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Jordan LC, Cook TM, Cook S, Dalton SJ, Collins K, Scott J, Peden CJ. Sustaining better care for patients undergoing emergency laparotomy. Anaesthesia 2020; 75:1321-1330. [DOI: 10.1111/anae.15088] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/15/2020] [Indexed: 12/20/2022]
Affiliation(s)
- L. C. Jordan
- Department of Anaesthesia and Critical Care Royal United Hospitals Bath NHS Foundation Trust Bath UK
| | - T. M. Cook
- Department of Anaesthesia and Critical Care Royal United Hospitals Bath NHS Foundation Trust Bath UK
- University of Bristol Bristol UK
| | - S.‐C. Cook
- Department of Critical Care University Hospital of Wales Cardiff UK
| | - S. J. Dalton
- Department of Surgery Royal United Hospitals Bath NHS Foundation Trust Bath UK
| | - K. Collins
- Department of Anaesthesia and Critical Care Royal United Hospitals Bath NHS Foundation Trust Bath UK
| | - J. Scott
- Department of Surgery Royal United Hospitals Bath NHS Foundation Trust Bath UK
| | - C. J. Peden
- Department of Anesthesiology, Keck Medicine University of Southern California Los Angeles CA USA
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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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Peden CJ, Stephens T, Martin G, Kahan BC, Thomson A, Everingham K, Kocman D, Lourtie J, Drake S, Girling A, Lilford R, Rivett K, Wells D, Mahajan R, Holt P, Yang F, Walker S, Richardson G, Kerry S, Anderson I, Murray D, Cromwell D, Phull M, Grocott MPW, Bion J, Pearse RM. A national quality improvement programme to improve survival after emergency abdominal surgery: the EPOCH stepped-wedge cluster RCT. HEALTH SERVICES AND DELIVERY RESEARCH 2019. [DOI: 10.3310/hsdr07320] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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.
Objectives
The objectives were to assess whether or not the QI programme improves 90-day survival after emergency abdominal surgery; to assess effects on 180-day survival, hospital stay and hospital readmission; and to better understand these findings through an integrated process evaluation, ethnographic study and cost-effectiveness analysis.
Design
This was a stepped-wedge cluster randomised trial. Hospitals were organised into 15 geographical clusters, and commenced the QI programme in random order over 85 weeks. Analyses were performed on an intention-to-treat basis. The primary outcome was analysed using a mixed-effects parametric survival model, adjusting for time-related effects. Ethnographic and economics data were collected in six hospitals. The process evaluation included all hospitals.
Setting
The trial was set in acute surgical services of 93 NHS hospitals.
Participants
Patients aged ≥ 40 years who were undergoing emergency abdominal surgery were eligible.
Intervention
The intervention was a QI programme to implement an evidence-based care pathway.
Main outcome measures
The primary outcome measure was mortality within 90 days of surgery. Secondary outcomes were mortality within 180 days, length of hospital stay and hospital readmission within 180 days. The main economic measure was the quality-adjusted life-years.
Data sources
Data were obtained from the National Emergency Laparotomy Audit database; qualitative interviews and ethnographic observations; quality-of-life and NHS resource use data were collected via questionnaires.
Results
Of 15,873 eligible patients from 93 NHS hospitals, primary outcome data were analysed for 8482 participants in the usual care group and 7374 in the QI group. The primary outcome occurred in 1393 participants in the usual care group (16%), compared with 1210 patients in the QI group (16%) [QI vs. usual care hazard ratio (HR) 1.11, 95% confidence interval (CI) 0.96 to 1.28]. No differences were found in mortality at 180 days or hospital readmission; there was a small increase in hospital stay in the QI group (HR for discharge 0.90, 95% CI 0.83 to 0.97). There were only modest improvements in care processes following QI implementation. The ethnographic study revealed good QI engagement, but limited time and resources to implement change, affecting which processes teams addressed, the rate of change and eventual success. In some sites, there were challenges around prioritising the intervention in busy environments and in obtaining senior engagement. The intervention is unlikely to be cost-effective at standard cost-effectiveness thresholds, but may be cost-effective over the lifetime horizon.
