Over the last decade, significant changes in the organisation, management and delivery of EGS services in units across the UK have resulted in improved service provision. A growing body of consultant surgeons with a special interest in EGS, combined with structural changes within these departments, have enabled the tailoring of strategic developments geared towards improving care for patients requiring EGS services. Many of these seismic shifts have been research driven. Studies reporting higher mortality rates with emergency laparotomies compared to elective cases, and others demonstrating wide variation in outcomes between trusts have highlighted the need for further research aimed at improving standards of care for emergency cases [1, 14, 15].

The National Confidential Enquiry into Patient Outcomes and Deaths (NECPOD) [16] and the National Emergency Laparotomy Audit (NELA) [6] were two studies designed to collect organised and comparative data on emergency service provision across the UK in an attempt to improve the quality of care for patients undergoing emergency surgery. The enhanced perioperative care for high-risk patients trial (EPOCH) [17] and the Emergency Laparotomy Collaborative (ELC) projects also focussed on areas in which patient outcomes could be improved. With approximately 25,000 patients undergoing emergency abdominal surgery annually in NHS hospitals with 30-day mortality rates of 9.6% [7], national clinical projects like these are essential. The Emergency Laparoscopic and Laparotomy Scottish Audit (ELLSA) aimed to capture an even more comprehensive EGS cohort than NELA by widening the inclusion of contributing sites and including laparoscopic procedures [18]. To our knowledge, this study is the first Delphi undertaken in the field of EGS and is intended to guide this much needed research and stimulate health care quality improvement.

Our modified Delphi process has produced a list of 17 high-priority research questions in the field of EGS. We adopted a non-biased approach of inviting members of two established surgical societies (ASGBI and WSES), but also publicised on Twitter in order to ensure that members of the public and patients were able to participate. Figure 2 demonstrates heat maps of the distribution of respondents prioritising research questions in Phase II (A) and III (B), respectively. The input of the latter two groups was a valued addition, with the focus of many research areas identified relating to patient experience and patient-reported outcomes.

Distribution of respondents prioritising research questions in A the first and B second phase of prioritisation

There are no defined criteria on setting cut-off consensus levels in Delphi studies [19]. Consensus levels are defined as a percentage higher than the average percentage of majority opinion [20], and many researchers have used different levels of agreement to achieve consensus. As the aim of our study was not to achieve a pre-determined consensus level, each phase of our Delphi was terminated based on subjective analysis of the number of questions remaining after each round. Following the first round of prioritisation, in the case of a 55% majority there was consensus on 41 questions, a 60% majority resulted in 23 questions and at 70% concordance 7 questions remained. To produce a manageable number of relevant questions, a majority view within the steering group chose a level of agreement of 55% for the first round of prioritisation. We chose a more strict criteria of 65% for the final list of questions, again to produce a manageable number of questions with the highest priority.

There were a number of questions that did not make the final list of prioritised questions. A ranked list of all questions is included in the Appendix (Table 3).

The Emergency Laparotomy and Frailty (ELF) study highlighted that 20% of patients undergoing emergent laparotomy in the UK are frail, presenting greater risk of post-operative morbidity and mortality, independent of age [21]. In the fourth patient report of NELA [7], researchers identified that despite evidence of improved outcomes with comprehensive geriatric assessment methodology [22], there was no improvement in the proportion of patients over the age of 70 benefiting from geriatric specialist input. This is reflected in our study. From our list of prioritised questions, a recurrent theme was consideration on focusing future research on the management of older adult and frail patients undergoing EGS.

Our final list of prioritised questions also included a significant emphasis on optimisation of EGS services and training. Further studies are also required to develop a greater understanding of optimisation of EGS patients peri-operatively, and research into technical considerations in emergency colorectal surgery is required to guide potential improvements in survival outcomes. The study’s results are particularly relevant in the current setting.

One major limitation we anticipated was that of survey fatigue—the tendency to not fully complete a survey when faced with several pages of questions, or reluctance to participate at all. To mitigate this, we designed the surveys with categories in reverse order between surveys.

Another limitation was the lack of patient input into this project, which risks avoiding the research areas which are of interest to patients. The intention of the study group was to hold a patient focus group at the end of Phase I. However, this was not possible as the timing coincided with the COVID-19 pandemic and the first lockdown in the UK. It was therefore decided to abandon this aspect of the study in the interest of the safety of our patients and to focus on gathering the views of members within the EGS multidisciplinary care team. Though views of EGS patients and patients’ families were still sought, they did not yield many responses. Health charities and patient support groups are often keen participants in this type of research. However, there are relatively few EGS groups compared to conditions such as Crohn’s disease and colitis [23], or bowel cancer [24], highlighting that the EGS patient group is overlooked. There is clear scope to address this limitation of our study in the future.

A final limitation of EGS research to date is the overemphasis on mortality and morbidity as outcomes, which comprise a valuable future project.

We have used this modified Delphi method to survey multiple stakeholder groups including patients, health care providers and multidisciplinary team members involved in all aspects of EGS care provision. We believe that this is an important body of work that demonstrates consensus across a broad and diverse group of stakeholders. The findings of this study can be used to guide future research studies and research funding in the EGS community.