APAGBI Small Research Grant
Children's Acute Surgical Abdomen Programme Pilot: CASAPP
Dr Ramani Moonesinghe
Emergency abdominal surgery has been highlighted as an area where the standard of healthcare provided to patients varies widely between NHS hospitals. In adults, this has led to the establishment of a national programme to assure (assess hospital level compliance with recommendations for patient care) and improve quality, with the aim of improving survival rates (www.nela.org.uk). Despite concern from surgeons and anaesthetists that emergency abdominal surgery is also high risk in children, with similar variation in practice, no equivalent national programme exists for a number of reasons. First, there are different issues affecting type and quality of care which should be delivered to children - for example, children are more likely to require transfer from a district hospital to a teaching hospital for surgery than adults, and therefore we would need to examine the care provided during transfer to be able to get a complete picture of the quality of care given to children undergoing this type of surgery. Second, the risk factors which might predispose patients to death or disability after emergency surgery are very different in adults and children (for example, increasing age is a risk factor in adults, whereas premature birth would be a risk factor in children). Finally, while death within 30 days occurs in one in ten adult patients, thankfully, death after emergency abdominal surgery is rare in children; however, children are likely to suffer a number of other adverse events which may be harder to measure, such as the requirement for long-term tube feeding and disruption to their schooling and education. Therefore, any national programme would need to measure these events, and do so in a way that ensures they are recorded accurately, and that is acceptable to children and parents.
Therefore we propose to conduct a pilot study which will help us address the uncertainties and issues highlighted above, so that we can go on to establish a long-term national programme to evaluate care delivered to children undergoing emergency abdominal surgery. Our proposed research has four components, the first three of which will be conducted in as many UK hospitals as possible, aiming for 100% coverage, and the fourth in a sub-group of 4 named centres. First, we will establish the need for a long-term national programme by measuring differences between hospitals in the way that care is provided to children, both in terms of the organisation of the hospitals (e.g. how many children's intensive care beds do they have) and also adherence to known guidelines for the care of individual children (e.g. does every child that should go to intensive care actually go to intensive care). Second, we will measure various risk factors which we believe (from the scientific literature and our clinical experience) are associated with good and bad results from surgery, to identify which ones we should measure in a future long-term national programme. Third, we will establish the acceptability to parents of having this sort of information routinely collected on their children. Finally, in a sub-group of 4 hospitals we will conduct additional research which will establish exactly how we should measure the result of surgery in this population (e.g. complications, quality of recovery and longer-term quality of life for both children and parents). By the end of this research, we will have a clear plan for how to implement a national long-term programme to evaluate the quality of care given to children undergoing emergency abdominal surgery. If our research demonstrates the need for such a programme, we will be able to move forward quickly to establish it, with the aim of reducing variation in practice and improving care and results of this high-risk surgery. Our team comprises national and internationally recognised clinical and research experts in children's surgery and anaesthesia, members of research teams which have previously delivered major projects of this type in adults and children, lay representation and junior doctors and researchers who will be responsible for the day-to-day delivery of this project. We have the support of the national organisations with an interest in improving care for these patients, including the Royal College of Anaesthetists and its Health Services Research Centre, the British Association of Paediatric Surgeons and the Association of Paediatric Anaesthetists.
