ABSTRACT
Background
Patients undergoing high‐risk emergency abdominal surgery have a high risk of postoperative complications and mortality. International studies suggest that standardised care protocol guidelines may improve outcomes, yet little is known about the dissemination of such guidelines in Denmark.
Methods
We conducted a nationwide cross‐sectional survey among Danish public hospitals treating high‐risk emergency abdominal surgical patients. Anaesthesiologists and surgeons responsible for emergency abdominal surgery were invited to report on the presence of joint care protocols, including core components, audit practices and barriers to implementation.
Results
A total of 35 out of 41 eligible departments (85%) responded, representing 20 out of 23 hospitals. Almost all participating hospitals (95%) reported having a joint guideline for high‐risk emergency abdominal surgery. The most included components were antibiotics within 3 h (90%), CT scan within 2 h (90%) and intended surgery within 6 h. Only 47% of hospitals showed agreement between surgeons and anaesthesiologists on six or more core components. Audits were conducted in 90% of hospitals, with variations between departments in audit methods and focus. The most frequently reported barriers were limited resources in specialised units, surgical capacity and time constraints.
Conclusion
This survey showed that nearly all Danish hospitals treating high‐risk emergency abdominal surgical patients reported having a joint guideline endorsed by both the surgical and anaesthesiology departments. Time‐critical components aiming at early diagnosis and treatment were the most frequently included core components in the guideline.
Editorial Comment
This survey‐based report describes how many Danish hospitals have a local guiding document for perioperative anaesthesia and surgical care for cases of high‐risk emergency abdominal surgery. The most common components of these across hospitals are described.
1. Introduction
Patients undergoing high‐risk emergency abdominal surgery have a high mortality rate and a high postoperative complication rate [1]. Studies have shown that the 30‐day mortality rate in Denmark is between 17% and 22% and even higher amongst elderly patients [1, 2, 3, 4, 5]. Factors associated with an increase in mortality and postoperative complications include the clinical condition of the patients preoperatively and sepsis as well as the lack of timely recognition and treatment of postoperative complications in high‐risk patients [5, 6]. Additionally, there has been an underutilisation of intensive care beds for patients who are at high risk of death [7].
During the last 15 years, several studies from primarily the United Kingdom and Denmark have shown that the implementation of a standardised care protocol for patients undergoing high‐risk emergency abdominal surgery might reduce mortality [8, 9, 10, 11, 12, 13]. The purpose of standardised care protocols is to ensure that patients consistently receive high‐quality care before, during and after surgery. Some of the main components reported include early antibiotics, expedited surgery, involvement of a senior surgeon or anaesthetist and implementation of postoperative intermediate care [9, 10, 12]. A recent systematic review showed that the number of components that the studies aimed to optimise varied between 6 and 37 components [8].
In recent times, national initiatives in the United Kingdom and Denmark have been aimed at supporting hospitals in implementing standardised care protocols in emergency surgery and in monitoring the quality of care provided [14, 15]. There are currently no official Danish national guidelines on which components of the standardised care protocol should be implemented. In the Danish Emergency Surgical Quality Database, some key components are sought to be monitored, but the database has been incomplete [16].
In this survey, we aim to investigate whether Danish hospitals have a standardised care protocol for patients undergoing high‐risk emergency abdominal surgery and to assess which core components are part of these protocols. Furthermore, how quality of care is monitored and which barriers are encountered during the implementation process.
2. Method
2.1. Design and Approvals
We conducted a Danish nationwide cross‐sectional survey in Denmark with self‐reported data from surgeons and anaesthetists. The survey was conducted via SurveyXact, an online electronic questionnaire system allowing collection of pseudo‐anonymous data [17]. The study did not require ethical approval according to Danish law. Informed consent was obtained from all participants before study participation. The project was approved by the Danish Data Protection Agency (RegionH, DK, journal‐nr.: P‐2022‐872). This paper is presented in accordance with the Consensus‐based Checklist for Reporting of Survey Studies (CROSS) [18].
2.2. Participants
All Danish public hospitals with an abdominal surgical department were invited to participate in the survey. For departments performing high‐risk emergency abdominal surgery (bowel obstruction, perforated intestine, bowel ischemia), the head of department anaesthetists and surgeons were asked to appoint the anaesthetist/surgeon responsible for the high‐risk emergency abdominal surgery patients to answer the questionnaire. In Denmark, emergency care is solely handled by public care facilities.
