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.
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Notes to the editor
Research paper: 'Effectiveness of a national quality improvement programme to improve survival after emergency abdominal surgery (EPOCH): a stepped-wedge cluster-randomised trial'. Carol J Peden, Tim Stephens, Graham Martin, Brennan C Kahan, Ann Thomson, Kate Rivett, Duncan Wells, Gerry Richardson, Sally Kerry, Julian Bion, Rupert M Pearse, on behalf of the Enhanced Peri-Operative Care for High-risk patients (EPOCH) trial group. The Lancet. DOI: 10.1016/S0140-6736(18)32521-2
Available online after the embargo lifts here: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)32521-2/fulltext
About Queen Mary University of London
At Queen Mary University of London, we believe that a diversity of ideas helps us achieve the previously unthinkable.
In 1785, Sir William Blizard established England's first medical school, The London Hospital Medical College, to improve the health of east London's inhabitants. Together with St Bartholomew's Medical College, founded by John Abernethy in 1843 to help those living in the City of London, these two historic institutions are the bedrock of Barts and The London School of Medicine and Dentistry.
Today, Barts and The London continues to uphold this commitment to pioneering medical education and research. Being firmly embedded within our east London community, and with an approach that is driven by the specific health needs of our diverse population, is what makes Barts and The London truly distinctive.
Our local community offer to us a window to the world, ensuring that our ground-breaking research in cancer, cardiovascular and inflammatory diseases, and population health not only dramatically improves the outcomes for patients in London, but also has a far-reaching global impact.
This is just one of the many ways in which Queen Mary is continuing to push the boundaries of teaching, research and clinical practice, and helping us to achieve the previously unthinkable.
About the NIHR
The National Institute for Health Research (NIHR) is the nation's largest funder of health and care research. The NIHR:
- Funds, supports and delivers high quality research that benefits the NHS, public health and social care
- Engages and involves patients, carers and the public in order to improve the reach, quality and impact of research
- Attracts, trains and supports the best researchers to tackle the complex health and care challenges of the future
- Invests in world-class infrastructure and a skilled delivery workforce to translate discoveries into improved treatments and services
- Partners with other public funders, charities and industry to maximise the value of research to patients and the economy
The NIHR was established in 2006 to improve the health and wealth of the nation through research, and is funded by the Department of Health and Social Care. In addition to its national role, the NIHR commissions applied health research to benefit the poorest people in low- and middle-income countries, using Official Development Assistance funding.
This work uses data provided by patients and collected by the NHS as part of their care and support and would not have been possible without access to this data. The NIHR recognises and values the role of patient data, securely accessed and stored, both in underpinning and leading to improvements in research and care. http://www.