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Stephens TJ, Peden CJ, Haines R, Grocott MPW, Murray D, Cromwell D, Johnston C, Hare S, Lourtie J, Drake S, Martin GP, Pearse RM. Hospital-level evaluation of the effect of a national quality improvement programme: time-series analysis of registry data. BMJ Qual Saf 2019; 29:623-635. [PMID: 31515437 DOI: 10.1136/bmjqs-2019-009537] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 08/07/2019] [Accepted: 08/23/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND OBJECTIVES A clinical trial in 93 National Health Service hospitals evaluated a quality improvement programme for emergency abdominal surgery, designed to improve mortality by improving the patient care pathway. Large variation was observed in implementation approaches, and the main trial result showed no mortality reduction. Our objective therefore was to evaluate whether trial participation led to care pathway implementation and to study the relationship between care pathway implementation and use of six recommended implementation strategies. METHODS We performed a hospital-level time-series analysis using data from the Enhanced Peri-Operative Care for High-risk patients trial. Care pathway implementation was defined as achievement of >80% median reliability in 10 measured care processes. Mean monthly process performance was plotted on run charts. Process improvement was defined as an observed run chart signal, using probability-based 'shift' and 'runs' rules. A new median performance level was calculated after an observed signal. RESULTS Of 93 participating hospitals, 80 provided sufficient data for analysis, generating 800 process measure charts from 20 305 patient admissions over 27 months. No hospital reliably implemented all 10 processes. Overall, only 279 of the 800 processes were improved (3 (2-5) per hospital) and 14/80 hospitals improved more than six processes. Mortality risk documented (57/80 (71%)), lactate measurement (42/80 (53%)) and cardiac output guided fluid therapy (32/80 (40%)) were most frequently improved. Consultant-led decision making (14/80 (18%)), consultant review before surgery (17/80 (21%)) and time to surgery (14/80 (18%)) were least frequently improved. In hospitals using ≥5 implementation strategies, 9/30 (30%) hospitals improved ≥6 care processes compared with 0/11 hospitals using ≤2 implementation strategies. CONCLUSION Only a small number of hospitals improved more than half of the measured care processes, more often when at least five of six implementation strategies were used. In a longer term project, this understanding may have allowed us to adapt the intervention to be effective in more hospitals.
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Affiliation(s)
- Timothy J Stephens
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Carol J Peden
- Department of Anesthesiology, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Ryan Haines
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | | | - Dave Murray
- Department of Anaesthesia, James Cook University Hospital, Middlesbrough, UK
| | - David Cromwell
- Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Carolyn Johnston
- Department of Anaesthesia, St Georges University Hospital NHS Foundation Trust, London, UK
| | - Sarah Hare
- Department of Aneasthesia, Medway Maritime Hospital, Gillingham, Kent, UK
| | | | | | | | - Rupert M Pearse
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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Dhesi J, Moonesinghe SR, Partridge J. Comprehensive Geriatric Assessment in the perioperative setting; where next? Age Ageing 2019; 48:624-627. [PMID: 31147709 DOI: 10.1093/ageing/afz069] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Indexed: 11/13/2022] Open
Abstract
Comprehensive Geriatric Assessment (CGA) is being employed in the perioperative setting to improve outcomes for older surgical patients. Traditionally CGA is delivered by a geriatrician led multidisciplinary team but with the acknowledged workforce challenges in geriatric medicine, it has been suggested that non-geriatricians may be able to deliver CGA. HOW-CGA developed a toolkit to facilitate the delivery of CGA by non-geriatricians in the perioperative setting. Across two hospital sites uptake and implementation of this toolkit was limited by a potential lack of face validity, behavioural and cultural barriers and an acknowledgement that geriatric medicine expertise is key to CGA and optimisation. In-keeping with this finding there has been an observed expansion in geriatrician led CGA services for older surgical patients in the UK. In order to demonstrate the effectiveness of perioperative CGA services, implementation science should be combined with health services research methodology and the use of big data through linked national audit.
