Estimated costs before, during and after the introduction of the emergency laparotomy pathway quality improvement care (<scp>ELPQ</scp>u<scp>IC</scp>) bundle

Eveleigh, Mark; Howes, T. E.; Peden, Carol J.; Cook, Tim

doi:10.1111/anae.13623

Cited by 9 publications

(9 citation statements)

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“…Emergency laparotomy is a commonly performed surgical procedure, with a high 30-day mortality [ 8 – 11 ] and wide variations in the standards of care delivered [ 10 – 12 ]. Previous small studies of quality improvement in this area have improved care delivery and reduced mortality without increasing costs [ 10 , 13 , 14 ]. The EPOCH trial was designed to establish whether a quality improvement approach could reduce mortality and length of hospital stay for this patient group, when delivered at a national level.…”

Section: Introductionmentioning

confidence: 99%

Improving care at scale: process evaluation of a multi-component quality improvement intervention to reduce mortality after emergency abdominal surgery (EPOCH trial)

et al. 2018

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BackgroundImproving the quality and safety of perioperative care is a global priority. The Enhanced Peri-Operative Care for High-risk patients (EPOCH) trial was a stepped-wedge cluster randomised trial of a quality improvement (QI) programme to improve 90-day survival for patients undergoing emergency abdominal surgery in 93 hospitals in the UK National Health Service.MethodsThe aim of this process evaluation is to describe how the EPOCH intervention was planned, delivered and received, at both cluster and local hospital levels. The QI programme comprised of two interventions: a care pathway and a QI intervention to aid pathway implementation, focussed on stakeholder engagement, QI teamwork, data analysis and feedback and applying the model for improvement. Face-to-face training and online resources were provided to support senior clinicians in each hospital (QI leads) to lead improvement. For this evaluation, we collated programme activity data, administered an exit questionnaire to QI leads and collected ethnographic data in six hospitals. Qualitative data were analysed with thematic or comparative analysis; quantitative data were analysed using descriptive statistics.ResultsThe EPOCH trial did not demonstrate any improvement in survival or length of hospital stay. Whilst the QI programme was delivered as planned at the cluster level, self-assessed intervention fidelity at the hospital level was variable. Seventy-seven of 93 hospitals responded to the exit questionnaire (60 from a single QI lead response on behalf of the team); 33 respondents described following the QI intervention closely (35%) and there were only 11 of 37 care pathway processes that > 50% of respondents reported attempting to improve. Analysis of qualitative data suggests QI leads were often attempting to deliver the intervention in challenging contexts: the social aspects of change such as engaging colleagues were identified as important but often difficult and clinicians frequently attempted to lead change with limited time or organisational resources.ConclusionsSignificant organisational challenges faced by QI leads shaped their choice of pathway components to focus on and implementation approaches taken. Adaptation causing loss of intervention fidelity was therefore due to rational choices made by those implementing change within constrained contexts. Future large-scale QI programmes will need to focus on dedicating local time and resources to improvement as well as on training to develop QI capabilities.EPOCH trial registrationISRCTN80682973 10.1186/ISRCTN80682973 Registered 27 February 2014 and Lancet protocol 13PRT/7655.Electronic supplementary materialThe online version of this article (10.1186/s13012-018-0823-9) contains supplementary material, which is available to authorized users.

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Section: Introductionmentioning

confidence: 99%

Improving care at scale: process evaluation of a multi-component quality improvement intervention to reduce mortality after emergency abdominal surgery (EPOCH trial)

et al. 2018

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“…It guides the junior doctor to early identification of abnormal physiology (sepsis, SIRS, high MEWS or high P‐POSSUM) and provides a checklist of jobs to do to initiate resuscitation (fluids, antibiotics, analgesia) while triggering early involvement of other practitioners, investigation and acceleration of definitive treatment. We wholeheartedly agree that early involvement of senior clinicians and routine use of critical care for postoperative management of these patients is important and have both reported the benefits of both these elsewhere and been involved in producing such guidance . Locally, we aspire to have consultant surgeon, anaesthetist and intensivist involvement in all patients undergoing emergency laparotomy, not only those with a P‐POSSUM mortality risk > 5% or > 10%.…”

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confidence: 75%

Bath Boarding Card and risk stratification – a reply

et al. 2016

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radiographic contrast and continuous imaging to confirm paravertebral spread (after ultrasound-guided needle placement) before administration of local anaesthetic. There is consistent demonstration that injection outside the SCTL shows very localised spread whilst injection deep to the SCTL shows typical multilevel paravertebral dispersion.Whilst we eagerly await the results of the authors' further cadaveric studies, we would caution against the changing of practice based on singular demonstrations of anatomic variability.

