Publishing quality improvement studies: learning to share and sharing to learn

This editorial welcomes the decision of BJA Open to publish quality improvement (QI) studies. It summarises the current problems with conducting, evaluating, and publishing QI studies. It highlights existing guidance for prospective authors to follow regarding the reporting of QI interventions, their context(s), underlying theories, and evaluation. In so doing, we hope to encourage the publication of more QI studies of sufficient quality to facilitate learning or replication elsewhere

Good intra-operative anaesthesia is more than an “ABCD with a three, two and a one".

The adoption of checklists within healthcare leads to improvements in patient safety. Perioperative management of patients with comorbidity and polypharmacy is complex and whilst physical checklists, aviation style computerised checklists, and mnemonics can all be used to make anaesthesia safer, these cannot cover the entirety or the complexity of perioperative care, and in particular, the principles by which anaesthetists work to promote restoration of function. Restoration of function is increasingly being seen as the marker of good anaesthetic care.Wellcome Trus

A scoping review of local quality improvement using data from UK perioperative National Clinical Audits

BACKGROUND: Significant resources are invested in the UK to collect data for National Clinical Audits (NCAs), but it is unclear whether and how they facilitate local quality improvement (QI). The perioperative setting is a unique context for QI due to its multidisciplinary nature and history of measurement. It is unclear which NCAs evaluate perioperative care, to what extent their data have been used for QI, and which factors influence this usage. METHODS: NCAs were identified from the directories held by Healthcare Quality Improvement Partnership (HQIP), Scottish Healthcare Audits and the Welsh National Clinical Audit and Outcome Review Advisory Committee. QI reports were identified by the following: systematically searching MEDLINE, CINAHL Plus, Web of Science, Embase, Google Scholar and HMIC up to December 2019, hand-searching grey literature and consulting relevant stakeholders. We charted features describing both the NCAs and the QI reports and summarised quantitative data using descriptive statistics and qualitative themes using framework analysis. RESULTS: We identified 36 perioperative NCAs in the UK and 209 reports of local QI which used data from 19 (73%) of these NCAs. Six (17%) NCAs contributed 185 (89%) of these reports. Only one NCA had a registry of local QI projects. The QI reports were mostly brief, unstructured, often published by NCAs themselves and likely subject to significant reporting bias. Factors reported to influence local QI included the following: perceived data validity, measurement of clinical processes as well as outcomes, timely feedback, financial incentives, sharing of best practice, local improvement capabilities and time constraints of clinicians. CONCLUSIONS: There is limited public reporting of UK perioperative NCA data for local QI, despite evidence of improvement of most NCA metrics at the national level. It is therefore unclear how these improvements are being made, and it is likely that opportunities are being missed to share learning between local sites. We make recommendations for how NCAs could better support the conduct, evaluation and reporting of local QI and suggest topics which future research should investigate. TRIAL REGISTRATION: The review was registered with the International Prospective Register of Systematic Reviews (PROSPERO: CRD42018092993 )

Novel approach to defining major abdominal surgery

Introduction: Over 5.8 million abdominal operations and procedures were recorded in England between April 2021 and March 20221. Although a definition of major surgery has been proposed by the Delphi consensus among European Surgical Association members2, there is no clear consensus regarding which surgical procedures constitute major abdominal surgery (MAS). Despite this, multiple sources in the literature, including perioperative morbidity and mortality scoring systems, national audits, and private healthcare coding schedules3–5, have alluded to this type of surgery without any underlying qualification. To clarify this area, a scoping literature review was conducted to derive a definition of MAS, based on content analysis of the terminology used to describe major abdominal surgical procedures6. MAS was defined as an intraperitoneal operation with no primary involvement of the thorax, involving either luminal resection and/or resection of a solid organ associated with the gastrointestinal tract. The aim of the current study was to verify the discriminative ability of this hypothesized definition of MAS using real-world data analysis and unsupervised machine learning

The incidence of postoperative vasopressor usage: protocol for a prospective international observational cohort study (SQUEEZE)