2.3. Questionnaire Design
The research group developed the questionnaire to explore whether Danish hospitals have standardised care protocols for high‐risk emergency abdominal surgery patients.
We focused on five main topics:
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Is there a complete local guideline that both anaesthetists and surgeons agree upon? If not, what is the implementation status?
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Which core components are included in the guidelines?
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How are the care protocol compliance and mortality monitored?
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What are the barriers to implementing a guideline endorsed by anaesthetists and surgeons?
2.4. Defining Core Components
To identify the most frequently studied components used in standardised care protocols, we conducted a search on the National Library of Medicine (PubMed) for original articles related to standardised care protocols for these patients (September 2022) [19]. We included 16 articles with a standard care protocol for patients undergoing high‐risk emergency abdominal surgery, in which we found 92 quality improvement components [9, 10, 11, 12, 13, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30]. Based on the condensations, we ended up with 10 core components in the questionnaire. For further details, please refer to the supplemental information, Figure S1. These core components were explored in the developed questionnaire (see Figures S2 and S3, Danish and English version, respectively). The surveyed core components are listed in Table 1.
TABLE 1.
Standardised care protocol core components surveyed.
| Early antibiotics within 3 h after arrival at the hospital |
| Preoperative sepsis screening |
| CT scan within 2 h after arrival at the hospital |
| Surgery as soon as possible or within 6 h after arrival at the hospital |
| Involvement of senior surgeon and anaesthetist in intraoperative patient care |
| Perioperative goal‐directed fluid therapy |
| Epidural as standard analgesia for laparotomy |
| All or some stratified patients are admitted to high dependency unit/intensive care unit (HDU/ICU) postoperative |
| Postoperative standard nursing care plan, including pain assessment, early nutrition and early mobilisation |
| Postoperative respiratory physical therapy |
2.5. Validation of the Questionnaire
The questionnaire was validated by experienced emergency surgeons, on‐call elective surgeons and anaesthetists with emergency experience from our hospital, which has had a standard care protocol since 2017. In the last round the questionnaire was validated by an emergency surgeon and an anaesthetist with emergency experience from a different hospital, which was ahead in the standard care protocol implementation. The questionnaire development consisted of internal and external content and cognitive validation, using cognitive interviews [31]. The validation process consisted of three rounds (Figure S4).
2.6. Outcomes
2.6.1. Primary Outcome
The prevalence of Danish hospitals with a joint guideline for the optimisation of high‐risk emergency abdominal surgery, which is endorsed by both the surgical and anaesthesiology departments.
2.6.2. Secondary Outcomes
Exploring which core components are included in the care protocol. Degree of consensus measured by prevalence of hospitals with agreement between surgeons and anaesthetists on six or more core components. Prevalence of hospitals conducting audits. Furthermore, exploring how audits are conducted and barriers to the implementation of a care protocol.
2.7. Statistical Plan
The data will be presented descriptively with categorical data presented as numbers, percentages and 95% confidence intervals (95% CI). Statistics are calculated in Excel (Microsoft, version 16).
3. Results
The survey was initiated in December 2023 and concluded in April 2024.
Forty‐four departments, 24 anaesthesiology and 20 surgical departments, were invited to participate in the survey. Three departments did not perform emergency abdominal surgery. The response rate was 35 of 41 departments (85.4%). Of the 23 hospitals invited, two were subsequently excluded for not conducting emergency abdominal surgery, and one was excluded due to a lack of response. Thirty‐five specialists from 20 hospitals participated in our survey (Figure S5).
3.1. Standardised Care Protocol Guidelines and Core Components Included
At all 20 hospitals, either the surgeon or the anaesthetist answered that they had a joint guideline standardising care of emergency high‐risk abdominal surgical patients.
In 19 of 20 hospitals (95%, CI 85.4–104.5), the surgeons and anaesthesiologists agreed on a joint guideline. In one hospital, the anaesthesiologists reported not having a joint guideline.
In addition to the surgical and anaesthesiology departments, the radiology department (20), the emergency department (19), the biochemistry department (9) and the porter service (7) were involved in the guideline.
Ten core components from 20 hospitals in Denmark are displayed in Figure 1. Antibiotics within 3 h and CT scan within 2 h (90%) were the most frequently included core components of the 10 core components evaluated (Figure 1). When preoperative sepsis screening was done, qSOFA was the most frequently used screening tool.
