This is a repository copy of Effectiveness of a national quality improvement programme to improve survival after emergency abdominal surgery (EPOCH) : a stepped-wedge cluster-randomised trial. Effectiveness of a national quality improvement programme to improve survival after emergency abdominal surgery (EPOCH) : a stepped-wedge cluster-randomised trial. The Lancet. ISSN 0140-6736 https://doi.org/10.1016/S0140-6736(18)32521-2 eprints@whiterose.ac.uk https://eprints.whiterose.ac.uk/ ReuseThis article is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs (CC BY-NC-ND) licence. This licence only allows you to download this work and share it with others as long as you credit the authors, but you can't change the article in any way or use it commercially. More information and the full terms of the licence here: https://creativecommons.org/licenses/ Implications of all the available evidenceDespite 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.

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This study involved an audit and a survey of the Acute Pain Service at Princess Alexandra Hospital. It was found in the audit that the relative choice of epidural analgesia had declined by 50% over the five-year time period of 1998-2003. The survey of consultants showed that 82% of them had changed their practice and that they were performing fewer epidural anaesthetics. Two of the most common reasons given for this change in practice related to fear of litigation (34%) and lack of evidence (21%). These results show that within this department approaches to postoperative pain control had changed and that this appears to have resulted from factors such as the medicolegal environment and the possible influence of evidence based medicine.