BackgroundAcute gallstone disease is a high‐volume emergency general surgery presentation with wide variations in the quality of care provided across the UK. This controlled cohort evaluation assessed whether participation in a quality improvement collaborative approach reduced time to surgery for patients with acute gallstone disease to fewer than 8 days from presentation, in line with national guidance.MethodsPatients admitted to hospital with acute biliary conditions in England and Wales between 1 April 2014 and 31 December 2017 were identified from Hospital Episode Statistics data. Time series of quarterly activity were produced for the Cholecystectomy Quality Improvement Collaborative (Chole‐QuIC) and all other acute National Health Service hospitals (control group). A negative binomial regression model was used to compare the proportion of patients having surgery within 8 days in the baseline and intervention periods.ResultsOf 13 sites invited to join Chole‐QuIC, 12 participated throughout the collaborative, which ran from October 2016 to January 2018. Of 7944 admissions, 1160 patients had a cholecystectomy within 8 days of admission, a significant improvement (P < 0·050) from baseline performance. This represented a relative change of 1·56 (95 per cent c.i. 1·38 to 1·75), compared with 1·08 for the control group. At the individual site level, eight of the 12 Chole‐QuIC sites showed a significant improvement (P < 0·050), with four sites increasing their 8‐day surgery rate to over 20 per cent of all emergency admissions, well above the mean of 15·3 per cent for control hospitals.ConclusionA surgeon‐led quality improvement collaborative approach improved care for patients requiring emergency cholecystectomy.
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.
Chole-QuIC = Cholecystectomy Quality Improvement Collaborative; ELC = Emergency Laparotomy Collaborative; EPOCH = Enhanced PeriOperative Care for High-risk patients; HICs = high income countries; IHI = Institute for Healthcare Improvement; NHS = National Health Service; PDSA = Plan-Do-Study-Act; QI = quality improvement; SPC = statistical process control A SUMMARY OF 3 MAJOR QI PROGRAMS The Enhanced PeriOperative Care for High-risk patients (EPOCH) trial was a stepped wedge cluster randomized trial of a QI program, enrolling >15,000 patients across 93 UK major acute hospitals. The QI program was designed to support the introduction of a standard pathway of care for emergency laparotomy patients to reduce mortality. 5 The care pathway was developed from an evidence-based review and included 37 care components. The QI program and implementation approach were designed with stakeholder input from earlier studies, 6 a UK network From the
Bamber: Correspondence extr usion. H owever, we find that this is in consistent with meas ured mass imb alances. This new id ea is tha t deep ice ma y squirt in time-pulses. Being faster th a n the extrusion consid ered above, episodic extrusion wou ld be mech a nically more important. It wo uld ca use a drop in icesurface elevation over th e site of origin of the extrusion a nd surface lifting over the destination. M easurem ents of rela tive vertical velocity obtained with precision GPS of an expa nd ed grid on I ce Stream B, Antarctica (Hulbe and Whillans, 1994), do show importa nt topogra phi c changes, but th e cha nges are not a t sites that wou ld acco unt for the negative basal drag. Thus, not even episodic, non-steady ex trusion can acco unt for the reverse basal drag.Since cond ucting th e work discussed in Whillans and Van d er Veen (1993 ), we have completed a mu ch more extensive stud y of the region , using a g rid expand ed fiv efold . Th e interpretation of these new results is given in Hulbe and Whillans ( 1994 ) and Hulbe (1994; whi ch contains data tables) . Based on this more extensive survey, our current view is that there a re zones of ice of differing viscosity horizontally juxtaposed. Includin g appropriau.: horizontal va riation in viscosity would lead to more sensible calcu lated basal drag. W e propose that bands of special strength d evelop in ice after ex trem e simple shear (a t the sid es of up-glacier tributaries). The viscosity may vary according to the up-glacier origin of the ice.Llibo utry's (1995 ) suggestion is very reasonabl e to the ex tent th a t he carri es it. H owever, the stresses imparted by th e envisioned ex tru sion arc too sm a ll to explain th e calcu lated backward basal fri ction. Th e reason the iss ue arises for Ice Stream B, Antarctica, could be that the ice stream is unusual or, alternatively, that the survey work was more thorough th a n on many other glaciers. Th e ice stream has such a simple geometry that unusual res ults cannot be a ttributed to uncertainties 111 Ice thickness or width.W e thank Professo r Llibo utry for raising this suggestion. It is good for Science to discuss possible oversights. \Ve remain co ncerned that we may have overlooked som e perfectly good explanation for the res ults and wou ld welcom e more suggestions, including furth er consid eration of ex trusion flow.
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