Frequently Asked Questions

NELA is the National Emergency Laparotomy Audit. It is a National Clinical Audit commissioned by the Health Quality Improvement Partnership (HQIP). NELA is part of the National Clinical Audit and Patient Outcomes Programme (NCAPOP). NCAPOP is a closely linked set of centrally-funded national clinical audit projects that collect data on compliance with evidence based standards, and provide local trusts with benchmarked reports on the compliance and performance. They also measure and report patient outcomes. NELA looks at structure, process and outcome measures for the quality of care received by patients undergoing emergency laparotomy and compares these against standards of care such as those detailed in recent NCEPOD reports, and the Department of Health/Royal College of Surgeons of England's "Higher Risk General Surgical Patient (2011)".

NELA is run by the National Institute of Academic Anaesthesia's Health Services Research Centre on behalf of the Royal College of Anaesthetists. The Clinical Effectiveness Unit of the Royal College of Surgeons of England and the Intensive Care National Audit & Research Centre are our partners and will provide important methodological and technical input as well as general advice on running national audits.

NELA is currently funded until 30th November 2022 with the possibility to further extend.

The NELA includes all NHS hospitals in England and Wales that carry out emergency laparotomy. This includes any hospitals with acute admission, emergency departments, or specialist centres which carry out emergency laparotomy as a complication of other types of surgery. Non-NHS hospitals and hospitals in Scotland, Northern Ireland, Republic of Ireland and Channel Islands will also be welcome to contribute to NELA, but funding arrangements will need clarification, as the current HQIP funding only extends to coverage of England and Wales.

The NHS standard contract requires that organisations providing NHS care must participate in all relevant NCAPOP audits and enquiries. NCAPOP audits and enquiries are those commissioned by HQIP. If providers do not participate in relevant NCAPOP audits they will be in breach of their contract with their commissioner, therefore any non-participation would need to be agreed with the commissioner and CQC as the regulator.

Further information is available on the HQIP website:

HQIP's popular guidance document outlining the statutory and mandatory requirements for providers of NHS care in England has also been updated. The latest update has been carried out to include the:

• 2017/2018 NHS Standard Contract
  
• Detailed requirements on Quality Reporting from Monitor and the ending of inspections under the Clinical Negligence Scheme for Trusts.

More information can be found at: http://www.hqip.org.uk/resources/hqip-statutory-and-mandatory-requirements-in-clinical-audit-guidance/

NELA has both organisational and patient audit components. We aim to achieve individual patient data collection in all eligible NHS hospitals by the end of the first three years of NELA. Data collection is prospective on all patients that fulfil the inclusion criteria. The aim of the audit is to generate data that drives Quality Improvement (QI). QI will be facilitated through dissemination of collected data as well as workshops and seminars to drive specific QI projects alongside data collection. Annual reports are published that provide detailed accounts of individual hospital outcomes.

• June-Sep 2013: Organisational Audit conducted
  
• Dec 2013: 1st year of data collection for patient audit commenced
  
• May 2014: Organisational Audit Report published
  
• Dec 2014: 2nd year of data collection for patient audit commenced
  
• July 2015: First Patient Audit Report published
  
• Dec 2015: 3rd year of data collection for patient audit commenced
  
• July 2016: Second Patient Audit Report published
  
• Oct 2016: Data collection for Second Organisational Audit
  
• Dec 2016: 4th year of data collection for patient audit commenced
  
• Oct 2017: Third Patient Audit Report published
  
• Dec 2017: 5th year of data collection for patient audit commenced
  
• Oct 2018: Fourth Patient Audit Report published
  
• Dec 2018: 6th year of data collection for patient audit commenced
  
• Dec 2019: Fifth Patient Audit Report published
  
• Dec 2019: 7th year of data collection for patient audit commenced
  
• Nov 2020: Sixth Patient Audit Report published
  
• Dec 2020: 8th year of data collection for patient audit commenced

• All patients over the age of 18 years, having a general surgical emergency laparotomy in all NHS hospitals in England and Wales are eligible for inclusion and will be enrolled on a prospective basis. There is the potential to include the Devolved Nations should their funding bodies choose.
  
