What is QI Notify-EmLap and what does it do?
QI Notify-EmLap, developed by The Dudley Group NHS Foundation Trust with support from the West Midlands Academic Health Science Network (WMAHSN), is a digitally assisted solution to support clinicians in their emergency laparotomy quality improvement work. Acute abdominal pain requiring assessment in hospital can be a symptom of a serious underlying illness and in some instances, if left untreated, can progress to cause rapid clinical deterioration and even death. For some patients, emergency major abdominal surgery, referred to as an ‘emergency laparotomy’ (EmLap), can be lifesaving. Therefore, identifying which patients need this surgery and accessing theatre before deterioration occurs is a high priority.
A local emergency laparotomy pathway supports clinicians to delivery this and the National Emergency Laparotomy Audit (NELA) supports hospitals by processing their locally collected data to produce overview reports and a dashboard of charts. However important and useful these summative data sources are, continuous Quality Improvement (cQI) is most successful when supplemented by real-time, patient level data. Indeed continuous learning demands a continuous awareness of care delivery processes, and continuous feedback loops to prompt action learning. Delivering this is a challenge in many areas of healthcare, especially along as complex a pathway as this. How do we learn, share and reinforce the many examples of excellent care delivered everyday in a way that is meaningful and timely? How do we understand why delay occurred and how it could be avoided? And how do we do this across the full emergency laparotomy pathway, from ‘door’ through ‘theatre’, to ‘recovery’ and ‘discharge’?
QI Notify-EmLap is a digital solution which helps address this challenge. It transforms uploaded coded data (mainly from NELA), into a ‘scrollable timeline’ and narrative description of care, that can be securely shared and viewed on the smart device of approved clinicians with an active account. It compares the care delivered to reported standards, and allows clinicians to review the standards in real time, as well as provide feedback, reflections and service improvement ideas. No data is stored on the user’s device. QI Notify-EmLap can release reports at two discreet time points – shortly after surgery and again at hospital discharge. These reports provide clinicians and others responsible for the emergency laparotomy pathway with the ‘near real-time’ information necessary to perform a ‘mini case note review’. Members of the team can review an individual case record within a few minutes, at a time convenient to them, and provide open feedback and learning which is captured centrally. QI Notify EmLap thereby enables learning from every patient journey to better understand why and how elements of care work well, to ensure this is replicated.
What were the aims of the QI Notify EmLap Quality Improvement project?
- To make data from the National Emergency Laparotomy Audit (NELA) readily interpretable in near real time for local staff responsible for delivery of the emergency laparotomy pathway.
- To provide an overview of each patient’s journey to theatre, allowing clinicians to contextualise the effectiveness of their intervention(s) while events are still recent.
- To enable NHS professionals responsible for delivering the emergency laparotomy pathway to review standards and reflect on the delivery of clinical best practice and provide feedback for enhancing the care of future patients.
What did we do?
QI Notify-EmLap is a Dudley Group NHSFT product. We have been supported by the WMAHSN from the outset, and have also worked with ‘Exploding Phone’ (a West Midlands based app developer), to create the QI Notify EmLap digital solution. We continue to develop the project with support from the WMAHSN including review and update of the APP and the associated data governance processes, ensuring it remains compliant with the evolving regulatory environment.
Progress and next steps
A QI Notify EmLap prototype is being piloted amongst a group of NHS professionals within The Dudley Group NHS Foundation Trust, to assess delivery against the initial aims. So far, this is limited to 11 individuals, reviewing 155 case records, and providing a total of 61 reflections. Separate feedback on the digital solution itself is being used to plan version 2.0 for wider roll-out locally. In addition to a redesign to enhance functionality and usability, this will include updates to ensure QI Notify EmLap maintains compliance with NHS data regulation, by undertaking an independent assessment (including ORCHA (2) accreditation) and is generically applicable to other hospitals utilising NELA to support cQI of their emergency laparotomy pathway. We have had discussions with the Cloud Centre of Excellence team at NHS Digital including the possibility of sharing the solution across the wider NHS following further development.
Evaluation of QI-Notify EmLap
App User Survey / Feedback
If you have used QI Notify-EmLap we would appreciate receiving your feedback. We would like to invite you to undertake a five-minute survey. This is being finalised and will be available shortly.
Expert evaluation of the potential for QI Notify-EmLap to fill an important information gap, support learning, and improve care for patients requiring an emergency laparotomy – September 2022
Approximately 22 000 emergency laparotomies are undertaken in England and Wales annually with a 30-day mortality rate of approximately 9% and an average length of stay of over 15 days. (Year 7 report)
The National Emergency Laparotomy Audit (NELA) is one of the National Clinical Audits (NCAs) and used to support local QI work as well as provide assurance to NHSE about the safety of the national emergency laparotomy pathway. NELA publish a comprehensive set of reports, including an annual report providing summative data at hospital, regional and national level, as well as more focused quarterly reports assessing hospital performance against agreed standards. In addition, NELA promote regular review and reporting of local data by local teams and provide tools to assist with this. However, despite the availability of patient level data, the transformation of NELA data into an easily interpretable and meaningful patient level report, with subsequent sharing to the wider emergency laparotomy team remains a significant challenge. This limits the ability of staff to reflect and learn from each episode of care in a timeframe where the delivery of care is still fresh in their memory. Is this important?
