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Editorial
Challenge of ensuring access to high-quality emergency surgical care for all
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  1. John W Scott,
  2. Justin B Dimick
  1. Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
  1. Correspondence to Dr Justin B Dimick, University of Michigan, Ann Arbor, MI 48109, USA; jdimick{at}med.umich.edu

https://doi.org/10.1136/bmjqs-2019-010219

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    Emergency general surgery (EGS) encompasses a variety of common acute surgical conditions with high morbidity and mortality that often require timely delivery of resource-intensive care. In the UK, over 30 000 patients require an emergency laparotomy each year1 and a 2012 audit by the UK Emergency Laparotomy Network revealed a greater than 10-fold variation in mortality rates between hospitals.2 The wide variability in both processes of care and clinical outcomes make EGS a prime target for quality improvement (QI) programmes, whereby promotion of evidence-based practices associated with better outcomes have the potential to impact thousands of lives.

    The Enhanced Peri-Operative Care for High-risk patients (EPOCH) trial was designed to evaluate the impact of a national QI programme on survival after emergency abdominal surgery across 93 National Health Service (NHS) hospitals in the UK.1 In this trial, a care pathway consisting of 37 consensus-derived best practices was implemented at each hospital using a step-wedged trial design. Over the 85-week study period, the trial failed to demonstrate any significant improvements in mortality, length of stay or readmissions among adults undergoing open emergency abdominal procedures.3 When QI efforts aimed at sweeping practice change fail to improve outcomes, they may fail for one of two reasons. First, it may be a failure of implementing the required changes to existing practice. A trial …

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      Timothy J Stephens Carol J Peden Ryan Haines Mike P W Grocott Dave Murray David Cromwell Carolyn Johnston Sarah Hare Jose Lourtie Sharon Drake Graham P Martin Rupert M Pearse On behalf of Enhanced Perioperative Care for High-risk patients (EPOCH) trial group Ruper Pearse Carol Peden Tim Stephens Julian Bion Graham Martin Ann Thomson Brennan Kahan Sally Kerry Kate Rivett Duncan Wells Gerry Richardson Stephen Brett Gareth Ackland Mike Grocott Peter Holt Glenn Robert Obioha Ukoumunne Justin Waring Kirsty Everingham Mandeep Phull David Cromwell Rachel Evley Richard Lilford David Kocman Miqdad Asaria Justin Waring Carolyn Tarrant Fan Yang Ajit Abraham Pieter Bothma Daniel Conway Clare Stapleton Mark Edwards Gary Minto David Saunders Tom Owen Carl Waldmann Paul Hayden Michael Gillies Sean Tighe Neil Smith Monty Mythen David Murray Dileep Lobo Martin Leuwer Justin Kirk-Bayley Simon Howell Anthony Gordon Iain Anderson Jose Lourtie Simon Walker Sharon Drake Dave Murray Nick Watson Tamas Szakmany Robert Sutcliffe Ravi Mahajan Alan Girling Gordon Forbes Omar Faiz Mark Blunt Surjait Singh Alistair Steel Kate Wong Leilani Cabreros Pieter Bothma Vivek Chitre Ayodele Obideyi Dhiraj Ali Karl Blenk Dan Broad Andreas Brodbeck Rajesh Dumpala Arnth Engel Ranjit Ganepola Sudha Garg Mike Gay Michael Karlikowsk Edward Lams Dean Millican Inga Misane Ajaya Mull Veena Naik Nathan Pushpa Chris Nutt Saravanna Sagadai Hazel Stuart Paul Noble Niko Van De Velde Liam Hudson Raoul Benlloch Satish Singh Karan Verma Damian Laba Jack Carmichael Peter Richardson Graham Wilson Ricky Lewis Karthik Surendran Essam El-Damatty Sarada Gurung Ilona Raulusaite Nabua Gerstina Chloe Rochester Rai Kuldip Andrew Lindner Therese Murray Vivek Chitre Roshan Lal Sarah Downey Vamsi Velchuru Kamal Aryal Raman Guruswamy Kirosh Shankar Helen Porter Matthew Tutton Helen Agostini Simon Fletcher Richard Wharton Steve Hutchinson Bala Maiya Richard Howard-Griffin Michael Crabtree Vlad Kushakovsky Senthil Nadarajavan 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      BMJ Quality & Safety 2019; 29 623-635 Published Online First: 12 Sep 2019. doi: 10.1136/bmjqs-2019-009537