ORCID Profile
0000-0003-4454-5523
Current Organisations
University of Leicester
,
University of Nottingham
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Publisher: BMJ
Date: 12-09-2019
DOI: 10.1136/BMJQS-2019-009537
Abstract: A clinical trial in 93 National Health Service hospitals evaluated a quality improvement programme for emergency abdominal surgery, designed to improve mortality by improving the patient care pathway. Large variation was observed in implementation approaches, and the main trial result showed no mortality reduction. Our objective therefore was to evaluate whether trial participation led to care pathway implementation and to study the relationship between care pathway implementation and use of six recommended implementation strategies. We performed a hospital-level time-series analysis using data from the Enhanced Peri-Operative Care for High-risk patients trial. Care pathway implementation was defined as achievement of % median reliability in 10 measured care processes. Mean monthly process performance was plotted on run charts. Process improvement was defined as an observed run chart signal, using probability-based ‘shift’ and ‘runs’ rules. A new median performance level was calculated after an observed signal. Of 93 participating hospitals, 80 provided sufficient data for analysis, generating 800 process measure charts from 20 305 patient admissions over 27 months. No hospital reliably implemented all 10 processes. Overall, only 279 of the 800 processes were improved (3 (2–5) per hospital) and 14/80 hospitals improved more than six processes. Mortality risk documented (57/80 (71%)), lactate measurement (42/80 (53%)) and cardiac output guided fluid therapy (32/80 (40%)) were most frequently improved. Consultant-led decision making (14/80 (18%)), consultant review before surgery (17/80 (21%)) and time to surgery (14/80 (18%)) were least frequently improved. In hospitals using ≥5 implementation strategies, 9/30 (30%) hospitals improved ≥6 care processes compared with 0/11 hospitals using ≤2 implementation strategies. Only a small number of hospitals improved more than half of the measured care processes, more often when at least five of six implementation strategies were used. In a longer term project, this understanding may have allowed us to adapt the intervention to be effective in more hospitals.
Publisher: Springer Science and Business Media LLC
Date: 12-2018
Publisher: Elsevier BV
Date: 06-2019
Publisher: Elsevier BV
Date: 07-2017
DOI: 10.1093/BJA/AEX164
Abstract: Elevated preoperative heart rate (HR) is associated with perioperative myocardial injury and death. In apparently healthy in iduals, high resting HR is associated with development of cardiac failure. Given that patients with overt cardiac failure have poor perioperative outcomes, we hypothesized that subclinical cardiac failure, identified by cardiopulmonary exercise testing, was associated with elevated preoperative HR > 87 beats min -1 (HR > 87). This was a secondary analysis of an observational cohort study of surgical patients aged ≥45 yr. The exposure of interest was HR > 87, recorded at rest before preoperative cardiopulmonary exercise testing. The predefined outcome measures were the following established predictors of mortality in patients with overt cardiac failure in the general population: ventilatory equivalent for carbon dioxide ( V˙E/V˙co2 ) ratio ≥34, heart rate recovery ≤6 and peak oxygen uptake ( V˙o2 ) ≤14 ml kg -1 min -1 . We used logistic regression analysis to test for association between HR > 87 and markers of cardiac failure. We also examined the relationship between HR > 87 and preoperative left ventricular stroke volume in a separate cohort of patients. HR > 87 was present in 399/1250 (32%) patients, of whom 438/1250 (35%) had V˙E/V˙co2 ratio ≥34, 200/1250 (16%) had heart rate recovery ≤6, and 396/1250 (32%) had peak V˙o2 ≤14 ml kg -1 min -1 . HR > 87 was independently associated with peak V˙o2 ≤14 ml kg -1 min -1 {odds ratio (OR) 1.69 [1.12-3.55] P =0.01} and heart rate recovery ≤6 (OR 2.02 [1.30-3.14] P 87 was not associated with V˙E/V˙co2 ratio ≥34 (OR 1.31 [0.92-1.87] P =0.14). In a separate cohort, HR > 87 (33/181 18.5%) was associated with impaired preoperative stroke volume (OR 3.21 [1.26-8.20] P =0.01). Elevated preoperative heart rate is associated with impaired cardiopulmonary performance consistent with clinically unsuspected, subclinical cardiac failure. ISRCTN88456378.
Location: United Kingdom of Great Britain and Northern Ireland
Location: United Kingdom of Great Britain and Northern Ireland
Location: United Kingdom of Great Britain and Northern Ireland
Location: United Kingdom of Great Britain and Northern Ireland
Location: United Kingdom of Great Britain and Northern Ireland
No related grants have been discovered for Rachel Evley.