Limitations
Substantial delays were encountered in securing data access to national registries. Fewer patients than expected underwent surgery and the mortality rate was lower than anticipated.
Conclusions
There was no survival benefit from a QI programme to implement a care pathway for patients undergoing emergency abdominal surgery. The modest impact of the intervention on process measures, despite good clinician engagement, may have been limited by the time and resources needed to improve patient care.
Future work
Future QI programmes must balance intervention complexity with the practical realities of NHS services to ensure that such programmes can be delivered with the resources available.
Trial registration
Current Controlled Trials ISRCTN80682973 and The Lancet protocol 13PRT/7655.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 7, No. 32. See the NIHR Journals Library website for further project information.
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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, Queen Mary University of London, London, UK
| | - Graham Martin
- Health Sciences, University of Leicester, Leicester, UK
| | - Brennan C Kahan
- Pragmatic Clinical Trials Unit, Queen Mary University of London, London, UK
| | - Ann Thomson
- Pragmatic Clinical Trials Unit, Queen Mary University of London, London, UK
| | - Kirsty Everingham
- William Harvey Research Institute, Queen Mary University of London, London, UK
| | - David Kocman
- Health Sciences, University of Leicester, Leicester, UK
| | | | | | - Alan Girling
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | | | | | | | - Ravi Mahajan
- Faculty of Medicine & Health Sciences, University of Nottingham, Nottingham, UK
| | - Peter Holt
- Molecular and Clinical Sciences Research Institute, St George’s University of London, London, UK
| | - Fan Yang
- Centre for Health Economics, University of York, York, UK
| | - Simon Walker
- Centre for Health Economics, University of York, York, UK
| | | | - Sally Kerry
- Pragmatic Clinical Trials Unit, Queen Mary University of London, London, UK
| | - Iain Anderson
- Salford Royal Hospital NHS Foundation Trust, Manchester, UK
| | - Dave Murray
- South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - David Cromwell
- London School of Hygiene and Tropical Medicine, London, UK
| | - Mandeep Phull
- William Harvey Research Institute, Queen Mary University of London, London, UK
- Department of Anaesthesia and Intensive Care, Queen’s Hospital, Romford, UK
| | - Mike PW Grocott
- National Institute for Health Research Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Anaesthesia and Critical Care Research Unit, University of Southampton, Southampton, UK
| | - Julian Bion
- Institute of Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Rupert M Pearse
- William Harvey Research Institute, Queen Mary University of London, London, UK
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Katz M, Silverstein N, Coll P, Sullivan G, Mortensen EM, Sachs A, Gross JB, Girard E, Liang J, Ristau BT, Stevenson C, Smith PP, Shames BD, Millea R, Ali I, Poulos CM, Ramaraj AB, Otukoya AO, Nolan J, Wahla Z, Hardy C, Al-Naggar I, Bliss LA, McFadden DW. Surgical care of the geriatric patient. Curr Probl Surg 2019; 56:260-329. [DOI: 10.1067/j.cpsurg.2019.03.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Accepted: 03/13/2019] [Indexed: 12/15/2022]
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Stephens TJ, Peden CJ, Pearse RM, Shaw SE, Abbott TEF, Jones E, Kocman D, Martin G. 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; 13:142. [PMID: 30424818 PMCID: PMC6233578 DOI: 10.1186/s13012-018-0823-9] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Accepted: 10/05/2018] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Improving the quality and safety of perioperative care is a global priority. The Enhanced Peri-Operative Care for High-risk patients (EPOCH) trial was a stepped-wedge cluster randomised trial of a quality improvement (QI) programme to improve 90-day survival for patients undergoing emergency abdominal surgery in 93 hospitals in the UK National Health Service. METHODS The aim of this process evaluation is to describe how the EPOCH intervention was planned, delivered and received, at both cluster and local hospital levels. The QI programme comprised of two interventions: a care pathway and a QI intervention to aid pathway implementation, focussed on stakeholder engagement, QI teamwork, data analysis and feedback and applying the model for improvement. Face-to-face training and online resources were provided to support senior clinicians in each hospital (QI leads) to lead improvement. For