This is a repository copy of Effectiveness of a national quality improvement programme to improve survival after emergency abdominal surgery (EPOCH) : a stepped-wedge cluster-randomised trial. Effectiveness of a national quality improvement programme to improve survival after emergency abdominal surgery (EPOCH) : a stepped-wedge cluster-randomised trial. The Lancet. ISSN 0140-6736 https://doi.org/10.1016/S0140-6736(18)32521-2 eprints@whiterose.ac.uk https://eprints.whiterose.ac.uk/
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Implications of all the available evidenceDespite the success of some smaller projects, there was no survival benefit from a national quality improvement programme to implement a care pathway for patients undergoing emergency abdominal surgery. To succeed, large national quality improvement programmes need to allow for differences between hospitals and ensure teams have both the time and resources needed to improve patient care.
Our findings confirm that hyperbilirubinaemia has a high specificity for distinguishing acute appendicitis, especially when perforated, from other causes of RIF pain, particularly those not requiring surgery.
The management of the acute blue finger is controversial with many regarding it as a benign condition. However, we would argue that it should always be considered as an emergency. We present a challenging case of a 43-year-old woman who presented with a 1-week history of sudden onset blue discolouration of the left fifth digit, and a 6-week history of episodic joint problems. Examination showed bilateral normal radial and ulnar pulses. Following blood investigations, an initial working diagnosis of early rheumatoid arthritis with associated Raynaud's phenomenon was made. Also, infective endocarditis was considered due to temporary misleading physical signs. Later, CT angiography of the left upper limb arteries showed a significant proximal left subclavian stenosis. Subsequently, a diagnosis of the left subclavian arteritis associated with digit ischaemia from embolic debris was made and the patient underwent a left subclavian angioplasty. However, delayed management resulted in a necrotic digit, which was left to autoamputate.
Background
Resumption of elective surgery during the current coronavirus disease 2019 (COVID-19) pandemic crisis has been debated widely and largely discouraged. This prospective cohort study aimed to assess the feasibility of resuming elective operations during the current and possible future peaks of COVID-19 pandemic.
Method
Data were collected during the peak of the first pandemic in the United Kingdom on adult patients who underwent elective surgery in a “COVID-19-free” hospital from April 8 to May 29, 2020. The study included patients from various surgical specialities. Non-elective and pediatric cases were excluded. The primary outcome was 30-day mortality postoperatively. Secondary outcomes were the rate of COVID-19 infections, new onset of pulmonary symptoms after hospitalization and requirement for admission to the intensive care unit.
Results
309 consecutive adult patients were included in this study. No patients died nor required intensive care unit admission. Operations graded “Intermediate” were the most performed procedures. One patient was diagnosed with COVID-19 infection after being transferred to the nearest local emergency hospital for management of postoperative pain and was successfully treated conservatively on the ward. No patient developed pulmonary complications. Three patients were admitted for greater than 23 hours. Twenty-seven patients (8.7%) developed complications. Complications graded as 2 and 3 according to the Clavien-Dindo classification occurred in 14 and 2 patients, respectively.
Conclusions
This prospective study shows that, despite the severity and high transmissibility of novel coronavirus 2 diseases, “COVID-19-free” hospitals can represent a safe setting to resume many types of elective surgery during the peak of a pandemic.
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