SummaryOesophageal Doppler monitoring allows non-invasive estimation of stroke volume and cardiac output. We studied the impact of Doppler guided fluid optimisation on haemodynamic parameters, peri-operative morbidity and hospital stay in patients undergoing major bowel surgery. Fifty-seven patients were randomly assigned to Doppler (D) or control (C) groups. All patients received intraoperative fluid therapy at the discretion of the non-investigating anaesthetist. In addition, Group D were given fluid challenges (3 ml.kg Surgical patients undergoing major bowel resection are at high risk of peri-operative complications and death. Centres in the UK report mortality rates in this group of between 4 and 9% [1, 2]. Many of these patients are elderly and suffer comorbid medical conditions as well as the local and systemic effects of colorectal disease. Studies of similar patient groups having major surgery have used fluid, inotrope and oxygen therapy to optimise cardiac output and oxygen delivery; these studies demonstrated reductions in mortality and length of hospital stay [3][4][5]. The method of cardiac output measurement in these reports, pulmonary artery catheterisation, is not commonly used for bowel surgery. Pulmonary artery catheter insertion can be time consuming and has been implicated with complications and excess mortality [6]. Furthermore some trials involving pulmonary artery catheter optimisation of oxygen delivery required pre-operative admission to intensive care which is currently not practical for colorectal resection.The minimally invasive oesophageal Doppler monitor permits real time assessment of cardiac output [7]. Haemodynamic parameters estimated by this device can be used to guide fluid therapy during surgery [8]. A study of patients undergoing repair of femoral neck fracture demonstrated a reduction in length of hospital stay when oesophageal Doppler was used to guide fluid therapy [9].The aim of this study was to examine the effect of oesophageal Doppler guided fluid administration during colorectal resection on haemodynamic performance, hospital stay and postoperative complications.

Purpose -The purpose of ths paper is to report that timely interventions to facilitate medical patient flow and reduce medical outliers may be associated with a reduction in hospital mortality. Design/methodology/approach -Interventions to improve the flow of medical patients were used to unblock and facilitate the discharge process allowing a reduction in medical outliers. SPC run charts of mortality were used to quality control the changes. Findings -Timeliness in daily senior medical review and discharge planning, a level 1 medical ward, and outreach including ALERT training and early warning scoring allowed a rationalisation in medical beds and a reduction in mortality for emergency medical admissions, reflected in a lower hospital standarised mortality rate (HSMR). Practical implications -Interventions to improve flow can also lead to a reduction in mortality. Originality/value -This paper emphasises how quantitative flow improvements can also generate qualitative improvements.

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NHS England is to introduce a new Commissioning for Quality and Innovation to reduce delayed discharges from adult critical care to ward-level care. A delayed discharge is greater than 4 h, this occurred in 64.2% of patients in the critical care minimum data set database from Intensive Care National Audit & Research Centre from the last five years; 46.3% were delayed between 4 and 24 h and 17.9% were delayed more than 24 h. For those who had a delay in their discharge of greater than 24 h, the data suggests that ''sicker'' patients ultimately do better, since there was a reduction in expected mortality of 5892 patients to an actual mortality of 5201 patients over the five years. More in depth analysis of this data is necessary to try to identify which patients are more likely to benefit from extending their critical care stay once the need for organ support has abated. The current Commissioning for Quality and Innovation offers a slightly perverse incentive against this cohort of patients.

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