Closing the implementation gap: Process outcomes following a structured intraoperative bundle for emergency...

Emergency laparotomy is associated with substantial morbidity and mortality. This study assessed the impact of the structured intraoperative component of Singapore's Emergency Laparotomy Audit (EMLA), inspired by the National Emergency Laparotomy Audit (NELA) conducted in the United Kingdom, in patients undergoing emergency laparotomy in an Asian context.

This prospective, single-centre quality improvement study was conducted at a 700-bed tertiary hospital using iterative Plan-Do-Study-Act cycles. Adult patients (aged 18 years or older) who underwent emergency laparotomy between August 2020 and August 2024 were included (n = 586). The intraoperative bundle consisted of three components: consultant-delivered anaesthesia and surgical care, goal-directed haemodynamic therapy (GDHT) for high-risk patients (NELA score greater than 10), and maintenance of normothermia. Primary measures included consultant presence, GDHT adherence, and intraoperative normothermia. Secondary outcomes were complications, intensive care unit (ICU) admission, length of stay (LOS), and 30-day mortality.

The presence of a consultant anaesthesiologist increased from 89.6% to 98.8% (P < 0.0001). Adherence to GDHT remained high across all phases (94.6%, 88%, and 86.7%). Hypothermia persisted in 11-16% of cases and was independently associated with longer LOS and higher ICU admission rates. No significant change in 30-day mortality was observed.

Implementation of the structured intraoperative EMLA bundle improved consultant coverage and maintained high adherence to GDHT. Consultant presence was associated with a 42% relative reduction in medical complications; however, causality cannot be established in this quality improvement project. Persistent hypothermia highlights the need for enhanced temperature management strategies.