Enhanced Peri-Operative Care for High-risk patients (EPOCH) Trial
Around two million patients undergo surgery each year in the NHS, following which 30,000 patients die without leaving hospital. Advancing age, abdominal surgery and the need for emergency surgery are amongst the strongest factors associated with poor post-operative outcome. Around 35,000 patients present to NHS hospitals each year with precisely this pattern of risk and undergo a procedure termed emergency laparotomy (major surgery to treat a life threatening problem within the abdomen). Almost 9000 of these patients will die within three months of surgery. Recent evidence shows that basic standards of care for this patient group vary widely between hospitals.
We plan to perform a randomised stepped-wedge cluster trial allocating ninety hospitals in random order to a quality improvement intervention which will enable local staff to deliver the highest possible standard of care for emergency laparotomy patients. A trial of this size should allow us to make use of data describing more than 25,000 patients undergoing emergency laparotomy over an 85 week period. Our primary objective is to confirm whether fewer patients die within 90 days of surgery in hospitals where the quality improvement initiative is in place. We will also conduct a parallel ethnographic study (a study involving in depth observations and interviews with staff) to find out how we can further improve uptake of the pathway.