Background: Postoperative hypotension is common after major non-cardiac surgery, due predominantly to vasodilation. Administration of infused vasopressors postoperatively may often be considered a surrogate indicator of vasodilation. The incidence of postoperative vasopressors has never been described for non-cardiac surgery, nor have outcomes associated with their use. This paper presents a protocol for a prospective international cohort study to address these gaps in knowledge. The primary objectives are to estimate the proportion of patients who receive postoperative vasopressor infusions (PVI) and to document the variation in this proportion between hospitals and internationally. Furthermore, we will identify factors in variation of care (patient, condition, surgery, and intraoperative management) associated with receipt of PVI and investigate how PVI use is associated with patient outcomes, including organ dysfunction, length of hospital stay, and 30-day in-hospital mortality. Method: This will be a prospective, international, multicentre cohort study that includes all adult (≥ 18 years) non-cardiac surgical patients in participating centres. Patients undergoing cardiac, obstetric, or day-case surgery will be excluded. We will recruit two cohorts of patients: cohort A will include all eligible patients admitted to participating hospitals for seven consecutive days. Cohort B will include 30 sequential patients per hospital, with the single additional inclusion criterion of postoperative vasopressor usage. We expect to collect data on approximately 40,000 patients for cohort A and 12,800 patients for cohort B. Discussion: While in cardiac surgery, clinical trials have informed the choice of vasopressors used to treat postoperative vasoplegia; there remains equipoise over the best approach in non-cardiac surgery. Our study will represent the first large-scale assessment of the use of vasopressors after non-cardiac surgery. These data will inform future studies, including trials of different vasopressors and potential management options to improve outcomes and reduce resource use after surgery. Trial registration: ClinicalTrials.gov Identifier: NCT03805230, 15 January 2019

Understanding recruitment to a perioperative randomised controlled trial: protocol for a mixed-methods substudy nested within a feasibility trial of octreotide infusion during liver transplantation

Introduction Recruitment to perioperative randomised controlled trials is known to be challenging. Qualitative methods offer insight into barriers and enablers to participation. This is a substudy within a feasibility randomised controlled trial of octreotide infusion during liver transplantation at two National Health Service hospitals, which will evaluate patient and staff experiences of trial processes. By sharing formative understanding from these methods with the trials team we aim to improve staff-patient interactions and hence recruitment rates. Methods and analysis This prospective mixed-methods study will comprise two workstreams. First, after consent to the randomised controlled trial is sought, all patients will be invited to complete a questionnaire to explore their perceptions of the information given to them and motivating factors that influenced their decision to consent or not. Questionnaires will be analysed using descriptive statistics and framework analysis. If the recruitment:approach ratio drops below a predetermined ratio or if there are any specific recruitment concerns from the trials team, a second workstream involving mixed-methods fieldwork will be implemented. This will involve audiorecording of recruitment consultations and a follow-up semistructured interview to explore patients' perception of their decision-making regarding recruitment. Semistructured interviews will also be conducted with the recruitment team to establish their views about the trial, barriers to recruitment and ways to overcome them. Recruitment consultations will be analysed using Q-QAT methodology and interviews will be analysed using framework analysis. Findings from both workstreams will be formatively fed back to the trials team to enable iterative improvement to recruitment processes. Ethics and dissemination Approval has been granted by Greater Manchester West Research Ethics Committee (ref 20/NW/0071), the Health Research Authority and the local Research and Development offices. A manuscript detailing the summative findings will be submitted to peer-reviewed journals. Trial registration number NCT04941911

SNAP-2 EPICCS: the second Sprint National Anaesthesia Project-EPIdemiology of Critical Care after Surgery: protocol for an international observational cohort study.

INTRODUCTION: The admission of high-risk patients to critical care after surgery is a recommended standard of care. Nevertheless, poor compliance against this recommendation has been repeatedly demonstrated in large epidemiological studies. It is unclear whether this is due to reasons of capacity, equipoise, poor quality clinical care or because hospitals are working creatively to create capacity for augmented care on normal surgical wards. The EPIdemiology of Critical Care after Surgery study aims to address these uncertainties. METHODS AND ANALYSIS: One-week observational cohort study in the UK and Australasia. All patients undergoing inpatient (overnight stay) surgery will be included. All will have prospective data collection on risk factors, surgical procedure and postoperative outcomes including the primary outcome of morbidity (measured using the Postoperative Morbidity Survey on day 7 after surgery) and secondary outcomes including length of stay and mortality. Data will also be collected on critical care referral and admission, surgical cancellations and critical care occupancy. The epidemiology of patient characteristics, processes and outcomes will be described. Inferential techniques (multilevel multivariable regression, propensity score matching and instrumental variable analysis) will be used to evaluate the relationship between critical care admission and postoperative outcome. ETHICS AND DISSEMINATION: The study has received ethical approval from the National Research Ethics Service in the UK and equivalent in Australasia. The collection of patient identifiable data without prior consent has been approved by the Confidentiality Advisory Group (England and Wales) and the Public Privacy and Patient Benefit Panel (Scotland). In these countries, patient identifiable data will be used to link prospectively collected data with national registers of death and inpatient administrative data. The study findings will be disseminated using a multimedia approach with the support of our lay collaborators, to patients, public, policy-makers, clinical and academic audiences