FIGURE 1.
Agreement of care protocol core components in Danish anaesthesiologists and abdominal surgeons in charge of high‐risk emergency abdominal surgery, 2024. Mixed consensus: yes from at least one department. HDU: high dependency unit. ICU: intensive care unit.
Twelve hospitals reported that both a senior anaesthesiologist and a senior surgeon should be involved in intraoperative care. One hospital indicated that only a senior surgeon should be involved, while three hospitals stated that only an anaesthesiologist should be involved.
Eighteen hospitals used planned postoperative HDU/ICU, 15 of 18 (83%) based on a risk score or other risk factors and in 3 of 18 (17%) all patients were admitted to the HDU/ICU regardless of their risk.
Sixteen hospitals reported postoperative nursing care plans, 15 of which included mobilisation within 24 h postoperatively. Fourteen had a nutritional plan within 48 h postoperatively. Only 10 included postoperative pain assessment.
3.2. Consensus on Joint Guideline
Of the 15 of 20 hospitals with responses from both departments, 7 of 15 (47%, 95% CI 21.4–72) reported agreement on having a joint guideline and had agreement on six or more core components. In Figure 2, the degree of consensus of the 10 core components is displayed.
FIGURE 2.
Degree of consensus, based on the number of core components included at 15 hospitals with responses from both the anaesthesiology and surgery departments treating high‐risk emergency abdominal surgery patients in Denmark, 2024.
3.3. Audit
Eighteen (90%, 95% CI 76.8–103.1) of the 20 surveyed hospitals reported conducting audits of emergency high‐risk abdominal surgical patients.
An audit of surgery within 6 h was reported by all 18 hospitals. Mortality was audited by 17 of 18 (94%), and antibiotics given within 3 h were audited by 13 of 18 (72%).
Thirteen (87%) hospitals report their audits to either an emergency abdominal surgery team or another interdisciplinary team.
3.4. Barriers to Standardised Care Protocol Guidelines for High‐Risk Emergency Abdominal Surgery
The three most frequently reported barriers by 14 hospitals (70%, 95% CI 49.9–90) for local joint guidelines implementation were inadequate capacity in specialised units (intermediate unit, intensive care unit or recovery/perioperative units), inadequate surgery capacity and insufficient time to organise and implement the guidelines (Figure 3).
FIGURE 3.
Barriers to implementation of local care protocol guidelines in high‐risk emergency abdominal surgery in Denmark, 2024. Other: Concerns about the time spent on suspected high‐risk emergency abdominal surgery patients increase the risk of a worse prognosis for different patients. High turnover of staff, especially in the emergency department.
4. Discussion
This Danish nationwide survey, with a response rate of 85% from the eligible departments, showed that 95% of hospitals had a joint guideline standardising the care of emergency high‐risk abdominal surgery patients. The most frequent core components were antibiotics within 3 h and a CT scan within 2 h, as reported by 90% of hospitals. However, looking at the degree of consensus between key surgeons and anaesthesiologists in each hospital, 47% agreed on six or more core components when reporting guideline content. The most frequent barriers to implementation of a joint guideline were limited resources for implementation, limited surgical capacity and limited specialised unit capacity for postoperative care.
Our study showed that almost all the surveyed emergency surgical hospitals in Denmark treating high‐risk abdominal surgical patients had a joint guideline that included both the surgical and anaesthesiology departments. To our knowledge, this is the first national survey on care protocol guideline dissemination across Danish hospitals in high‐risk abdominal surgery.
Studies on Enhanced Recovery After Surgery (ERAS) guidelines in elective surgeries show a dissemination rate of 70% of hospitals [32, 33]. This is a low dissemination rate, considering that ERAS in elective surgery, especially in colorectal surgery, has been a common practice for the last 30 years [34]. Our findings demonstrated a widespread adoption of standardised care principles for emergency surgery in Denmark. Several reasons can explain this high adherence to standardised patient care in emergency surgery. During the last 20 years, there has been an increased focus on emergency surgery patients. Several studies have been conducted on the topic, suggesting an optimised approach to perioperative care [5, 10, 35]. The Danish Emergency Surgical Quality Database was established in 2003 to monitor emergency abdominal surgery patients and is a part of the national quality monitoring initiative coordinated by the regional authorities in Denmark [16].