this evaluation, we collated programme activity data, administered an exit questionnaire to QI leads and collected ethnographic data in six hospitals. Qualitative data were analysed with thematic or comparative analysis; quantitative data were analysed using descriptive statistics. RESULTS The EPOCH trial did not demonstrate any improvement in survival or length of hospital stay. Whilst the QI programme was delivered as planned at the cluster level, self-assessed intervention fidelity at the hospital level was variable. Seventy-seven of 93 hospitals responded to the exit questionnaire (60 from a single QI lead response on behalf of the team); 33 respondents described following the QI intervention closely (35%) and there were only 11 of 37 care pathway processes that > 50% of respondents reported attempting to improve. Analysis of qualitative data suggests QI leads were often attempting to deliver the intervention in challenging contexts: the social aspects of change such as engaging colleagues were identified as important but often difficult and clinicians frequently attempted to lead change with limited time or organisational resources. CONCLUSIONS Significant organisational challenges faced by QI leads shaped their choice of pathway components to focus on and implementation approaches taken. Adaptation causing loss of intervention fidelity was therefore due to rational choices made by those implementing change within constrained contexts. Future large-scale QI programmes will need to focus on dedicating local time and resources to improvement as well as on training to develop QI capabilities. EPOCH TRIAL REGISTRATION ISRCTN80682973 https://doi.org/10.1186/ISRCTN80682973 Registered 27 February 2014 and Lancet protocol 13PRT/7655.
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Affiliation(s)
- T. J. Stephens
- William Harvey Research Institute, Queen Mary University of London, London, UK
- Critical Care and Perioperative Medicine Research Group, Adult Critical Care Unit, Royal London Hospital, London, E1 1BB UK
| | - C. J. Peden
- Keck School of Medicine, University of Southern California, Los Angeles, USA
| | - R. M. Pearse
- William Harvey Research Institute, Queen Mary University of London, London, UK
| | - S. E. Shaw
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - T. E. F. Abbott
- William Harvey Research Institute, Queen Mary University of London, London, UK
| | - E. 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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Vashistha N, Singhal D, Budhiraja S, Aggarwal B, Tobin R, Fotedar K. Outcomes of Emergency Laparotomy (EL) Care Protocol at Tertiary Care Center from Low-Middle-Income Country (LMIC). World J Surg 2018; 42:1278-1284. [PMID: 29159605 DOI: 10.1007/s00268-017-4333-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Emergency laparotomy mortality ranges between 10 and 20% in best of Western healthcare systems and is currently a major focus for quality improvement programs. In contrast, emergency surgery scenario in LMIC is largely undefined, often neglected and complex (large burden of diseases but only limited capacity for adequate treatment). We evaluated the efficacy of 'EL care protocol' aimed at cost-effective optimal utilization of best available local expertise and infrastructure. METHODS One hundred and two consecutive adult patients (≥16 years) who underwent EL from December 2012-December 2015 at a private tertiary hospital were retrospectively analyzed. The patients who underwent emergency laparoscopic procedures were excluded from the analysis. The EL care protocol included. (1) Admission to surgical intensive care unit for pre- and postoperative optimization. (2) Preferred radiologic investigation: abdominal computed tomography (CT) scan. (3) Surgery and critical care by senior surgical gastroenterologists and internists/anesthesiologists, respectively. Outcome measures were procedure-related complications (Clavien-Dindo classification), readmissions and costs. RESULTS Of the 102 patients, there were 62 males and 40 females with median age of 60 (range 16-93) years. There were no complications in 22 (21.6%) patients, while Clavien-Dindo complications grade I or II occurred in 48 (47%) patients. Grade V Clavien-Dindo complications and the 30-day mortality were similar of 19 (18.6%). The readmission rate was 8 (7.8%). The expected mortality for the study group by P-POSSUM score was 31.2 (30.6%). The ratio (O/E) of observed to expected mortality was 0.61. The all inclusive median cost of treatment was INR 379,255 ($5590). CONCLUSIONS LMIC centers should develop their own center-specific EL care protocols to improve outcomes of EL.
