The Perioperative Quality Improvement Programme (PQIP patient study): protocol for a UK multicentre, prospective cohort study to measure quality of care and outcomes after major surgery

Introduction

Major surgery accounts for a substantial proportion of health service activity, due not only to the primary procedure, but the longer-term health implications of poor short-term outcome. Data from small studies or from outside the UK indicate that rates of complications and failure to rescue vary between hospitals, as does compliance with best practice processes. Within the UK, there is currently no system for monitoring postoperative complications (other than short-term mortality) in major non-cardiac surgery. Further, there is variation between national audit programmes, in the emphasis placed on quality assurance versus quality improvement, and therefore the principles of measurement and reporting which are used to design such programmes.

Methods and analysis

The PQIP patient study is a multi-centre prospective cohort study which recruits patients undergoing major surgery. Patient provide informed consent and contribute baseline and outcome data from their perspective using a suite of patient-reported outcome tools. Research and clinical staff complete data on patient risk factors and outcomes in-hospital, including two measures of complications. Longer-term outcome data are collected through patient feedback and linkage to national administrative datasets (mortality and readmissions). As well as providing a uniquely granular dataset for research, PQIP provides feedback to participating sites on their compliance with evidence-based processes and their patients’ outcomes, with the aim of supporting local quality improvement.

Ethics and dissemination

Ethical approval has been granted by the Health Research Authority in the UK. Dissemination of interim findings (non-inferential) will form a part of the improvement methodology and will be provided to participating centres at regular intervals, including near-real time feedback of key process measures. Inferential analyses will be published in the peer-reviewed literature, supported by a comprehensive multi-modal communications strategy including to patients, policy makers and academic audiences as well as clinicians.

Core outcome set for peripheral regional anesthesia research: a systematic review and Delphi study

BACKGROUND/IMPORTANCE

There is heterogeneity among the outcomes used in regional anesthesia research.

OBJECTIVE

We aimed to produce a core outcome set for regional anesthesia research.

METHODS

We conducted a systematic review and Delphi study to develop this core outcome set. A systematic review of the literature from January 2015 to December 2019 was undertaken to generate a long list of potential outcomes to be included in the core outcome set. For each outcome found, the parameters such as the measurement scale, timing and definitions, were compiled. Regional anesthesia experts were then recruited to participate in a three-round electronic modified Delphi process with incremental thresholds to generate a core outcome set. Once the core outcomes were decided, a final Delphi survey and video conference vote was used to reach a consensus on the outcome parameters.

RESULTS

Two hundred and six papers were generated following the systematic review, producing a long list of 224 unique outcomes. Twenty-one international regional anesthesia experts participated in the study. Ten core outcomes were selected after three Delphi survey rounds with 13 outcome parameters reaching consensus after a final Delphi survey and video conference.

CONCLUSIONS

We present the first core outcome set for regional anesthesia derived by international expert consensus. These are proposed not to limit the outcomes examined in future studies, but rather to serve as a minimum core set. If adopted, this may increase the relevance of outcomes being studied, reduce selective reporting bias and increase the availability and suitability of data for meta-analysis in this area.

Prioritisation of quality indicators for elective perioperative care: a Delphi consensus

BACKGROUND

A systematic review of the peer-reviewed and grey literature previously identified over 1200 perioperative structure and process quality indicators. We undertook a Delphi consensus process with the aim of creating a concise list of indicators that experts deemed most important for assessing quality in perioperative care.

METHODS

A basic Delphi consensus was completed using an online survey which was distributed to surgeons, anaesthetists, nurses, physicians and lay representatives. Participants were asked to prioritise the indicators in order of importance (high, medium or low) to be included for collection in a national perioperative quality improvement programme.

RESULTS

One hundred and thirty-seven indicators were included in the first iteration of the Delphi consensus (91 structure and 48 process indicators). Sixty-three experts agreed to participate and the consensus was completed in five rounds. Ninety-five indicators were agreed as high priority: 65 structural and 30 process indicators.

CONCLUSION

The Delphi consensus process was able to reduce the number of recommended indicators to only a modest extent. Further work to evaluate the practicalities of routinely collecting such a comprehensive list of quality indicators is now required.

Improving the Peri-operative care of Patients by instituting a 'Block Room' for Regional Anaesthesia

Regional anaesthesia has multiple known benefits over general anaesthesia alone, but requires time and expertise for its application. This study aimed to decrease anaesthetic time and increase total surgical operative time by instituting a ‘block room’ where regional anaesthesia nerve blocks could be provided by expert anaesthetists in regular scheduled sessions.

A baseline audit showed that 2 hours per day was spent on performing nerve blocks. Development of the block room allowed nerve blocks to be performed in parallel to surgical operations, reducing the mean anaesthetic control time from 44 mins to 27 mins. This freed time for an extra operative case per day. In addition, pooling of expertise to one site has allowed excellent teaching opportunities for anaesthetic trainees, and a specific training programme for regional anaesthesia is being produced.

In conclusion, instituting a block room has improved the efficiency of our theatre complex, and improved the service deliverable to our patients.