The NELA risk prediction model for emergency laparotomies discriminates well between low- and high-risk patients and is suitable for producing risk-adjusted provider mortality statistics.

The Shuttle Radar Topography Mission (SRTM) successfully acquired terrain elevation data for 80 percent of the Earth's landmass in February 2000. The radar system and data collection scheme designed by NASA's Jet Propulsion Laboratory (JPL) met the global requirements of the U.S. Department of Defense for Level 2 Digital Terrain Elevation Data (DTED ®). JPL processed the raw data into unfinished DTED ® 2 and other products that were delivered to two contractors of the National Geospatial-Intelligence Agency. The contractors edited the unfinished DTED ® 2, updated the associated products, and generated finished products for distribution. Automated processes were developed by each contractor to identify, delineate and set heights for lakes, rivers, and ocean coastlines in conformance with an extensive set of editing rules created to maintain consistency and uniformity in the final products. The finished DTED ® is significantly better than the 16 m vertical accuracy required by the original specification.

Background: Socioeconomic circumstances can influence access to healthcare, the standard of care provided, and a variety of outcomes. This study aimed to determine the association between crude and risk-adjusted 30-day mortality and socioeconomic group after emergency laparotomy, measure differences in meeting relevant perioperative standards of care, and investigate whether variation in hospital structure or process could explain any difference in mortality between socioeconomic groups. Methods: This was an observational study of 58 790 patients, with data prospectively collected for the National Emergency Laparotomy Audit in 178 National Health Service hospitals in England between December 1, 2013 and November 31, 2016, linked with national administrative databases. The socioeconomic group was determined according to the Index of Multiple Deprivation quintile of each patient's usual place of residence. Results: Overall, the crude 30-day mortality was 10.3%, with differences between the most-deprived (11.2%) and leastdeprived (9.8%) quintiles (P<0.001). The more-deprived patients were more likely to have multiple comorbidities, were more acutely unwell at the time of surgery, and required a more-urgent surgery. After risk adjustment, the patients in the most-deprived quintile were at significantly higher risk of death compared with all other quintiles (adjusted odds ratio [95% confidence interval]: Q1 [most deprived]: reference; Q2: 0.83 [0.76e0.92]; Q3: 0.84 [0.76e0.92]; Q4: 0.87 [0.79e0.96]; Q5 [least deprived]: 0.77 [0.70e0.86]). We found no evidence that differences in hospital-level structure or patient-level performance in standards of care explained this association. Conclusions: More-deprived patients have higher crude and risk-adjusted 30-day mortality after emergency laparotomy, but this is not explained by differences in the standards of care recorded within the National Emergency Laparotomy Audit.

Background and objectivesA clinical trial in 93 NHS 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. MethodsWe performed a hospital-level time-series analysis using data from the Enhanced Peri-Operative Care for High-risk patients (EPOCH) trial. Care-pathway implementation was defined as achievement of >80% median reliability in ten 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. ResultsOf 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 ten 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 ≥5implementation strategies, 9/30 (30%) hospitals improved 6 care processes compared with 0/11 hospitals using ≤2 implementation strategies. ConclusionOnly a small number of hospitals improved more than half of the measured care-processes, more often when at least 5 of 6 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. BACKGROUNDAs the volume of surgical procedures performed worldwide continues to increase [1,2] the need for improvement in the quality and safety of surgical care has become a global healthcare priority [3][4][5]. This is of particular importance considering both the increasing age and complexity of the surgical population and the global mortality burden associated with surgery [6,7]. Emergency abdominal surgery is a commonly performed procedure worldwide, with high mortality rates, and wide variations in the standards of care [8][9][10][11]. The Enhanced Peri-Operative Care for High-risk patients (EPOCH) trial was performed to test whether a national quality improvement (QI) programme to implement a carepathway could reduce 90-day mortality following emergency abdominal surgery [12].The EPOCH trial intervention consisted of an evidence based care-pathway designed to improve patient o...