Understanding the influences on successful quality improvement in emergency general surgery: learning from the RCS Chole-QuIC project

Abstract: Background: Acute gallstone disease is the highest volume Emergency General Surgical presentation in the UK. Recent data indicate wide variations in the quality of care provided across the country, with national guidance for care delivery not implemented in most UK hospitals. Against this backdrop, the Royal College of Surgeons of England set up a 13-hospital quality improvement collaborative (Chole-QuIC) to support clinical teams to reduce time to surgery for patients with acute gallstone disease requiring emergency cholecystectomy. Methods: Prospective, mixed-methods process evaluation to answer the following: (1) how was the collaborative delivered by the faculty and received, understood and enacted by the participants; (2) what influenced teams’ ability to improve care for patients requiring emergency cholecystectomy? We collected and analysed a range of data including field notes, ethnographic observations of meetings, and project documentation. Analysis was based on the framework approach, informed by Normalisation Process Theory, and involved the creation of comparative case studies based on hospital performance during the project. Results: Chole-QuIC was delivered as planned and was well received and understood by participants. Four hospitals were identified as highly successful, based upon a substantial increase in the number of patients having surgery in line with national guidance. Conversely, four hospitals were identified as challenged, achieving no significant improvement. The comparative analysis indicate that six inter-related influences appeared most associated with improvement: (1) achieving clarity of purpose amongst site leads and key stakeholders; (2) capacity to lead and effective project support; (3) ideas to action; (4) learning from own and others’ experience; (5) creating additional capacity to do emergency cholecystectomies; and (6) coordinating/managing the patient pathway. Conclusion: Collaborative-based quality improvement is a viable strategy for emergency surgery but success requires the deployment of effective clinical strategies in conjunction with improvement strategies. In particular, achieving clarity of purpose about proposed changes amongst key stakeholders was a vital precursor to improvement, enabling the creation of additional surgical capacity and new pathways to be implemented effectively. Protected time, testing ideas, and the ability to learn quickly from data and experience were associated with greater impact within this cohort

Assessment of the IMV diameter as a surrogate marker to evaluate response to neoadjuvant chemoradiotherapy for locally advanced rectal adenocarcinoma.

We read with interest the paper by Ivan CV et al (1) assessing the relationship between inferior mesenteric vein diameter and evidence of extra-mural invasion (EMVI) in rectal cancer. Recent literature has focused on the identification of EMVI on the pre-treatment MRI due to its presence being a major determinant and an important prognostic independent factor for risk stratification of local and distant recurrence [2, 3]. The authors have based their hypothesis and the rationale for using inferior mesenteric vein (IMV) measurement on the emerging evidence that suggested that a correlation existed between splanchnic venous circulation, colorectal cancer and EMVI [3] This article is protected by copyright. All rights reserved

Preoperative intravenous iron and the risk of blood transfusion in colorectal cancer surgery: meta-analysis of randomized clinical trials

 Preoperative anaemia commonly affects 30–60 per cent of the general surgical population, and is associated with an increased risk of postoperative morbidity, prolonged hospital stay, and impaired recovery. Anaemia is more prevalent in colorectal cancer, affecting 60–80 per cent of patients, and as many as 40 per cent of non-anaemic patients with colorectal cancer experience iron deficiency. Iron deficiency and anaemia in patients with colorectal cancer are linked to tumour location and tumour stage. In locally advanced colorectal cancer, intraluminal blood loss and subsequent anaemia can lead to absolute iron deficiency, whereas distant disease, characterized by inflammation and altered catabolism, can cause functional iron deficiency and chronic disease anaemia. Anaemia and iron deficiency are important factors in patients with colorectal cancer owing to their association with increased postoperative complications, impaired recovery, and poorer survival rates. Treating anaemia with allogeneic blood transfusion, however, is associated with adverse patient outcomes as well as increased cancer recurrence rates and higher overall mortality. </p

Evaluation of a quality improvement intervention to reduce anastomotic leak following right colectomy (EAGLE): pragmatic, batched stepped-wedge, cluster-randomized trial in 64 countries

Background Anastomotic leak affects 8 per cent of patients after right colectomy with a 10-fold increased risk of postoperative death. The EAGLE study aimed to develop and test whether an international, standardized quality improvement intervention could reduce anastomotic leaks. Methods The internationally intended protocol, iteratively co-developed by a multistage Delphi process, comprised an online educational module introducing risk stratification, an intraoperative checklist, and harmonized surgical techniques. Clusters (hospital teams) were randomized to one of three arms with varied sequences of intervention/data collection by a derived stepped-wedge batch design (at least 18 hospital teams per batch). Patients were blinded to the study allocation. Low- and middle-income country enrolment was encouraged. The primary outcome (assessed by intention to treat) was anastomotic leak rate, and subgroup analyses by module completion (at least 80 per cent of surgeons, high engagement; less than 50 per cent, low engagement) were preplanned. Results A total 355 hospital teams registered, with 332 from 64 countries (39.2 per cent low and middle income) included in the final analysis. The online modules were completed by half of the surgeons (2143 of 4411). The primary analysis included 3039 of the 3268 patients recruited (206 patients had no anastomosis and 23 were lost to follow-up), with anastomotic leaks arising before and after the intervention in 10.1 and 9.6 per cent respectively (adjusted OR 0.87, 95 per cent c.i. 0.59 to 1.30; P = 0.498). The proportion of surgeons completing the educational modules was an influence: the leak rate decreased from 12.2 per cent (61 of 500) before intervention to 5.1 per cent (24 of 473) after intervention in high-engagement centres (adjusted OR 0.36, 0.20 to 0.64; P &lt; 0.001), but this was not observed in low-engagement hospitals (8.3 per cent (59 of 714) and 13.8 per cent (61 of 443) respectively; adjusted OR 2.09, 1.31 to 3.31). Conclusion Completion of globally available digital training by engaged teams can alter anastomotic leak rates. Registration number: NCT04270721 (http://www.clinicaltrials.gov)