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Affiliation(s)
- Nitin Vashistha
- Department of Surgical Gastroenterology, Max Super Speciality Hospital, Saket, New Delhi, 110017, India
| | - Dinesh Singhal
- Department of Surgical Gastroenterology, Max Super Speciality Hospital, Saket, New Delhi, 110017, India.
| | - Sandeep Budhiraja
- Department of Internal Medicine, Max Super Speciality Hospital, Saket, New Delhi, 110017, India
| | - Bharat Aggarwal
- Department of Radiology, Max Super Speciality Hospital, Saket, New Delhi, 110017, India
| | - Raj Tobin
- Department of Anesthesiology, Max Super Speciality Hospital, Saket, New Delhi, 110017, India
| | - Kamal Fotedar
- Department of Anesthesiology, Max Super Speciality Hospital, Saket, New Delhi, 110017, India
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Shu QH, Fu ZX. Effect of different anesthesia and analgesic methods on recovery of gastrointestinal function in elderly patients after open surgery. Shijie Huaren Xiaohua Zazhi 2018; 26:1199-1204. [DOI: 10.11569/wcjd.v26.i19.1199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM To explore the effect of different anesthesia and analgesia methods on gastrointestinal function recovery in elderly patients after open surgery.
METHODS A total of 100 elderly patients undergoing open surgery from April 2016 to December 2017 were selected and divided into a control group (n = 50) and an observation group (n = 50) according to the method of anesthesia and analgesia. In the control group, systemic intravenous anesthesia and meridian analgesia were used. In the observation group, combined spinal and epidural anesthesia and epidural analgesia were used. Time to first defecation, time to recovery of gastrointestinal peristalsis, and time to food intake were recorded. Immunoradiometric method was used to determine plasma motilin levels before and after anesthesia and analgesia. The visual analog scale (VAS) was used to evaluate the pain degree of the two groups before anesthesia and analgesia and 6 h, 12 h, 18 h and 24 h after anesthesia and analgesia. The incidence of complications such as nausea and vomiting, elevated blood pressure, abnormal liver and kidney function, and post-cognitive dysfunction (POCD) were also recorded.
RESULTS Time to first defecation, time to recovery of gastrointe-stinal peristalsis, and time to food intake in the observation group were significantly shorter than those in the control group (P < 0.05). Plasma motilin levels in the observation group after anesthesia and analgesia were significantly higher in the observation group than in the control group (P < 0.05). VAS scores at 6 h, 12 h, and 18 h after anesthesia and analgesia were significantly lower than those before anesthesia and analgesia in both groups, and were significantly lower in the observation group than in the control group (P < 0.05). The incidence of nausea and vomiting, diarrhea, elevated blood pressure, abnormal liver and kidney function, and POCD was significantly lower in the observation group than in the control group (P < 0.05).
CONCLUSION The combination of lumbar-sparing anesthesia and epidural analgesia in elderly patients undergoing laparo-tomy can promote the early recovery of gastrointestinal function and reduce pain, and has a low incidence of postoperative complications.
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Affiliation(s)
- Qing-Hua Shu
- Department of Anesthesiology, Anji County People's Hospital, Ji'an 313300, Zhejiang Province, China
| | - Zhao-Xia Fu
- Department of Orthopaedics, Anji County People's Hospital, Ji'an 313300, Zhejiang Province, China
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Cook TM, Peden CJ, Richards S, Dalton SJ, Howes TE. Bath Boarding Card and risk stratification - a reply. Anaesthesia 2016; 71:1373-1374. [PMID: 27734481 DOI: 10.1111/anae.13696] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- T M Cook
- Royal United Hospital, Bath, UK.
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