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Affiliation(s)
- Jugdeep Dhesi
- Perioperative medicine for Older People undergoing Surgery (POPS), Guy’s and St Thomas’ NHS Foundation Trust, London
- Primary Care and Public Health Sciences, Faculty of Life Sciences and Medicine, King’s College London
| | - S Ramani Moonesinghe
- University College London Hospitals & National Institute of Health Biomedical Research Centre, London, UK
| | - Judith Partridge
- Perioperative medicine for Older People undergoing Surgery (POPS), Guy’s and St Thomas’ NHS Foundation Trust, London
- Primary Care and Public Health Sciences, Faculty of Life Sciences and Medicine, King’s College London
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Stephens TJ, Bamber JR, Beckingham IJ, Duncan E, Quiney NF, Abercrombie JF, Martin G. Understanding the influences on successful quality improvement in emergency general surgery: learning from the RCS Chole-QuIC project. Implement Sci 2019; 14:84. [PMID: 31443689 PMCID: PMC6708165 DOI: 10.1186/s13012-019-0932-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 04/05/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Acute gallstone disease is the highest volume Emergency General Surgical presentation in the UK. Recent data indicate wide variations in the quality of care provided across the country, with national guidance for care delivery not implemented in most UK hospitals. Against this backdrop, the Royal College of Surgeons of England set up a 13-hospital quality improvement collaborative (Chole-QuIC) to support clinical teams to reduce time to surgery for patients with acute gallstone disease requiring emergency cholecystectomy. METHODS Prospective, mixed-methods process evaluation to answer the following: (1) how was the collaborative delivered by the faculty and received, understood and enacted by the participants; (2) what influenced teams' ability to improve care for patients requiring emergency cholecystectomy? We collected and analysed a range of data including field notes, ethnographic observations of meetings, and project documentation. Analysis was based on the framework approach, informed by Normalisation Process Theory, and involved the creation of comparative case studies based on hospital performance during the project. RESULTS Chole-QuIC was delivered as planned and was well received and understood by participants. Four hospitals were identified as highly successful, based upon a substantial increase in the number of patients having surgery in line with national guidance. Conversely, four hospitals were identified as challenged, achieving no significant improvement. The comparative analysis indicate that six inter-related influences appeared most associated with improvement: (1) achieving clarity of purpose amongst site leads and key stakeholders; (2) capacity to lead and effective project support; (3) ideas to action; (4) learning from own and others' experience; (5) creating additional capacity to do emergency cholecystectomies; and (6) coordinating/managing the patient pathway. CONCLUSION Collaborative-based quality improvement is a viable strategy for emergency surgery but success requires the deployment of effective clinical strategies in conjunction with improvement strategies. In particular, achieving clarity of purpose about proposed changes amongst key stakeholders was a vital precursor to improvement, enabling the creation of additional surgical capacity and new pathways to be implemented effectively. Protected time, testing ideas, and the ability to learn quickly from data and experience were associated with greater impact within this cohort.
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Affiliation(s)
- Timothy J. Stephens
- William Harvey Research Institute, Queen Mary University of London, c/o ACCU RESEARCH TEAM, 4th Floor, Central Tower, The Royal London Hospital, LONDON, E1 1BB United Kingdom
| | | | - Ian J. Beckingham
- Department of Hepatobiliary and Pancreatic Surgery, The Queens Medical Centre, Nottingham, UK
| | - Ellie Duncan
- Department of Professional Standards, The Royal College of Surgeons of England, London, UK
| | - Nial F. Quiney
- Department of Anaesthesia, Royal Surrey County Hospital, Guildford, UK
| | | | - Graham Martin
- THIS Institute (The Healthcare Improvement Studies Institute), University of Cambridge, Cambridge, UK
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Stephens T, Pearse RM. Learning from the EPOCH trial (Editorial). What we have learnt from a trial of an intervention to improve survival following emergency laparotomy. Anaesth Crit Care Pain Med 2019; 38:321-322. [DOI: 10.1016/j.accpm.2019.06.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 06/17/2019] [Indexed: 10/26/2022]
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Molliex S, Lanoiselée J, Bruckert V. The EPOCH trial: A non-resolved dilemma between ambition and pragmatism? Anaesth Crit Care Pain Med 2019; 38:319-320. [PMID: 31345405 DOI: 10.1016/j.accpm.2019.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Serge Molliex
- Saint-Etienne University Hospital, Jean-Monnet University, Saint-Etienne, France.
