Scaling Up Quality Improvement for Surgical Teams (QIST) - avoiding surgical site infection and anaemia at the time of surgery: protocol for a cluster randomised controlled trial

Abstract

Background: Measures shown to improve outcomes for patients often fail to be adopted into routine practice in the NHS. The Institute for Health Improvement Breakthrough Series Collaborative (BSC) model is designed to support implementation at scale. This trial aims to assess the effectiveness and cost-effectivenessof quality improvement collaboratives based on the BSC method for introducing service improvements at scale in the NHS. Methods: Forty Trusts will be randomised (1:1) to introduce one of two protocols already shown to improve outcomes in patients undergoing elective total hip and knee replacement surgery. The intervention is improvement collaboratives based on the BSC model, a learning system that brings together a large number of teams to seek improvement focused on a proven intervention. Collaboratives aim to deliver at scale, maximise local engagement and leadership and are designed to build capacity, enable learning and prepare for sustainability. Collaboratives involve learning sessions, action periods, and a summative congress. Trusts will be supported to introduce either: decolonisation for MSSA to reduce post-operative infection (QIST:Infection), or an anaemia optimisation programme to reduce peri-operative blood transfusions (QIST:Anaemia). Trusts will continue with their usual practice for whichever protocol they are not introducing. Anonymised data related to both infection and anaemia outcomes for patients undergoing hip or knee arthroplasty at all sites will mean the two groups act as controls for each other. The primary outcome for the QIST: Infection collaborative is deep MSSA surgical site infection within 90 days of surgery, and for the QIST: Anaemia collaborative is blood transfusion within 7 days of surgery. Patient-level secondary outcomes include length of hospital stay and re-admission, which will also inform the economic costings. Qualitative interviews will evaluate the support provided to teams. Discussion: The scale of this trial brings considerable challenges and potential barriers to delivery. Anticipated challenges relate to recruiting and sustaining up to 40 organisations, each with their own culture and context. This complex project with multiple stakeholders across a large geography will be managed by experienced senior-level project leaders with a proven track record in advanced project management. The team will ensure effective project governance and communications.