Effectiveness of a national quality improvement programme to improve survival after emergency abdominal surgery (EPOCH): a stepped-wedge cluster-randomised trial (original) (raw)

Evidence before this study Emergency abdominal surgery is associated with poor post-operative outcomes. Around 30,000 patients undergo this type of surgery each year in the UK National Health Service (NHS), with 30-day mortality rates in excess of 10% and wide variation in standards of care between hospitals. We searched for peer reviewed publications describing the effects of quality improvement programmes on survival for adult patients using the terms 'emergency abdominal surgery' and 'emergency laparotomy'. Several groups have studied the effect of quality improvement initiatives to implement individual interventions or 'care bundles' of several treatments, and so improve care for these patients. Overall, the findings of these small studies suggest survival benefit, but most utilised weak study designs associated with a high risk of bias. The feasibility and benefit of a national quality improvement programme to implement a more extensive acute care pathway for this patient group remain uncertain. Added value of this study We conducted a large national quality improvement programme to implement a care pathway for patients undergoing emergency abdominal surgery. In a stepped-wedge cluster randomised trial of 15,873 patients aged ≥40 years, in 93 NHS hospitals organised into fifteen geographical clusters, we did not identify any survival benefit at either 90 or 180 days after surgery. There was good engagement with the quality improvement programme but staff had limited time and resources to implement change. Consequently, there were only modest overall changes in the processes of patient care from before to after quality improvement implementation. There were wide variations in intervention fidelity between hospitals, with differences in the processes teams tried to change, the rate of change and eventual success. Implications of all the available evidence Despite the success of some smaller projects, there was no survival benefit from a national quality improvement programme to implement a care pathway for patients undergoing emergency abdominal surgery. To succeed, large national quality improvement programmes need to allow for differences between hospitals and ensure teams have both the time and resources needed to improve patient care.

Sign up for access to the world's latest research.

checkGet notified about relevant papers

checkSave papers to use in your research

checkJoin the discussion with peers

checkTrack your impact