| | - Julien Lanoiselée
- Saint-Etienne University Hospital, Jean-Monnet University, Saint-Etienne, France
| | - Vincent Bruckert
- Réanimation médico-chirurgicale et transplantation d'organes, hôpital l'Archet 2, Nice university hospital - Groupe jeunes - french society of anaesthesia and intensive care medicine (SFAR)
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Wagstaff D, Moonesinghe SR, Fulop NJ, Vindrola-Padros C. Qualitative process evaluation of the Perioperative Quality Improvement Programme (PQIP): study protocol. BMJ Open 2019; 9:e030214. [PMID: 31296515 PMCID: PMC6624057 DOI: 10.1136/bmjopen-2019-030214] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 05/30/2019] [Accepted: 06/07/2019] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION The Perioperative Quality Improvement Programme (PQIP) is designed to measure complications after major elective surgery and improve these through feedback of data to clinicians. Previous research suggests that despite the significant resources which go into collecting data for national clinical audits, the information they contain is not always used effectively to improve local services. METHODS AND ANALYSIS We will conduct a formative process evaluation of PQIP comprising a multisited qualitative study to analyse PQIP's programme theory, barriers, facilitators and wider contextual factors that influence implementation. The research will be carried out with the PQIP project team and six National Health Service (NHS) Trusts in England, selected according to geographical location, type of hospital, size and level of engagement with PQIP. We will include one Trust which has not expressed interest in the PQIP for comparison and to explore the role of secular trend in any changes in practice. We will use semi-structured interviews (up to 144 in Trusts and 12 with the project team), non-participant observations (up to 150 hours) and documentary analysis. We will track the lifecycle of perioperative data, exploring the transformations it undergoes from creation to use. We will use framework analysis with categories both from our research questions and from themes emerging from the data. ETHICS AND DISSEMINATION Ethical approval has been granted from the University College London Research Ethics Committee (ref 10375/001). Permissions to conduct research at NHS Trusts have been granted by local Research and Development offices in coordination with the Health Research Authority. We will follow guidelines for data security, confidentiality and information governance. Findings will be shared at regular time points with the PQIP project team to inform the implementation of the programme, and with participating NHS Trusts to help them reflect on how they currently use data for improvement of perioperative services.
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Affiliation(s)
- Duncan Wagstaff
- Health Services Research Centre, Royal College of Anaesthetists, London, UK
- Centre for Perioperative Medicine, Research Department of Targeted Intervention, University College London, London, UK
| | - S Ramani Moonesinghe
- Health Services Research Centre, Royal College of Anaesthetists, London, UK
- Centre for Perioperative Medicine, Research Department of Targeted Intervention, University College London, London, UK
| | - Naomi J Fulop
- Department of Applied Health Research, University College London, London, UK
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Peden CJ, Stephens T, Martin G, Kahan BC, Thomson A, Rivett K, Wells D, Richardson G, Kerry S, Bion J, Pearse RM. Effectiveness of a national quality improvement programme to improve survival after emergency abdominal surgery (EPOCH): a stepped-wedge cluster-randomised trial. Lancet 2019; 393:2213-2221. [PMID: 31030986 DOI: 10.1016/s0140-6736(18)32521-2] [Citation(s) in RCA: 104] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Revised: 10/01/2018] [Accepted: 10/05/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Emergency abdominal surgery is associated with poor patient outcomes. We studied the effectiveness of a national quality improvement (QI) programme to implement a care pathway to improve survival for these patients. METHODS We did a stepped-wedge cluster-randomised trial of patients aged 40 years or older undergoing emergency open major abdominal surgery. Eligible UK National Health Service (NHS) hospitals (those that had an emergency general surgical service, a substantial volume of emergency abdominal surgery