The three most frequently reported components in local joint guidelines are all process indicators included in the Danish Emergency Surgical Quality Database, whereas other core components, such as preoperative sepsis screening, goal‐directed fluid therapy and postoperative respiratory physiotherapy, are not currently reported. The public reporting of specific process indicators may influence which components are prioritised when departments develop local joint guidelines in this area in the absence of a national guideline [14, 16].
We found that in 47% of hospitals, key surgeons and anaesthesiologists agreed on six or more core components of the care protocol, indicating inconsistency in consensus on some core components, mirroring the difference between having a guideline and achieving consensus on its contents. As key clinicians are knowledgeable of the components of the joint guidelines and were encouraged to consult guidelines, the discrepancy might reflect differences in the clinical roles of surgeons and anaesthetists.
In this study, we focused on the presence of a local joint guideline and its core components. The first step in quality improvement is to agree on the core components and develop a local guideline. This is particularly important because a recent systematic review found considerable variation in the components of protocolised care pathways for emergency abdominal surgery, highlighting a lack of standardisation across existing pathways [36]. These basic requirements are key before it is possible to monitor the individual components, which is best done through continuous monitoring of process indicators, such as in national quality databases [37]. The Danish Emergency Surgical Quality Database has included major emergency abdominal surgery since 2020. While still under development, incomplete data is a challenge as data from electronic journal systems does not flow freely and supplemental data must be entered manually [16]. However, data on surgery within 6 h of admission is based on administrative data from national health registers, which has been shown to be reliable [38]. In the 2025 Danish Emergency Surgical Quality Database report [39], the process indicator ‘surgery within 6 h’ was met in only 34% of patients. Our survey showed that the component ‘surgery within 6 h’ was frequently part of the local guidelines; despite this, very few patients undergo surgery within 6 h.
The involvement of a senior physician in intraoperative care is a commonly occurring core component in previous publications [9, 10, 11, 13, 20, 26, 27, 29, 30], with our study revealing that only 55% of Danish hospitals had included involvement of senior physicians in their local guideline. Ensuring the presence of senior physicians during emergency abdominal surgery poses practical challenges, particularly for smaller regional hospitals where 24/7 on‐site consultant availability may not be feasible. Furthermore, the absence of this indicator in the Danish Emergency Surgical Quality Database might reduce the incentive for hospitals to consistently involve senior physicians in intraoperative care. In contrast, The National Emergency Laparotomy Audit in the United Kingdom has included the presence of both anaesthetic and surgical consultants as a quality measure, with > 92% fulfilment reported in 2025 [40]. If this is to be implemented as a process indicator in the Danish Emergency Surgical Quality Database, it is important to have a clear definition of the extent of senior physicians' involvement.
With our findings of 90% of Danish hospitals conducting audits of high‐risk abdominal surgical patients, the value of audit and quality monitoring appears standardised. Our findings suggest that time‐critical interventions and mortality are the primary focus of current audits. Future quality monitoring should also incorporate patient‐reported outcome measures to reflect the quality of care that is important to patients and their quality of life [41].
Our findings suggest that local quality monitoring is prioritised; however, to support implementation and sustain prioritisation, it is essential to maintain and further develop national quality databases, such as the Danish Emergency Surgical Quality Database, thereby motivating stakeholders to allocate resources. However, local audits remain vital for evaluating the implementation and impact of new clinical initiatives, identifying gaps in care and promoting a culture of continuous improvement, which is also strongly recommended in new guidelines on ERAS in emergency laparotomy [42].
In Denmark, a national Learning and Quality Team for emergency high‐risk abdominal surgery was established between 2021 and 2023 to support implementation of evidence‐based practices, continuous monitoring and collaborative quality improvement across hospitals [16]. The programme aims to reduce variation in care and improve patient outcomes. Despite these initiatives, further work is needed to achieve consistent implementation of standardised local joint guidelines. The approach is consistent with other national quality improvement initiatives, such as the UK National Emergency Laparotomy Audit (NELA), which use national audit to support implementation of evidence‐based care [15].
