Quality improvement in emergency surgery shows no difference in patient survival
Researchers from Queen Mary University of London studied the effectiveness of one of the largest ever national quality improvement programmes in the National Health Service (NHS) and found no improvement in patient survival.
The overall risk of death after inpatient surgery within the NHS is one in 65. However, one in ten patients undergoing emergency bowel surgery die within 30 days.
The Effectiveness of a national quality improvement programme to improve survival after emergency abdominal surgery (EPOCH) trial, which was funded by the National Institute for Health Research (NIHR) and published in The Lancet, tested the effectiveness of a national quality improvement programme in 93 NHS hospitals.
The trial involved patients aged 40 years or older, undergoing emergency major bowel surgery. Data were analysed for 15,856 patients to test whether hospital staff could improve survival by making major improvements to the quality of patient care. There were 37 quality improvements which included more involvement of senior doctors (consultants) in decision making, better assessment of patient risk before and after surgery, consultant presence during surgery and critical admission after surgery.
The researchers found that such extensive changes were too difficult to implement in a short period of time. The 90-day mortality rate was 16 per cent in both the usual care group and Quality Improvement groups, meaning the team found no survival benefit from the programme.
Senior author, Rupert Pearse, Professor and Consultant in Intensive Care Medicine at Queen Mary University of London said: "The main message from this trial is that improving the quality of complex patient care pathways is much harder than we expected. Healthcare leaders, such as senior doctors and nurses, need more dedicated time and resources to improve patient care."
Some health care professionals have argued that quality improvement programmes are ineffective. Despite this, health-care policy is promoting their widespread use to drive large-scale change. The findings of the EPOCH trial suggest this approach will not work unless hospital leaders have the resources to make changes that last.
Before the EPOCH trial, most experts believed that poor awareness of the number of deaths after emergency abdominal surgery was the main reason for poor patient care.
Professor Pearse said: "We now understand the problem better. Clinicians were too busy delivering patient care and had no spare time to improve it. Quality improvement programmes are not a quick or easy solution to improving NHS patient care. We are now taking a much more realistic approach to this work."
The findings suggest future quality improvement programmes should implement fewer changes over a longer time period, and ensure doctors and nurses leading these changes have enough time in their working day to make improvements in patient care.
Professor Pearse added: "This trial tells us why our quality improvement didn't work and what we need to do differently."
This learning has already been shared with teams from the ongoing National Emergency Laparotomy Audit (NELA, http://www.nela.org.uk) and the Emergency Laparotomy Collaborative (ELC) project running across England's Academic Health Science Networks (AHSNs) and in Wales, between now and 2020.
More information: Carol J Peden et al, Effectiveness of a national quality improvement programme to improve survival after emergency abdominal surgery (EPOCH): a stepped-wedge cluster-randomised trial, The Lancet (2019). DOI: 10.1016/S0140-6736(18)32521-2