cases, and contributed data to the National Emergency Laparotomy Audit) were organised into 15 geographical clusters and commenced the QI programme in a random order, based on a computer-generated random sequence, over an 85-week period with one geographical cluster commencing the intervention every 5 weeks from the second to the 16th time period. Patients were masked to the study group, but it was not possible to mask hospital staff or investigators. The primary outcome measure was mortality within 90 days of surgery. Analyses were done on an intention-to-treat basis. This study is registered with the ISRCTN registry, number ISRCTN80682973. FINDINGS Treatment took place between March 3, 2014, and Oct 19, 2015. 22 754 patients were assessed for elegibility. Of 15 873 eligible patients from 93 NHS hospitals, primary outcome data were analysed for 8482 patients in the usual care group and 7374 in the QI group. Eight patients in the usual care group and nine patients in the QI group were not included in the analysis because of missing primary outcome data. The primary outcome of 90-day mortality occurred in 1210 (16%) patients in the QI group compared with 1393 (16%) patients in the usual care group (HR 1·11, 0·96-1·28). INTERPRETATION No survival benefit was observed from this QI programme to implement a care pathway for patients undergoing emergency abdominal surgery. Future QI programmes should ensure that teams have both the time and resources needed to improve patient care. FUNDING National Institute for Health Research Health Services and Delivery Research Programme.
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Affiliation(s)
- Carol J Peden
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Tim Stephens
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, London, UK
| | - Graham Martin
- Health Sciences, University of Leicester, Leicester, UK
| | - Brennan C Kahan
- Pragmatic Clinical Trials Unit, Barts and The London School of Medicine and Dentistry, London, UK
| | - Ann Thomson
- Pragmatic Clinical Trials Unit, Barts and The London School of Medicine and Dentistry, London, UK
| | | | | | | | - Sally Kerry
- Pragmatic Clinical Trials Unit, Barts and The London School of Medicine and Dentistry, London, UK
| | - Julian Bion
- Institute of Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Rupert M Pearse
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, London, UK.
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Charlesworth M, Agarwal S. Recycling old data – an ethical and pragmatic way to generate new evidence? Anaesthesia 2019; 74:1087-1090. [DOI: 10.1111/anae.14648] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2019] [Indexed: 12/14/2022]
Affiliation(s)
- M. Charlesworth
- Department of Cardiothoracic Anaesthesia Wythenshawe Hospital Manchester University Hospitals NHS Foundation Trust ManchesterUK
| | - S. Agarwal
- Department of Cardiothoracic Anaesthesia Manchester Royal Infirmary Manchester University Hospitals NHS Foundation Trust Manchester UK
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Stephens TJ, Peden CJ, Pearse RM, Shaw SE, Abbott TEF, Jones EL, Kocman D, Martin G. Correction to: Improving care at scale: process evaluation of a multi-component quality improvement intervention to reduce mortality after emergency abdominal surgery (EPOCH trial). Implement Sci 2018; 13:148. [PMID: 30526645 PMCID: PMC6287357 DOI: 10.1186/s13012-018-0840-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 11/19/2018] [Indexed: 11/30/2022] Open
Affiliation(s)
- T J Stephens
- Critical Care and Perioperative Medicine Research Group, WHRI, c/o Adult Critical Care Unit, The Royal London Hospital, London, E11BB, UK.
| | - C J Peden
- Keck School of Medicine, University of Southern California, Los Angeles, USA
| | - R M Pearse
- Critical Care and Perioperative Medicine Research Group, WHRI, c/o Adult Critical Care Unit, The Royal London Hospital, London, E11BB, UK
| | - S E Shaw
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - T E F Abbott
- Critical Care and Perioperative Medicine Research Group, WHRI, c/o Adult Critical Care Unit, The Royal London Hospital, London, E11BB, UK
| | - E L Jones
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - D Kocman
- SAPPHIRE Group, Department of Health Sciences, University of Leicester, Leicester, UK
| | - G Martin
- THIS Institute (The Healthcare Improvement Studies Institute), University of Cambridge, Cambridge, UK
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