C are for H ighrisk patients Introductory slideset 234 million major surgical procedures worldwide True mortality rate is not known A preventable death rate of 1 would result in 23 million avoidable deaths each year ID: 628471
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Enhanced Peri-Operative Carefor High-risk patients
Introductory slide-setSlide2
234 million major surgical procedures worldwide True mortality rate is not known A preventable death rate of 1% would result in... ...2.3 million avoidable deaths each yearSlide3Slide4
Variation in mortality after emergency surgery in the UKSymons N et al. Brit J Surg 2013; 100: 1318-25.Slide5
More patients die following surgery on a Friday…Slide6
Background80% of surgical deaths in high-risk groupEmergency laparotomy is a typical casePatient care is highly variableSurvival is highly variableQuality improvement may improve outcomeSlide7
1987Slide8
Objectives Can a quality improvement project to implement a care pathway improve 90 day survival for emergency laparotomy?Integrated ethnographic evaluationCost-effectiveness of projectLong-term impact on mortality (via HQIP-NELA)Slide9
Pilot dataEmergency Laparotomy Network & HES dataWide variations in standards of care30 day mortality varies widely (4 to 31%)25% mortality at 90 days
Saunders et al. Brit J Anaesth 2012;109: 368-75.Slide10
Trial designStepped wedge randomised cluster trialHospitals randomised in geographical clustersIntegrated ethnographic & economics analysesData capture via HQIP-NELAInterventionIntegrated Care Pathway
Local leadership by ‘champions’QI training, cluster meetings, web-based resourcesSlide11
Integrated Care Pathway adapted from:Higher Risk Surgical Patient; RCS 2011 Slide12
PatientsAged ≥40 years undergoing non-elective open abdominal surgery in acute NHS hospitalsExclusions: Gynaecological and trauma laparotomy, Repeat laparotomy, AppendicectomySlide13
Outcome measuresPrimary: 90 day mortalitySecondary:Hospital stayHospital re-admission180 day mortalityCost effectivenessSlide14
Sample sizeRecruited 98 NHS hospitals in 15 regional clusters 27,540 patients90% power for mortality reduction from 25 to 22%Fixed 85 week intervention period
Potential to recruit every eligible patientSlide15
Project teamPragmatic CTU, QMULQuality improvement team led by Carol PedenEthnography expertise from LeicesterMethodology expertise from BirminghamEPOCH pathfinder hospitals
Advisory group representing all stakeholdersSlide16
Trial timelinesWinter 2013/14 Start-upMarch 2014 Trial starts (data collection via NELA)
April 2014 First cluster ‘activated’ to QI interventionAugust 2015 Final cluster activated
Mid - Sept
2015
Final patient recruited
Cluster randomisation diagramSlide17
QI intervention: site timelineSlide18
?EPOCH Contacts
Trial Querieskirsty.everingham@bartshealth.nhs.uk0203 594 0352
Quality Improvement Queries
qi@epochtrial.org
0203 594 0352