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

Implicit Finite Element Contact With a Multigrid Solver on Parallel Computers

137 p.Thesis (Ph.D.)--University of Illinois at Urbana-Champaign, 2001.Finite element contact is an important analysis tool that has received a significant amount of research attention. The fact that contact problems are geometrically non-smooth as well as algebraically non-linear makes them difficult to solve. Since the bulk of the work in a contact algorithm is associated with solving systems of linear equations, efficient linear solvers are attractive. The geometric multigrid method is an iterative linear equation solving method able to arrive at a solution after O(n) work. Enabling a multigrid method to work for a contact problem requires special treatment of the contact stiffness matrix on coarse meshes. This dissertation describes the mathematical formulation of finite element contact, the multigrid method, and how to couple finite element contact and the multigrid method. The dissertation also demonstrates the scalability of the resulting scheme on several parallel computers and gives results for non-trivial test problems.U of I OnlyRestricted to the U of I community idenfinitely during batch ingest of legacy ETD

Effect of shell drilling stiffness on response calculations of rectangular plates and tubes of rectangular cross-section under compression.

This report considers the calculation of the quasi-static nonlinear response of rectangular flat plates and tubes of rectangular cross-section subjected to compressive loads using quadrilateralshell finite element models. The principal objective is to assess the effect that the shell drilling stiffness parameter has on the calculated results. The calculated collapse load of elastic-plastic tubes of rectangular cross-section is of particular interest here. The drilling stiffness factor specifies the amount of artificial stiffness that is given to the shell element drilling Degree of freedom (rotation normal to the plane of the element). The element formulation has no stiffness for this degree of freedom, and this can lead to numerical difficulties. The results indicate that in the problems considered it is necessary to add a small amount of drilling tiffness to obtain converged results when using both implicit quasi-statics or explicit dynamics methods. The report concludes with a parametric study of the imperfection sensitivity of the calculated responses of the elastic-plastic tubes with rectangular cross-section

Presto user<U+2019>s guide version 2.6.

Presto is a Lagrangian, three-dimensional explicit, transient dynamics code for the analysis of solids subjected to large, suddenly applied loads. Presto is designed for problems with large deformations, nonlinear material behavior, and contact. There is a versatile element library incorporating both continuum and structural elements. The code is designed for a parallel computing environment. This document describes the input for the code that gives users access to all of the current functionality in the code. Presto is built in an environment that allows it to be coupled with other engineering analysis codes. The input structure for the code, which uses a concept called scope, reflects the fact that Presto can be used in a coupled environment. This guide describes the scope concept and the input from the outermost to the innermost input scopes. Within a given scope, the descriptions of input commands are grouped based on code functionality. For example, all material input command lines are described in a section of the user's guide for all of the material models in the code

Summary compilation of shell element performance versus formulation.

This document compares the finite element shell formulations in the Sierra Solid Mechanics code. These are finite elements either currently in the Sierra simulation codes Presto and Adagio, or expected to be added to them in time. The list of elements are divided into traditional two-dimensional, plane stress shell finite elements, and three-dimensional solid finite elements that contain either modifications or additional terms designed to represent the bending stiffness expected to be found in shell formulations. These particular finite elements are formulated for finite deformation and inelastic material response, and, as such, are not based on some of the elegant formulations that can be found in an elastic, infinitesimal finite element setting. Each shell element is subjected to a series of 12 verification and validation test problems. The underlying purpose of the tests here is to identify the quality of both the spatially discrete finite element gradient operator and the spatially discrete finite element divergence operator. If the derivation of the finite element is proper, the discrete divergence operator is the transpose of the discrete gradient operator. An overall summary is provided from which one can rank, at least in an average sense, how well the individual formulations can be expected to perform in applications encountered year in and year out. A letter grade has been assigned albeit sometimes subjectively for each shell element and each test problem result. The number of A's, B's, C's, et cetera assigned have been totaled, and a grade point average (GPA) has been computed, based on a 4.0-system. These grades, combined with a comparison between the test problems and the application problem, can be used to guide an analyst to select the element with the best shell formulation