Predictive tools

Aim

Emergency laparotomy is associated with a high mortality and morbidity. Early identification of high-risk patients allows for timely involvement of other members of the multidisciplinary team, including care of the elderly (CoE) specialists. This improves the likelihood of a successful post-operative recovery. This study investigated the adherence to the NELA guidelines regarding the use of the clinical frailty score and input from the CoE team.

Methods

A prospective analysis was conducted, collating data on patients undergoing an emergency laparotomy in one centre in East London. Data collected included the date of admission, findings at operation, clinical frailty scores, and input from CoE team members.

Results

16 patients had an emergency laparotomy during May 2024. Ages ranged from 44 to 92. 11 patients were aged 65 years or older but none had a clinical frailty score within 4 hours of admission, as per NELA guidelines. 6/11 (55%) were reviewed post-operatively by the CoE team during their inpatient stay. These findings were reported at the monthly morbidity and mortality meeting. Our interventions included a surgical teaching session, posters in the department and a stamp for CoE review kept in CEPOD theatre for use post-laparotomy. The second cycle showed significant improvement with a 33% increase in CFS and a 12% improvement in care of the elderly reviews.

Conclusions

In conclusion, it is known that older patients have a poorer post-operative outcome, which is improved by perioperative CoE input. With this audit, we improved awareness within our department regarding older, frail patients and began to see a change regarding assessing patients mobility and need for CoE input. However, we are still not doing this for all of our patients so there are still improvements to be made. Interestingly, in terms of interventions, we found that teaching and discussion had the greatest impact.

Introduction:
Risk prediction tools help guide prognostic conversations and benchmarking in hip fracture care. The Nottingham Hip Fracture Score (NHFS) shows only moderate predictive ability for 30-day mortality. We assessed whether routine markers of inflammation could improve the discriminant ability of the NHFS to predict 30-day mortality following hip fracture surgery.

Methods:
We studied consecutive patients admitted with hip fractures at a large-volume trauma unit between 2015 and 2020. Baseline NHFS and postoperative outcome data were extracted from a local registry and linked to routine laboratory data from patients’ electronic clinical records. We selected measurements taken closest to admission pre-operatively. The biomarkers studied were albumin (negative acute-phase reactant), C-reactive protein (CRP), neutrophil-lymphocyte ratio (NLR) and monocyte-lymphocyte ratio (MLR). Univariate and multivariate logistic regression analyses were performed separately for each combination of NHFS and inflammatory marker. C-statistics were calculated to assess the discriminant ability of the NHFS with and without each inflammatory marker for 30-day mortality.

Results:
We included 1710 patients, mean age 82.5 years (SD 8.2). 1199 (70.1%) were women. 104 (6.1%) patients died within 30 days of admission. In univariate analysis, admission NHFS, albumin, CRP and NLR were significantly different between those alive and dead at 30 days. Higher admission albumin was an independent predictor of 30-day mortality in multivariate analysis (OR=0.86 [95%CI 0.81-0.91], p≤0.001) as was higher CRP (OR=1.93 [95%CI 1.04-1.44], p=0.013). The addition of albumin significantly improved the discriminant ability of the NHFS for 30-day mortality (p≤0.001) (c-statistic 0.742 [95%CI 0.683-0.800] vs 0.681 [95%CI 0.617-0.745] for the NHFS alone). Other inflammatory biomarkers did not significantly improve discrimination of 30-day mortality when added to the NHFS.

Conclusions:
Admission albumin improves the discrimination of 30-day mortality in patients undergoing hip fracture surgery when combined with the NHFS, whereas other markers of inflammation including CRP, MLR and NLR did not.