title: Factors associated with adverse events after emergency laparotomy in Cape Town, South Africa: identifying opportunities for quality improvement.
abstract: 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.
  
  
  
  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.
  
  
  
  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.
  
  
  
  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.
authors.affiliation: Codman Center for Clinical Effectiveness, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts; Department of Surgery, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa. Electronic address: spnric004@myuct.ac.za.
authors.forename: Richard Trafford
authors.initials: RT
authors.lastname: Spence
authors.affiliation: Department of General Surgery, Victoria Hospital, Cape Town, South Africa.
authors.forename: Mark
authors.initials: M
authors.lastname: Hampton
authors.affiliation: Department of Surgery, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa.
authors.forename: Kent
authors.initials: K
authors.lastname: Pluke
authors.affiliation: Department of Surgery, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa.
authors.forename: Miriam
authors.initials: M
authors.lastname: Kahn
authors.affiliation: Department of Surgery, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa.
authors.forename: Nkhabe
authors.initials: N
authors.lastname: Chinyepi
authors.affiliation: Department of Surgery, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa.
authors.forename: Mohamed
authors.initials: M
authors.lastname: Elmusbahi
authors.affiliation: Department of Surgery, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa.
authors.forename: Tirsa
authors.initials: T
authors.lastname: van Wyngaard
authors.affiliation: Department of Surgery, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa.
authors.forename: Eugenio
authors.initials: E
authors.lastname: Panieri
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002648:Child; D004630:Emergencies; D005260:Female; D006801:Humans; D007813:Laparotomy; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D017063:Outcome Assessment, Health Care; D011183:Postoperative Complications / Q000453:epidemiology / Q000209:etiology*; D058996:Quality Improvement; D019984:Quality Indicators, Health Care; D012307:Risk Factors; D013019:South Africa; D055815:Young Adult
keywords: Gastrointestinal; Global Surgery; Quality Improvement; Trauma