Clinical effectiveness and cost-effectiveness of emergency surgery for adult emergency hospital admissions with common acute gastrointestinal conditions: the ESORT study

Background: Evidence is required on the clinical effectiveness and cost-effectiveness of emergency surgery compared with non-emergency surgery strategies (including medical management, non-surgical procedures and elective surgery) for patients admitted to hospital with common acute gastrointestinal conditions. Objectives: We aimed to evaluate the relative (1) clinical effectiveness of two strategies (i.e. emergency surgery vs. non-emergency surgery strategies) for five common acute conditions presenting as emergency admissions; (2) cost-effectiveness for five common acute conditions presenting as emergency admissions; and (3) clinical effectiveness and cost-effectiveness of the alternative strategies for specific patient subgroups. Methods: The records of adults admitted as emergencies with acute appendicitis, cholelithiasis, diverticular disease, abdominal wall hernia or intestinal obstruction to 175 acute hospitals in England between 1 April 2010 and 31 December 2019 were extracted from Hospital Episode Statistics and linked to mortality data from the Office for National Statistics. Eligibility was determined using International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, diagnosis codes, which were agreed by clinical panel consensus. Patients having emergency surgery were identified from Office of Population Censuses and Surveys procedure codes. The study addressed the potential for unmeasured confounding with an instrumental variable design. The instrumental variable was each hospital’s propensity to use emergency surgery compared with non-emergencysurgery strategies. The primary outcome was the ‘number of days alive and out of hospital’ at 90 days. We reported the relative effectiveness of the alternative strategies overall, and for prespecified subgroups (i.e. age, number of comorbidities and frailty level). The cost-effectiveness analyses used resource use and mortality from the linked data to derive estimates of incremental costs, quality-adjusted life-years and incremental net monetary benefits at 1 year. Results: Cohort sizes were as follows: 268,144 admissions with appendicitis, 240,977 admissions with cholelithiasis, 138,869 admissions with diverticular disease, 106,432 admissions with a hernia and 133,073 admissions with an intestinal obstruction. Overall, at 1 year, the average number of days alive and out of hospitals at 90 days, costs and quality-adjusted life-years were similar following either strategy, after adjusting for confounding. For each of the five conditions, overall, the 95% confidence intervals (CIs) around the incremental net monetary benefit estimates all included zero. For patients with severe frailty, emergency surgery led to a reduced number of days alive and out of hospital and was not cost-effective compared with non-emergency surgery, with incremental net monetary benefit estimates of –£18,727 (95% CI –£23,900 to –£13,600) for appendicitis, –£7700 (95% CI –£13,000 to –£2370) for cholelithiasis, –£9230 (95% CI –£24,300 to £5860) for diverticular disease, –£16,600 (95% CI –£21,100 to –£12,000) for hernias and –£19,300 (95% CI –£25,600 to –£13,000) for intestinal obstructions. For patients who were ‘fit’, emergency surgery was relatively cost-effective, with estimated incremental net monetary benefit estimates of £5180 (95% CI £684 to £9680) for diverticular disease, £2040 (95% CI £996 to £3090) for hernias, £7850 (95% CI £5020 to £10,700) for intestinal obstructions, £369 (95% CI –£728 to £1460) for appendicitis and £718 (95% CI £294 to £1140) for cholelithiasis. Public and patient involvement translation workshop participants emphasised that these findings should be made widely available to inform future decisions about surgery. Limitations: The instrumental variable approach did not eliminate the risk of confounding, and the acute hospital perspective excluded costs to other providers. Conclusions: Neither strategy was more cost-effective overall. For patients with severe frailty, nonemergency surgery strategies were relatively cost-effective. For patients who were fit, emergency surgery was more cost-effective. Future work: For patients with multiple long-term conditions, further research is required to assess the benefits and costs of emergency surgery. Study registration: This study is registered as reviewregistry784