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.

Ovarian hyperstimulation syndrome (OHSS) is a well-recognised iatrogenic complication following controlled ovarian stimulation (COS). Mild to moderate cases are mostly managed conservatively. Severe cases of OHSS can be potentially fatal. For this reason, UK clinics providing licensed fertility treatment are obliged to follow Human Fertilisation and Embryology Authority guidelines for reporting severe incidents. We present an unusually severe complication of OHSS resulting in significant morbidity. A nulligravida woman aged 25, with a 4-year history of subfertility and multiple risk factors for the development of OHSS, underwent COS. Immediately following oocyte retrieval, the patient developed symptoms of early-onset severe OHSS. The subsequent clinical deterioration of the patient precipitated multiple organ failure, including renal and hepatic dysfunction. Despite supportive management in an intensive care unit, the patient required transfer to a tertiary liver centre for specialist treatment. OHSS is a preventable complication; therefore, such an uncommon presentation of the syndrome provides important clinical lessons to be discussed.

AimsThe unexpected death of a four month old baby during an emergency endotracheal intubation in our district general hospital highlighted the critical need to improve the process and safety of emergency paediatric intubation. A root cause analysis investigation into the event identified multiple factors contributing to this unfortunate outcome with human factors playing a significant role: A poorly structured intubation process with poor communication and role division between the paediatric and anaesthetic teams was significant. There is already strong evidence for the value of checklists in reducing errors in procedures. We therefore designed a checklist to be used in our district general hospital in emergency paediatric intubations to try to improve patient safety.MethodThe checklist was designed to include prompts for consideration of patient, equipment and team factors. It is to be used as a ‘time-out’ before induction is attempted to improve team members’ situational awareness and ensure all necessary preparations are made. It is on a single-sided A4 sheet that is completed in a tick-box format then filed in the patient’s notes. The first stage involves ensuring that the patient’s condition is optimised, including oxygenation and haemodynamic status. The next stage checks that appropriate monitoring is applied to the patient and all necessary equipment and medications are to hand. Clearly identified roles are then allocated to team members. A back-up plan for difficult intubation is then identified and the relevant equipment accessible. After these checks, induction and intubation commences. The checklist was introduced to the paediatric and anaesthetic teams and used over a three month period before a questionnaire was sent out for users to provide feedback on the checklist.ResultsThe checklist was well received by both the paediatric and anaesthetic teams and received strongly positive feedback. Results from the questionnaire reported that it was very useful, creating an important structure and focusing everyone’s attention. This helps to calm the situation, which can become highly fraught, and seems to reassure the team, patient and parents.ConclusionA checklist appears to be a valuable tool for improving team communication and creating structure during emergency endotracheal intubation in paediatrics.

We conclude that, in a manikin, the new design blade can make nasogastric tube insertion easier when compared with the Macintosh blade and it can be used to facilitate laryngoscopy and tracheal intubation. Further studies are needed to evaluate its use in patients.

A 75-year-old female patient presented to the accident and emergency department following a collapse. She was treated for a saddle pulmonary embolism and underlying urinary tract infection. However, 48 hours later she was found to have reduced consciousness with no apparent cause (Glasgow Coma Scale of 8 out of 15). Subsequent blood results revealed a highammonia level. After reflection into her medical history, it was found that she had bladder exstrophy, which was managed with urinary diversion surgery as an infant, and her presentation was a rare complication of this operation.