The NHS Patient Safety Strategy 2019 challenges the NHS to use technology to provide better more timely feedback to staff, not only when care is perceived to have been problematic, but also when care has gone well [Pt Safety Strat ref]. We know that when done well clinical audit and feedback drives a continuous cycle of quality improvement, but only when the following characteristics are present [audit and feedback ref]:
- Provides multiple instances of feedback to the team.
- Provides feedback as soon as possible and at a frequency informed by the number of new patient cases.
- Provides individual rather than general data.
- Closely links the visual display and summary message.
- Addresses barriers to feedback use.
- Prevent defensive reactions to feedback.
- Feedback constructed through social interaction
Typical clinical audit lacks many of these characteristics, indeed it usually includes only summative data presented once to a limited audience, long after care was delivered and in a format which can be challenging to understand and share.
QI Notify-EmLap is a digital resource which is intended to address this challenge for the emergency laparotomy pathway, enabling staff to visualise what they did well, understand why it went well, and embed this deeply into day-to-day care; delivering what works more often and more reliably.
Evidence supports this approach [audit and feedback ref], But do clinicians, managers and clinical leaders with responsibilities across the pathway believe there is a problem and do they think QI Notify can help solve it?
Assessment and methods
In July 2022 the WMAHSN hosted the 7th in a series of Emergency Laparotomy Collaboratives, at which the QI Notify-EmLap solution in use at Dudley Group NHS FT was demonstrated, explained and discussed. The session was attended by 54 delegates, with representatives from 13 of the 14 hospitals across the West Midlands, and included surgeons, anaesthetists, emergency physicians, geriatricians, theatre staff, senior managers, a Medical Director, executives and others with responsibility for the emergency laparotomy pathway. At the end of the meeting delegates were asked to indicate (Strongly agree, Agree, Neutral, Disagree, Strongly disagree, Unable to comment) the extent to which they agreed with the following statements:
- Individual patient level feedback about the delivery of care to patients on the emergency laparotomy audit, is rarely or never performed at my hospital outside of an occasional Root Cause Analysis (RCA)
- QI Notify-EmLap has the potential to fill an information gap and improve learning and understanding about what works well, and what could be improved along the emergency laparotomy pathway.
- Assuming NELA data collection was optimised, and sufficient admin support provided to allow the full adoption of QI Notify-EmLap at my hospital, then QI Notify-EmLap could lead to an improvement in quality of care and outcomes for patients undergoing an emergency laparotomy
- 65% of respondents agreed or strongly agreed that ‘Individual patient level feedback is rarely or never performed at their hospital outside of a RCA’.
Nobody (0%) disagreed or strongly disagreed, and 35% were neutral or felt unable to comment.
- 85% of respondents agreed or strongly agreed that ‘QI Notify-EmLap has the potential to fill an information gap and improve learning and understanding about what works well, and what could be improved along the emergency laparotomy pathway’.
Nobody (0%) disagreed and 15% were neutral. Nobody (0%) felt unable to comment.
- 89% of respondents agreed or strongly agreed that ‘Assuming NELA data collection was optimised, and sufficient admin support provided to allow the full adoption of QI Notify-EmLap at my hospital, then QI Notify-EmLap could lead to an improvement in quality of care and outcomes for patients undergoing an emergency laparotomy’.
Nobody (0%) disagreed or strongly disagreed and 11% were neutral or felt unable to comment.
Our survey of expert clinicians, managers and clinical leaders across the emergency laparotomy pathway confirms a lack of individualised ‘near real-time’ patient feedback in acute hospitals, as well as support for the idea that QI Notify-EmLap could fill that gap, and that such a tool should lead to embedding high quality care and subsequently lead to improved outcomes.
It is recognised that the carefully collected and clinically validated NELA datais at risk of disapearing into a ‘black whole’ before reappearing as summative feedback in to either NELA’s quarterly orannual reports. Therefore NELA encourage local teams to use their own data regularly, although the richness and frequency of local audits cans vary enormously.. Even then the outputs are summative as individual level feedback would be excessively resource heavy if done manually.
QI Notify has completed a successful pilot at Dudley group. Me Peter Waterland (Consultant colorectal surgeon) was the first to adopt the solution and has provided feedback and insight into the impact and potential offered by QI Notify-EmLap.
Evaluation of the App by Mr Peter Waterland
To access a video in which Mr Peter Waterland, Consultant Colorectal Surgeon (Dudley Group NHSFT) gives his evaluation of the QI Notify App please click below:
Here you can find further information relating to the following:
- QI-Notify-EmLap Privacy Notice – explaining how QI Notify-EmLap manages personal data
- If you are interested in finding out more about Qi Notify-Emlap in your organisation or Trust please follow this Link to our Expression Of Interest form.