The main barriers to implementing local joint guidelines for emergency high‐risk abdominal surgery as a whole were organisational barriers, including (1) inadequate capacity in specialised units (e.g., ICU, intermediate care, high dependency units, post‐anaesthesia care units), (2) limited surgical capacity and (3) insufficient time for organising and implementing the guidelines. Our survey found that 70% of responding hospitals reported challenges, highlighting widespread organisational constraints. In contrast, clinician‐related barriers, including lack of training, lack of a designated person responsible and lack of support from department management, were each reported by only 5% of respondents, suggesting that organisational constraints rather than clinician‐related factors were perceived as the main barriers to implementation. Our findings are consistent with the process evaluation of the EPOCH trial by Stephens et al., which showed substantial variation in how the intervention was implemented across hospitals. Organisational challenges, including limited time and resources, influenced how local teams approached implementation and which components they prioritised. Their findings also suggested clinician‐related barriers such as lack of engagement of colleagues and hospital executives. These findings support our observations that organisational constraints as well as clinician‐related barriers may represent important barriers to the implementation of standardised care protocols [43].
The strengths of this study include, first, its high national coverage, with responses from 85% of eligible Danish departments performing high‐risk emergency abdominal surgery, ensuring broad representativeness. Secondly, our extensive literature search identified relevant standardised care protocols and compiled a condensed list of the most frequently studied components. Our findings align with recently published international guidelines [44, 45]. Thirdly, the questionnaire was rigorously developed and validated through multiple rounds of internal and external review, including cognitive interviews, which strengthen the reliability of the findings.
Fourth, we ‘triangulated’ core components by surveying both anaesthesiologists and surgeons to improve sensitivity for local implementation.
However, the study also has limitations. First, the data were self‐reported, which introduces recall bias, although participants could consult their department's guidelines if in doubt. An alternative approach could have been to require the guidelines directly and review them. Second, discrepancies between surgical and anaesthetic respondents from the same hospitals may reflect differences in their familiarity or focus on speciality‐related content within the local guidelines rather than actual differences in guideline content. Finally, we received responses from both anaesthesiology and surgical departments at only 15 hospitals, which could affect the accuracy of the information reported in this study.
Future research should clarify which core components have the most significant impact on patient outcomes, including quality of life, facilitating the development, implementation and monitoring of effective standardised care protocol guidelines for high‐risk emergency abdominal surgical patients.
In conclusion, this nationwide survey demonstrated that nearly all Danish hospitals treating high‐risk emergency abdominal surgical patients reported having a joint guideline endorsed by both the surgical and anaesthesiology departments. The most frequently included components were time‐critical interventions such as administration of antibiotics within 3 h, CT scan within 2 h and surgery within 6 h, reflecting alignment with national process indicators. The most frequently reported barriers were limited resources in specialised units, surgical capacity and time constraints.
Author Contributions
The methodology and survey design: M.V.‐A., K.W. and I.V.F.G. Core component condensation: M.V.‐A., I.V.F.G. and K.W. Survey validation: M.V.‐A., I.V.F.G., K.W. and J.B. Survey distributed, data collection and data analysis: I.V.F.G. Data interpretation: I.V.F.G., M.V.‐A. and K.W. Facilitation of access to validation participants and respondents: M.V.‐A. and J.B. Drafting the initial manuscript: I.V.F.G. All authors reviewed and revised the manuscript. All authors read and approved the final version of the manuscript.
Funding
The authors have nothing to report.
Conflicts of Interest
The authors declare no conflicts of interest.
Supporting information
Figure S1: Flowchart: Condensation process.
Figure S2: Questionnaire in Danish.
Figure S3: Questionnaire in English. Translated using AI and validated by IG.
Figure S4: Flowchart: Validation process of the questionnaire.
Figure S5: Flowchart of departments and respondents, in a Danish nationwide survey of the dissemination of care protocol guidelines in high‐risk emergency abdominal surgery, 2024.
Acknowledgements
The authors thank Nicolas Storm (surgeon), Søren Kristen Lundgaard Hoffmann (anaesthesiologist), Joan Stens Petersen (surgeon), Mark Wounlund Langer (anaesthesiologist), Mette Dorthea Schlichtkrull Wiese (anaesthesiologist) and Torben Bridstrup Pedersen (anaesthesiologist) for their time and effort in the validation of the questionnaire.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Figure S1: Flowchart: Condensation process.
Figure S2: Questionnaire in Danish.
Figure S3: Questionnaire in English. Translated using AI and validated by IG.
Figure S4: Flowchart: Validation process of the questionnaire.
Figure S5: Flowchart of departments and respondents, in a Danish nationwide survey of the dissemination of care protocol guidelines in high‐risk emergency abdominal surgery, 2024.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.