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• W4385663485 abstract "The National Emergency Laparotomy Audit (NELA) is to be commended for its significant contribution to raising the standard of care for patients undergoing emergency laparotomy. We are pleased to see that the risk score has been updated to a more simplified ‘Parsimonious NELA Risk Calculator’ [1] requiring fewer clinical and biochemical parameters. Risk stratification for emergency laparotomy is now embedded in clinical practice as part of a wider bundle of standards derived from the NELA project. Some of these interventions, such as postoperative ICU admission and consultant presence in theatre, depend on this risk stratification, with patients being designated ‘high risk’ depending on the underlying risk calculation. There are also potential financial consequences for Trusts failing to meet targets based on the delivery of these interventions, such as NELA best-practice tariffs [2]. In addition, outlier Trusts can be identified through exponentially weighted moving averages charts and flagged to national regulatory bodies. We have been working to include the NELA calculation in an upcoming electronic health record implementation to continue to improve care for patients undergoing emergency laparotomy. During this process, a discrepancy was identified between the online calculator [1] and the published model calculation [3] from August 2020. The discrepancy is related to the centring of pulse and systolic blood pressure (SBP). The centring for a pulse in the publication was ‘Pulse – 91’ and the centring for SBP was ‘SBP – 127’. However, in the online calculator source code [4], the centring was ‘Pulse – 92’ and ‘SBP – 128’ (Box 1). This would mean that, potentially, every calculation performed within the old scoring system was subject to a small degree of error. We have demonstrated a calculation based on one dataset where this can be shown to affect the outcome around the threshold for requiring consultant surgical and anaesthetic input and critical care admission [5]. On close review of the source materials, there appears to have been a change made to these centring values between the commissioning of the web-based risk calculator in November 2016 and peer-reviewed publication of the model in 2018 [6]. // bp var bp = parseInt(risk.bp); if (bp > 190) {bp = 190 } if (bp < 70) {bp = 70 } b1 = SysBPWins * (bp - 128); b2 = SysBPSqWins * Math. pow((bp - 128), 2); bp = b1 + b2; // pulse var pulse = parseInt(risk. pulse); if (pulse >145) {pulse = 145 } if (pulse <55) {pulse = 55 } p1 = PulseWins * (pulse - 92); p2 = PulseSqWins * Math. pow((pulse - 92), 2); pulse = p1 + p2; We alerted the NELA project team of this discrepancy in November 2022 but the error in the online calculator remained uncorrected until the release of the new Parsimonious NELA Risk Calculator in April 2023. We have not received any details of any review of the implications of this discrepancy on the wider dataset or of any review of the governance processes around the implementation of changes to the NELA risk model. We note that, at the time of writing, the correct centring values are used within the NELA portal. It is unclear when this correction was applied or which version of the calculation code has been used to derive risk for previously locked cases. It is also unclear if the same calculation code has been used in the NELA data collection tool (used for reporting and to adjust the NELA risk model over time) and the separate online calculator, commonly used to augment clinical decision-making. Beyond influencing clinical practice previously, the possible implications of this uncertainty could even mean that development of the parsimonious model may have relied on an erroneous model, thus potentially invalidating it. We believe the methodology for the both the derivation and implementation of this calculation should be thoroughly tested, be reliable and have clear and accountable oversight. We are concerned there has been an apparent reduction in testing of the implementation of the new score; internal self-testing has been removed alongside the CE marking, potentially indicating a move away from compliance with medical device regulations. We also invite the NELA group to consider developing an application programming interface (API) in full compliance with MHRA medical device regulations [7], which would allow easier integration into electronic health records, whereby datasets could be passed to the API and the result returned to the user. The benefits of this would include having a definitive source of truth and avoiding potential errors when trying to integrate NELA scoring within electronic record systems. It would also be helpful for the NELA group to provide an official test dataset to validate their own and third-party implementations of the calculation. We look forward to reading the upcoming publication detailing the revised NELA score and commend the NELA project team for ensuring the NELA calculation is open to users within the online risk calculator. We urge that the NELA project team investigate the implications of the discrepancy identified and consider their internal processes to quality assure the NELA risk calculation. Established models of open-source software development in collaboration with the external user base would give continued confidence in NELA to continue to improve outcomes for emergency laparotomy patients in the future." @default.
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• W4385663485 date "2023-08-08" @default.
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• W4385663485 title "Reassessing the numbers: discrepancies, implications and potential solutions for the <scp>NELA</scp> Risk Calculator" @default.
• W4385663485 cites W2888124966 @default.
• W4385663485 doi "https://doi.org/10.1111/anae.16073" @default.
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