Quality improvement and emergency laparotomy care: what have we learnt from recent major QI efforts?

Stephens, Tim; Johnston, Carolyn; Hare, Sarah

doi:10.7861/clinmed.2019.0251

“…Fluid optimization in emergency laparotomy (FLO-ELA) is an ongoing randomized trial to compare cardiac output-guided hemodynamic therapy against usual care in emergency laparotomy patients. 2 Currently, the trial has been temporarily paused due to COVID-19 pandemic.…”

Section: O Utcomementioning

confidence: 99%

“…Regular audits and perioperative care pathways have been used to enhance outcome of these surgeries in many high-income countries. 2 As these countries already have separate well-developed trauma care network, only non-trauma laparotomies (acute abdomen) are included in their audits and care pathways for emergency laparotomies. National Emergency Laparotomy Audit (NELA), Australian and New Zealand Emergency Laparotomy Audit—Quality Improvement (ANZELA-QI), and American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) are some of the large national-level audit programs for improving care in this subgroup of surgical patients.…”

Section: Introductionmentioning

confidence: 99%

Emergency Laparotomies: Causes, Pathophysiology, and Outcomes

Ahmed

¹

,

Azim

²

2020

Indian Journal of Critical Care Medicine

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A bstract Emergency laparotomies have remained a challenging entity since many decades. Only during the past 10 years, serious efforts have been made to improve their outcome by conducting audits and designing care pathways. Indications for emergency laparotomies can be broadly classified into trauma and non-trauma surgeries, which are either done for control of hemorrhage or/and done for control of sepsis and organ dysfunction. Goal-directed resuscitation for septic/hemorrhagic shock, consultant-led multidisciplinary teams, and timely transfer to intensive care units form core principles of management for these patients. Global inequity in access to standard and affordable emergency surgeries is an area of concern requiring integrated efforts at international level. How to cite this article: Ahmed A, Azim A. Emergency Laparotomies: Causes, Pathophysiology, and Outcomes. Indian J Crit Care Med 2020;24(Suppl 4):S183–S189.

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“…The Quality Improvement (QI) literature has documented both the sustained effect, and the gradual change and simplification of interventions over time in hospital settings [20]. Team-based QI interventions demand significant time and resources commitments and so there has been experimentation in many settings with "Light Touch" variations [21][22][23][24]. We conducted a study to see if a lessdemanding Light Touch intervention could produce improvments in person-centered care similar to a fullintensity QI initiative.…”

Section: Challengementioning

confidence: 99%

A comparison of intensive vs. light-touch quality improvement interventions for maternal health in Uttar Pradesh, India

Montagu

¹

,

Giessler

²

,

Nakphong

³

et al. 2020

BMC Health Serv Res

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Background Poor patient experiences during delivery leads to delayed presentation at facilities and contributes to poor maternal health outcomes. Person-centered maternity care (PCMC) is a key component of quality. Improving PCMC requires changing the process of care which can be complex and necessitate significant external input, making replication and scale difficult. This study compares the effectiveness two Quality Improvement (QI) intervention phases, one Intensive, one Light-Touch. Methods We use a matched case-control design to compare two phases of a QI Intervention targeting PCMC, with three facilities in each. The Intensive phase was introduced into three government facilities where teams were supported to identify, design, and test potential improvements over 12 months. The Light-Touch phase was subsequently introduced in three other government facilities and changes were tracked over six months. We compared the two groups using multivariate linear regression and difference-in-difference models to assess changes in PCMC outcome Results Both Intensive and Light-Touch arms demonstrated large improvements in PCMC. On a scale from 0 to 100, Intensive facilities increased in PCMC scores from 85.02 to 97.13, while Light-Touch facilities increased from 63.42 to 87.47. For both there was a ‘halo’ effect, with a similar improvement recorded for the specific improvement activities focused on, as w ell as aspects of PCMC not directly addressed. Conclusions This study demonstrates that a short, inexpensive, light-touch and directive intervention can change staff practices and significantly improve the experiences of women during childbirth. It also shows that improvements in a few areas of provider-patient interaction have a ‘halo’ effect, changing many other aspects of patient-provider interaction at the same time. Trial registration QI Phase 1 - NCT04208867. Retrospectively registered. December 19th, 2019. QI Phase 2 –NCT04208841. Retrospectively registered. December 23, 2019.

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“…variations (17)(18)(19)(20). We conducted a study to see if less-demanding interventions could create similar results in improving person-centered care.…”

Section: Challengementioning

confidence: 99%

A Comparison of Intensive vs. Light-Touch Quality Improvement Interventions for Maternal Health in Uttar Pradesh, India

Montagu

¹

,

Giessler

²

,

Nakphone

³

et al. 2020

Preprint

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BackgroundPoor patient experiences during delivery leads to delayed presentation at facilities and contributes to poor maternal health outcomes. Person-centered maternity care (PCMC) is a key component of quality. Improving PCMC requires changing the process of care which can be complex and require significant external input, making replication and scale difficult. This study compared the effectiveness two Quality Improvement (QI) intervention phases, one Intensive, one Light-Touch. MethodsWe used a matched case-control design to compare two phases of a QI Intervention targeting PCMC, with three facilities in each. The Intensive phase was introduced into three government facilities where teams were supported to identify, design, and test potential improvements over 12 months. The Light-Touch phase was subsequently introduced in three other government facilities and changes were tracked over six months. We compared the two groups using multivariate linear regression and difference-in-difference models to assess changes in PCMC outcome. ResultsBoth Intensive and Light-Touch arms demonstrated large improvements in PCMC. On a scale from 0 to 100, Intensive facilities increased in PCMC scores from 85.02 to 97.13, while Light-Touch facilities increased from 63.42 to 87.47. For both there was a ‘halo’ effect, with a similar improvement recorded for the specific improvement activities focused on, as w ell as aspects of PCMC not directly addressed. ConclusionsThis study demonstrated that a short, inexpensive, light-touch and directive intervention can change staff practices and significantly improve the experiences of women during childbirth. It also shows that improvements in a few areas of provider-patient interaction have a ‘halo’ effect, changing many other aspects of patient-provider interaction at the same time. Trial RegistrationQI Phase 1 - NCT04208867. Retrospectively registered. December 19th, 2019. link to the registration:https://clinicaltrials.gov/ct2/show/NCT04208867?term=NCT04208867&draw=2&rank=1QI Phase 2 – NCT04208841. Retrospectively registered. December 23, 2019. link to the registration:https://clinicaltrials.gov/ct2/show/NCT04208841?term=NCT04208841&draw=2&rank=1CONTRIBUTIONS TO THE LITERATURE 98 words· Medical practioners’ treatment of patients are influenced by institutional norms and difficult to change. · Team-based initiatives which actively engage staff have been effective in wealthy countries but are not common in middle-income settings, and have not been applied to person-centered aspects of care.· We found that team-based quality improvement efforts were effective in India at changing patient experience. Once change-practices were identified, these practices were introduced to new facilities with low-intesity support and proved equally effective at improving care.· These findings add to the limited evidence on team-based quality improvement, and provide evidence of effective scaleable implementation opportunities.

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Quality improvement and emergency laparotomy care: what have we learnt from recent major QI efforts?

Cited by 3 publications

References 41 publications

Emergency Laparotomies: Causes, Pathophysiology, and Outcomes

Emergency Laparotomies: Causes, Pathophysiology, and Outcomes

A comparison of intensive vs. light-touch quality improvement interventions for maternal health in Uttar Pradesh, India

A Comparison of Intensive vs. Light-Touch Quality Improvement Interventions for Maternal Health in Uttar Pradesh, India

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