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“…Earlier, smaller studies have shown that marked improvement may take time and can continue after the intervention period. 59 There are other plausible explanations for our failure to change the primary outcome metrics. It is possible that our programme theory was incorrect, and there was only a weak causal link between the interventions and ultimate outcomes.…”

Section: Discussionmentioning

confidence: 99%

A national quality improvement programme to improve survival after emergency abdominal surgery: the EPOCH stepped-wedge cluster RCT

Peden

Stephens

Martin

et al. 2019

Health Serv Deliv Res

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Background Emergency abdominal surgery is associated with poor patient outcomes. We studied the effectiveness of a national quality improvement (QI) programme to implement a care pathway to improve survival for these patients. Objectives The objectives were to assess whether or not the QI programme improves 90-day survival after emergency abdominal surgery; to assess effects on 180-day survival, hospital stay and hospital readmission; and to better understand these findings through an integrated process evaluation, ethnographic study and cost-effectiveness analysis. Design This was a stepped-wedge cluster randomised trial. Hospitals were organised into 15 geographical clusters, and commenced the QI programme in random order over 85 weeks. Analyses were performed on an intention-to-treat basis. The primary outcome was analysed using a mixed-effects parametric survival model, adjusting for time-related effects. Ethnographic and economics data were collected in six hospitals. The process evaluation included all hospitals. Setting The trial was set in acute surgical services of 93 NHS hospitals. Participants Patients aged ≥ 40 years who were undergoing emergency abdominal surgery were eligible. Intervention The intervention was a QI programme to implement an evidence-based care pathway. Main outcome measures The primary outcome measure was mortality within 90 days of surgery. Secondary outcomes were mortality within 180 days, length of hospital stay and hospital readmission within 180 days. The main economic measure was the quality-adjusted life-years. Data sources Data were obtained from the National Emergency Laparotomy Audit database; qualitative interviews and ethnographic observations; quality-of-life and NHS resource use data were collected via questionnaires. Results Of 15,873 eligible patients from 93 NHS hospitals, primary outcome data were analysed for 8482 participants in the usual care group and 7374 in the QI group. The primary outcome occurred in 1393 participants in the usual care group (16%), compared with 1210 patients in the QI group (16%) [QI vs. usual care hazard ratio (HR) 1.11, 95% confidence interval (CI) 0.96 to 1.28]. No differences were found in mortality at 180 days or hospital readmission; there was a small increase in hospital stay in the QI group (HR for discharge 0.90, 95% CI 0.83 to 0.97). There were only modest improvements in care processes following QI implementation. The ethnographic study revealed good QI engagement, but limited time and resources to implement change, affecting which processes teams addressed, the rate of change and eventual success. In some sites, there were challenges around prioritising the intervention in busy environments and in obtaining senior engagement. The intervention is unlikely to be cost-effective at standard cost-effectiveness thresholds, but may be cost-effective over the lifetime horizon. Limitations Substantial delays were encountered in securing data access to national registries. Fewer patients than expected underwent surgery and the mortality rate was lower than anticipated. Conclusions There was no survival benefit from a QI programme to implement a care pathway for patients undergoing emergency abdominal surgery. The modest impact of the intervention on process measures, despite good clinician engagement, may have been limited by the time and resources needed to improve patient care. Future work Future QI programmes must balance intervention complexity with the practical realities of NHS services to ensure that such programmes can be delivered with the resources available. Trial registration Current Controlled Trials ISRCTN80682973 and The Lancet protocol 13PRT/7655. Funding This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 7, No. 32. See the NIHR Journals Library website for further project information.

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Estimated costs before, during and after the introduction of the emergency laparotomy pathway quality improvement care (ELPQuIC) bundle

Cited by 9 publications

References 8 publications

Improving care at scale: process evaluation of a multi-component quality improvement intervention to reduce mortality after emergency abdominal surgery (EPOCH trial)

Improving care at scale: process evaluation of a multi-component quality improvement intervention to reduce mortality after emergency abdominal surgery (EPOCH trial)

Bath Boarding Card and risk stratification – a reply

A national quality improvement programme to improve survival after emergency abdominal surgery: the EPOCH stepped-wedge cluster RCT

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