Kat Parmar ST7 General Surgery ELF Steering Committee chair ELF E mergency L aparotomy amp F railty ELF An Overview Who are the ELF team What is our research question Why is this relevant ID: 719160
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A National Multi-Centre Study of Frail Older Surgical Patients undergoing Emergency Laparotomy
Kat ParmarST7 General SurgeryELF Steering Committee chair
ELF
:
Emergency Laparotomy & FrailtySlide2
ELF - An Overview
Who are the ELF team?
What is our research question?Why is this relevant?
How do we plan to answer our research question?What do participating sites need to do?Slide3
ELF Team
Chief Investigator: Susan Moug, Consultant Colorectal Surgeon, OPSOC
Steering Committee (North West Research Collaborative): Kat Parmar, Jen Law, Jemma Boyle, Patrick Casey, Ian Farrell, Ishaan MaitraOPSOC
(Older Persons Surgical Outcomes Collaboration): Jonathan Hewitt (Geriatrician) Lyndsay Pearce (General Surgeon) Ben Carter (Statistics Lead)Slide4
ELF Study Proportionate Ethical review November 2016:
favourable opinion granted
NHS Research Ethics Committee (REC) Proportionate Review Service Ethical ApprovalSlide5
Research Question
Does the use of a validated frailty score correlate with outcomes in emergency laparotomies in older surgical patients?Slide6
Relevance
The most recent NELA report (2016) found that:
Over half of patients undergoing emergency general
surgical procedures are aged 65 and olderMore should be done to specifically target outcomes in these patientsCurrent risk prediction tools are generally extrapolated from cohorts of
much younger patients NELA project team. Second Patient report of the National Emergency Laparotomy Audit. RCoA London 2016Slide7
FrailtyA relatively new medical concept with many definitions
One definition: Various frailty scores have been developed and validated
‘A medical syndrome with multiple causes and contributors that is characterised by diminished strength, endurance, and reduced physiologic function that increases an individual’s vulnerability for developing increased dependency and/or death’Slide8
Frailty Scores - EvidenceResearch so far has suggested that high frailty scores pre-operatively correlate with:
The majority of these previous studies have been performed in elective rather than emergency patients
Moug et al on behalf of OPSOC, Ann R Coll Surg Eng 2016
Hewitt et al, Am J Surg 2016Farhat et al, J Trauma Acute Care Surg 2012
↑ post-operative complications ↑ length of stay ↑ 30 and 90 day mortality and ↑ likelihood of institutionalisation Slide9
Rockwood CHSA Frailty Score
1 – Very fit
Robust, active, energetic, well motivated and fit; these people commonly exercise regularly and are in the most fit group for their age.
2 – Well
Without active disease, but less fit than people in category 1.
3 – Well, with treated comorbid disease
Disease symptoms are well controlled compared with those in category 4.
4 – Apparently vulnerable
Although not frankly dependent, these people commonly complain of being “slowed up” or have disease symptoms.
5 – Mildly frail
With limited dependence on others for instrumental activities of daily living.
6 – Moderately frail
Help is needed with both instrumental and non-instrumental activities of daily living.
7 – Severely frail
Dependent on others for activities of daily living, or terminally ill.
Rockwood K, et al. A global clinical measure of fitness and frailty in elderly people. CMAJ. 2005;173:489-95Slide10
ELF Study Process
Identification of patients (~3 months)
↓
Data collection↓Entry of data into central secure REDCap
Database ↓Analysis of data by ELF statistician↓Dissemination of resultsSlide11
ELF Study TimeframeSlide12
Outcome Measures
Primary Outcome Measure:
90 day mortalitySecondary Outcome Measures: LOS
ComplicationsChange in level of independenceLOS HDU/ICUIntermediate care stay30 day mortality & re-admissionSlide13
Sample SizeUsing unpublished OPSOC data, frailty exists in 28% of all patients undergoing emergency laparotomy
In order to detect a 10% difference in mortality rate at Day 90 between frail and non frail patients a sample size of 480 is requiredWe anticipate minimal patients that we are unable to follow up, but to account for this, we will aim to recruit 500 patients
166 patients/month
Monthly laparotomy rates in ≥65
yr olds: 5-9 per unit30 units needed for 500 patients in 3 months50 units recruitedSlide14
Case Report FormSlide15
Site List
1
Addenbrookes
2
Arrowe
Park
3
Ashford
4
Barnet General Hospital
5
Barrow
6
Birmingham QECH
7
Blackburn
8
Blackpool
9
Bolton
10
Brighton
11
Bristol Royal Infirmary
12
Cardiff
13
Chester
14
Crewe
15
Croydon
16
Doncaster
17
Dundee
18
East Surrey
19
Edinburgh Western General
20
Edinburgh Royal Infirmary
21
Essex
22
Exeter
23
Glamorgan
24
Glan
Clywd
25Glasgow QEUH
26
Glasgow Royal Infirmary
27
Kilmarnock
28
Lancaster
29
Maidstone & Tunbridge Wells
30
Macclesfield
31
Manchester Royal Infirmary
32
Mid Yorkshire
33
Milton Keynes
34
Newport
35
North Bristol
36
North Somerset
37
Oban
38
Orpington PRUH
39
Paisley
40
Portsmouth
41
Preston
42
Reading
43
Royal Surrey
44
Royal London
45
Salford
46
Swansea
47
Tameside
48
Taunton
49
Whiston
50
Wigan
51
Wrexham
52
WythenshaweSlide16
What Next for ELF?
REDCap Login Details:
→ All sites to submit names and Email addresses of local collaborators requiring REDCap login details
contact ELFcommittee@hotmail.comSlide17
Thank You
ELF
Steering Committee