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

Evaluation of a semi-structured assessment interview derived from a systems model of career

Current literature indicates that vocational assessment in the field of career counseling and guidance has been dominated by quantitative and empirical methods. Recent criticism of the field from the post-modernist perspective has stimulated the development of theories that account for a wider range of influences present in an individual's phenomenal world with respect to career. This study investigated the practical efficacy of a semi-structured interview, derived from the Systems Theory Framework (STF), which was developed for application in the career counselling service at a university. Another interview derived from 'standard' practice methods was also developed for comparison purposes. Clients of a careers counselling service received either form of interview in an experiment that utilised a pre-test post-test design. Three measures of outcome (self-exploration, environment exploration, and attributional style) were used to assess the two interview methods. Results indicated that the interview based upon the STF has some tentative merit as a potential alternative method for career assessment

The influence of socio‐economic status on salt consumption in Northern Ireland

The long-established association between high salt consumption and hypertension has led to calls for a reduction in salt intake. There is particular concern for the health status of Northern Irish consumers, who already have among the highest rates of coronary heart disease and stroke in the United Kingdom. With these concerns in mind, it is essential to establish the sources and patterns of salt consumption from discretionary and processed food sources before a reduction can be achieved. This study investigated differences in salt consumption patterns among consumers of varying socio-economic status. Research consisted of a consumer questionnaire (n= 360) distributed within Northern Ireland. The results of the study revealed high discretionary salt usage and frequent consumption of processed foods among consumers of lower socio-economic status. General observations from the questionnaire would suggest a need for improved health education for consumers in this group. The objective of health promotion should be to encourage a reduction in table and cooking salt usage and, in particular, in the consumption of highly salted processed foods. Enhanced product labelling is also encouraged to increase consumer awareness of current salt levels in food and of the availability of low-salt foods. In addition, the results of this study advocate further development activity in the production of product formulations with low-salt statu