Every year, 27,000 patients in the UK undergo emergency laparotomy—major abdominal surgery—and the NHS spends £650 million on their care, yet no standard evidence-based pathway exists to guide their recovery after the operation. This matters because post-operative care for these patients is inconsistent and outcomes are worse than they should be. Without a structured, tested approach, hospitals rely on ad hoc practices that vary widely, leaving patients with preventable complications and longer recoveries. The project aims to fill that gap by designing a co-developed care pathway—called EMERALD—that bundles medical, nursing, physiotherapy, nutritional, and psychological support into a single, deliverable intervention. If successful, the research will produce a ready-to-test post-operative pathway that could be rolled out across NHS hospitals. That would directly improve recovery for tens of thousands of patients each year, reduce the burden on surgical wards, and potentially save the health service money by cutting complications and readmissions. The project also develops a core set of outcomes and a patient-reported measure specific to emergency laparotomy, giving future trials a standard way to measure what matters.
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Background Each year 27,000 patients undergo an emergency laparotomy (EmLap). EmLap is associated with significant burden to patients and costs the NHS £650 million annually. Outcomes require improvement and post-operative care is key. Currently, evidence-based standard post-operative care pathways are lacking. Development of a high quality, cost-effective intervention for post-operative EmLap care is needed. Objectives My overall aim is to improve post-operative care and outcomes in EmLap. To understand current peri-operative processes and their impact on recovery, clinical, patient-reported and health economic outcomes. To identify core clinical and patient-reported outcomes of importance and to reach consensus on measurable outputs. To co-develop a complex intervention (EMERALD). To assess the feasibility of implementation of EMERALD. To identify the optimal trial design for a future evaluation. Methods Preparatory work for this fellowship includes a preliminary logic model of the EMERALD intervention, which will be iteratively refined. The hypothesised EMERALD intervention will consist of several components which may include medical, nursing, physiotherapy, nutritional and psychological. Work Package 1: Describing current standards of peri-operative care in EmLap I will undertake a cohort study utilising routine patient data in EmLap to identify interventions currently delivered in the peri-operative setting. Clinical, patient-reported and health economic outcomes will be collected. Sites with an established peri-operative pathway will be invited to participate in multidisciplinary team focus groups to identify facilitators of and barriers to implementation. Patients at these sites will be recruited to understand their perceptions and needs. Work Package 2: Design and development of EMERALD Identified interventions, with their associated outcomes (WP1), will be incorporated into a Delphi study and will be prioritised by an expert panel for inclusion into the overarching EMERALD intervention. Prioritised interventions will be co-developed into a post-operative care pathway jointly by patients and healthcare professionals using the principles of Experience-based Co-Design. An upfront EMERALD implementation strategy will be devised based on my findings using the principles of Normalisation Process Theory. Work Package 3: Feasibility evaluation of EMERALD I have designed a feasibility-implementation study; a sequential cohort study consisting of fixed and variable time periods with integrated process evaluation to assess the feasibility of EMERALD intervention implementation, the need for further optimisation and optimal future trial design. The study consists of five phases rolled out sequentially across five hospital sites. Work Package 4: Outcome assessment in EmLap I will supervise a PhD student (funded by Leeds University) to identify outcomes of important to clinicians and patients and develop these into a core outcome set and patient-reported outcome measure for EmLap. Impact I will have developed a high-quality, multidisciplinary, patient-centred, complex intervention and will have identified the optimal trial design for a future phase III evaluation. Results will be discussed with NHS leaders and key organisations to influence future health policy. Methodologically, this project will generate new data in EmLap including the integration of two routinely collected datasets, use of co-design and upfront implementation in EmLap complex intervention development, innovative feasibility study design and the development of EmLap specific COS and PROM.
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