• The aim is to include all emergency gastrointestinal procedures on the stomach, large and small bowel, for conditions such as perforation, bleeding, abdominal abscess or obstruction, via open or laparoscopic approaches.
  Emergency laparotomies following elective surgical complications will also be included in the NELA.
  
• Patients requiring vascular surgery, gynaecological surgery, surgery on the renal tract, and laparotomy following trauma will be excluded.

To see the exact full inclusion / exclusion criteria click below:

NELA includes information about the structure of the service (e.g. provision of emergency theatres, provision of out-of-hours radiology), process measures (e.g. seniority of clinical staff in theatre, admission direct to critical care), and outcome measures (e.g. 30-day mortality, length of hospital stay). We also collect demographic data, and clinical information to allow us to risk-adjust outcomes.

Data is collected via an online data collection web-tool so that patient data can be entered directly into the audit database.

At present, we do not have clearly defined codes for emergency laparotomy - this has always been one of the difficulties in auditing this area as there are potentially around 400 of them. The documents below give some clarification which we hope will be useful. We are hoping to issue additional guidance at some point in the future.
 NELA HES Algorithm OPCS (Oct 2017).pdf (60 KB)
 Emergency Laparotomy Article - Anaesthesia Journal 2012 - AAGBI.pdf (77 KB)
 NELA Inclusion-Exclusion Criteria - Updated Format 28-02-19v2.pdf (292 KB)

NELA is on the list of national audits for inclusion in Trusts' Quality Accounts. We issue annual reports that include key outcome data, identifiable at hospital level, adjusted for risk. We also provide comments on whether relevant standards are being met. We also issue Quarterly Reports of hospital data to allow hospitals to make use of their most recent NELA data and to track their performance over time.

You should contact your hospital's NELA Local Administrator if you would like to be involved in NELA. If you are unsure if your trust or hospital is participating, or need the name of the local administrator, please contact us.

Emergency laparotomy is a complex clinical pathway that includes input from surgeons, anaesthetists, intensivists, physicians, radiologists, nursing staff, and other allied medical professions. All of these specialities will need to be aware of the audit and many will need to participate directly. Even if you are not the local NELA coordinator, you can help by starting to discuss the audit within your hospital. Its success will depend on a coordinated effort by all involved. Your clinical audit department is also likely to be able to help. We will also be writing to every Chief Executive and Medical Director to inform them of the audit, and the need for every hospital to participate.

Q4.2 and Q4.3 ask for senior surgeon grade and senior anaesthetist present in theatre.
If selecting 'consultant' this must be a surgeon or anaesthetist whose name appears on the specialist register and be appointed as a substantive, fixed term or honorary consultant in the NHS. Senior trainees grade ST7 and ST8 should be recorded as trainees even if they have passed the FRCS exit exam (or equivalent) or hold a CCT unless they are appointed to a consultant post as detailed above.

We will work closely with the established Emergency Laparotomy Network (ELN). In many cases, ELN members will be the first point of contact, and many have already asked to be the local NELA coordinator. More information about the ELN can be found at: www.networks.nhs.uk/laparotomy.

The age of referral to Elderly Care in the NELA audit is now considered to be 65 year old. This reflects the recommendations by the Royal College of Surgeons published in 2018.

The definition of level 2 or 3 care has been clearly defined in the guidelines for the provision of intensive care services (see further info here: https://www.ics.ac.uk/ICS/guidelines-and-standards.aspx/). Many hospitals, though, have developed systems to bridge gaps in local service provision, such as extended recovery areas or post anaesthesia care units. This may meet many of the ICS standards of care, and does reflect that the level of care a patient receives is not tied to a specific location. Unfortunately, though, unless an area is commissioned by the local CCG to receive the associated tariff for level 2 or 3 care, it will not meet the standard required to receive the enhanced BPT. If the postoperative area is recognised for level 2 or 3 tariffs, then this should be recorded in the NELA webtool as a level 2 or 3 admission.

The NELA dataset currently asks if patients (over age 65) were reviewed by a geriatrician during the perioperative period. For the purposes of this question, the perioperative period is defined as from the time of the decision being made for surgery to occur to within 72 hours of step down from critical care, or within 7 days or surgery - which ever is sooner.