Factors associated with adverse events after emergency laparotomy in Cape Town, South Africa: identifying opportunities for quality improvement

Background Surgical outcomes research is limited in areas of the world with the greatest unmet surgical need and likely greatest variation in outcomes. Measurement alone may improve outcomes—the so-called Hawthorne effect. The purpose of this multicenter cohort study was to identify factors that are both feasible to collect and are associated with a major adverse event following a targeted procedure in Cape Town, South Africa. Methods A collaborative of four acute care surgical units was formed to develop a data set with minimal data burden describing outcomes after an emergency exploratory laparotomy during a 3-mo period (February-April 2015). Controlling for patient, problem, provider, procedure and process predictors, multivariate models were built to identify risk factors for a major adverse event and higher resource use after surgery in our collaborative. Results The outcomes of 450 exploratory laparotomies from the four participating hospitals were audited, 319 (70.9%) were for non-trauma and 131 (29.1%) were for trauma. The major adverse event rate was 15.7% (95% CI 12.6-19.4). In the multivariate analysis, factors associated with the primary outcome included age, American Society of Anesthesia score of greater than 2, bowel resection, preoperative CT scan, and a nontherapeutic laparotomy. A major adverse event was associated with all three outcomes assessing increased resource utilization. Conclusions This study supports the comparative outcome assessment of a high-volume or high-risk procedure as a proxy for measuring the quality of care provided in a surgical collaborative. Such an exercise can identify opportunities for quality improvement.