Reducing variation in hospital mortality for alcohol-related liver disease in North West England.

BACKGROUND: Variations in emergency care quality for alcohol-related liver disease (ARLD) have been highlighted. AIM: To determine whether introduction of a regional quality improvement (QI) programme was associated with a reduction in potentially avoidable inpatient mortality. METHOD: Retrospective observational cohort study using hospital administrative data spanning a 1-year period before (2014/2015) and 3 years after a QI initiative at seven acute hospitals in North West England. The intervention included serial audit of a bundle of process metrics. An algorithm was developed to identify index ("first") emergency admissions for ARLD (n = 3887). We created a standardised mortality ratio (SMR) to compare relative mortality and regression models to examine risk-adjusted odds of death. RESULTS: In 2014/2015, three of seven hospitals had an SMR above the upper control limit ("outliers"). Adjusted odds of death for patients admitted to outlier hospitals was higher than non-outliers (OR 2.13, 95% CI 1.32-3.44, P = 0.002). Following the QI programme there was a step-wise reduction in outliers (none in 2017/2018). Odds of death was 67% lower in 2017/2018 compared to 2014/2015 at original outlier hospitals, but unchanged at other hospitals. Process audit performance of outliers was worse than non-outliers at baseline, but improved after intervention. CONCLUSIONS: There was a reduction in unexplained variation in hospital mortality following the QI intervention. This challenges the pessimism that is prevalent for achieving better outcomes for patients with ARLD. Notwithstanding the limitations of an uncontrolled observational study, these data provide hope that co-ordinated efforts to drive adoption of evidence-based practice can save lives.

Advancing quality in sepsis management: a large-scale programme for improving sepsis recognition and management in the North West region of England.

OBJECTIVE: To evaluate the impact of a collaborative programme for the early recognition and management of patients admitted with sepsis in the northwest of England. SETTING: 14 hospitals in the northwest of England. INTERVENTION: A quality improvement programme (Advancing Quality (AQ) Sepsis) that promoted a sepsis care bundle including time-based recording of early warning scores, documenting systemic inflammatory response syndrome criteria and suspected source of infection, taking of blood cultures, measuring serum lactate levels, administration of intravenous antibiotics, administration of oxygen, fluid resuscitation, measurement of fluid balance and senior review. MAIN OUTCOME MEASURES: Inpatient mortality, 30-day readmission rates and duration of hospital ≥10 days. RESULTS: Data for 7776 patients were included in this study between 1 July 2014 and 29 December 2015. Participation in the AQ Sepsis programme was associated with a reduction in readmissions within 30 days (OR 0.81 (0.69-0.95)) and hospital stays over 10 days (OR 0.69 (0.60-0.78)). However, there was no reduction in mortality. Administration of a second litre of intravenous fluid within 2 hours, oxygen therapy and review by a senior clinician were associated with increased mortality. Starting a fluid balance chart within 4 hours was the only clinical process measure that did not affect mortality. Taking a blood culture sample, administering antibiotic therapy and measuring serum lactate within 3 hours of hospital arrival were all associated with reduced mortality (OR 0.69 (0.59-0.81), OR 0.77 (0.67-0.89) and OR 0.64 (0.54-0.77), respectively) and shorter hospitalisations (OR 0.58 (0.49-0.69), OR0.81 (0.70-0.94) and OR 0.54 (0.45-0.66), respectively). However, none of these measures had an impact on the risk of readmission to hospital within 30 days. CONCLUSIONS: The AQ Sepsis collaborative in northwest of England improved readmission and length of stay for patients admitted with sepsis but did not affect mortality. Further cost-effectiveness evaluation of the programme is needed.

The association between pre-hospital antibiotic therapy and subsequent in-hospital mortality in adults presenting with community-acquired pneumonia: an observational study.

BACKGROUND: The majority of patients with community acquired-pneumonia (CAP) are treated in primary care and the mortality in this group is very low. However, a small but significant proportion of patients who begin treatment in the community subsequently require admission due to symptomatic deterioration. This study compared patients who received community antibiotics prior to admission to those who had not, and looked for associations with clinical outcomes. METHODS: This study analysed the Advancing Quality (AQ) Pneumonia database of patients admitted with CAP to 9 acute hospitals in the northwest of England over a 12-month period. RESULTS: There were 6348 subjects (mean age 72 [SD 16] years; gender ratio 1:1) admitted with CAP, of whom 17% had been pre-treated with antibiotics. The in-hospital mortality was 18.6% for the pre-treatment group compared to 13.2% in the "antibiotic naïve" group (p < 0.001). On multivariate analysis, age, male gender and antibiotic pre-treatment were predictors of in-hospital mortality along with a history of cerebrovascular accident, congestive cardiac failure, dementia, renal disease and cancer. After adjustment for CURB-65 score, age, co-morbidities and pre-treatment with antibiotics remained as independent risk factors for in-hospital mortality (OR 1.43, 95% CI 1.19-1.71). CONCLUSION: CAP patients admitted to hospital were more likely to die during admission if they had received antibiotics for the same illness pre-admission. Future studies should endeavor to determine the mechanisms underlying this association, such as microbiological factors and the role of comorbidities. Patients hospitalized with CAP despite prior antibiotic treatment in the community require close monitoring.