope that the standard will lead to improvements similar to those seen with hip fracture and stroke clinical standards.

Professor David Watters, surgeon with Deakin University and Safer Care Victoria, stated that a delay of one to two hours can significantly affect recovery chances.

Matthew Burstow, Director of General Surgery at Logan Beaudesert Health Service, stated that a standardized approach to emergency laparotomy is overdue and that the Standard provides a framework to support clinical care for high-risk patients.

Chuan-Whei Lee, Anaesthetist and Pain Medicine Specialist at Royal Melbourne Hospital, stated that the Standard supports a coordinated, multidisciplinary approach across the entire perioperative journey, defining expectations for rapid escalation and risk stratification.

Evidence of Impact

A case study from Bunbury Regional Hospital in Western Australia reported improved outcomes and standardized care after implementing regular data review and using ANZELA-QI indicators.