Effectiveness of a national quality improvement programme to improve survival after emergency abdominal surgery (EPOCH): a stepped-wedge cluster-randomised trial

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. Methods: We did a stepped-wedge cluster-randomised trial of patients aged 40 years or older undergoing emergency open major abdominal surgery. Eligible UK National Health Service (NHS) hospitals (those that had an emergency general surgical service, a substantial volume of emergency abdominal surgery cases, and contributed data to the National Emergency Laparotomy Audit) were organised into 15 geographical clusters and commenced the QI programme in a random order, based on a computer-generated random sequence, over an 85-week period with one geographical cluster commencing the intervention every 5 weeks from the second to the 16th time period. Patients were masked to the study group, but it was not possible to mask hospital staff or investigators. The primary outcome measure was mortality within 90 days of surgery. Analyses were done on an intention-to-treat basis. This study is registered with the ISRCTN registry, number ISRCTN80682973. Findings: Treatment took place between March 3, 2014, and Oct 19, 2015. 22 754 patients were assessed for elegibility. Of 15 873 eligible patients from 93 NHS hospitals, primary outcome data were analysed for 8482 patients in the usual care group and 7374 in the QI group. Eight patients in the usual care group and nine patients in the QI group were not included in the analysis because of missing primary outcome data. The primary outcome of 90-day mortality occurred in 1210 (16%) patients in the QI group compared with 1393 (16%) patients in the usual care group (HR 1·11, 0·96–1·28). Interpretation: No survival benefit was observed from this QI programme to implement a care pathway for patients undergoing emergency abdominal surgery. Future QI programmes should ensure that teams have both the time and resources needed to improve patient care. Funding: National Institute for Health Research Health Services and Delivery Research Programme

Effectiveness of a national quality improvement programme to improve survival after emergency abdominal surgery (EPOCH): a stepped-wedge cluster-randomised trial

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. METHODS: We did a stepped-wedge cluster-randomised trial of patients aged 40 years or older undergoing emergency open major abdominal surgery. Eligible UK National Health Service (NHS) hospitals (those that had an emergency general surgical service, a substantial volume of emergency abdominal surgery cases, and contributed data to the National Emergency Laparotomy Audit) were organised into 15 geographical clusters and commenced the QI programme in a random order, based on a computer-generated random sequence, over an 85-week period with one geographical cluster commencing the intervention every 5 weeks from the second to the 16th time period. Patients were masked to the study group, but it was not possible to mask hospital staff or investigators. The primary outcome measure was mortality within 90 days of surgery. Analyses were done on an intention-to-treat basis. This study is registered with the ISRCTN registry, number ISRCTN80682973. FINDINGS: Treatment took place between March 3, 2014, and Oct 19, 2015. 22 754 patients were assessed for elegibility. Of 15 873 eligible patients from 93 NHS hospitals, primary outcome data were analysed for 8482 patients in the usual care group and 7374 in the QI group. Eight patients in the usual care group and nine patients in the QI group were not included in the analysis because of missing primary outcome data. The primary outcome of 90-day mortality occurred in 1210 (16%) patients in the QI group compared with 1393 (16%) patients in the usual care group (HR 1·11, 0·96-1·28). INTERPRETATION: No survival benefit was observed from this QI programme to implement a care pathway for patients undergoing emergency abdominal surgery. Future QI programmes should ensure that teams have both the time and resources needed to improve patient care. FUNDING: National Institute for Health Research Health Services and Delivery Research Programme

Theatre censorship in Britain: silencing, censure and suppression

Why do people censor? How do we strike a balance between freedom of speech and respect for the sacred? Do we know what we mean by censorship? Theatre Censorship in Britain brings these questions to its exploration of the wide variety of censorship that has shaped theatrical performance in twentieth- and twenty-first century Britain. Its eight case studies assess the interventions of the Lord Chamberlain - who licensed every performance until 1968 - but they also analyse the powers of censure wielded by the media and public interest groups; the self-censorship of playwrights; and the constraints placed upon producers by public funding bodies and corporate sponsors. They examine the unpredictable outcomes of censorship, deep-seated anxieties about the performative influence of the stage, and the complex questions raised by acts of theatrical censorship and silencing in the context of contemporary debates over civil liberties and freedom of speech

Theatre and audience

What does theatre do for – and to – those who witness, watch, and participate in it? Theatre& Audience provides a provocative overview of the questions raised by theatrical encounters between performers and audiences. Focusing on European and North American theatre and its audiences in the twentieth and twenty-first centuries, it explores belief in theatre's potential to influence, impact and transform. Illustrated by examples of performance which have sought to generate active audience involvement – from Brecht's epic theatre to the Blue Man Group – it seeks to unsettle any simple equation between audience participation and empowerment

Delirium: in rehearsal with Theatre O

Book synopsis: Devising in Process examines the creative process of eight theatre companies making devising-based performances. Authors were granted unusual access to the rehearsal room, enabling them to provide unique insights into how ideas evolve and develop, how strategies and methods are applied and how roles and relationships are structured. Covering a broad range of styles, the collection explores physical theatre, political theatre, puppetry, live art, new writing and performance with new technology. Accessibly framed, the book includes a comprehensive introduction which highlights similarities and differences in approach, examines the impact of economic and cultural factors and explores how definitions of devised theatre are changing and developing. This eye-opening collection will be important reading for students and practitioners interested in exploring 21st century devising processes