Challenge of ensuring access to high-quality emergency surgical care for all

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 …