title: Reliability in the process of care during emergency general surgical admission: A prospective cohort study.
abstract: BACKGROUND
  Emergency general surgery (EGS) is responsible for 80-90% of surgical in-hospital deaths and the early management of these unwell patients is critical to improving outcomes. Unfortunately care for EGS patients is often fragmented and important care processes are frequently omitted.
  
  
  METHODS
  This study aimed to define a group of important processes during EGS admission and assess their reliability. Literature review and semi-structured interviews were used to define a draft list of processes, which was refined and validated using the Delphi consensus methodology. A prospective cohort study of the 22 included processes was performed in 315 patients across 5 acute hospitals.
  
  
  RESULTS
  Prospective study of the 22 selected processes demonstrated omission of 1130/5668 (19.9%) processes. Only 6 (1.9%) patients had all relevant processes performed correctly. Administration of oxygen to hypoxic patients (82/129, 64%), consultant review (202/313, 65%) and administration of antibiotics within 3 h for patients with severe sepsis (41/60, 68%) were performed particularly poorly. There were significant differences in the mean number of omissions per patient between hospitals (
  F = 11.008, p < 0.001) and this was strongly correlated with hospitals' median length of stay (Spearman's rho = 0.975, p = 0.005).
  
  
  CONCLUSIONS
  Reliability of admissions processes in this study was poor, with significant variability between hospitals. It is likely that improvements in process reliability would enhance EGS patients' outcomes. This will require engagement of the entire surgical team and the implementation of multiple interventions to improve the effectiveness of the admission phase of care.
authors.affiliation: Imperial Patient Safety Translational Research Centre, Department of Surgery, Imperial College London, London, UK.
authors.forename: Nicholas R A
authors.initials: NR
authors.lastname: Symons
authors.affiliation: Imperial Patient Safety Translational Research Centre, Department of Surgery, Imperial College London, London, UK. Electronic address: k.moorthy@imperial.ac.uk.
authors.forename: Krishna
authors.initials: K
authors.lastname: Moorthy
authors.affiliation: Department of Experimental Psychology, University of Oxford, Oxford, UK.
authors.forename: Charles A
authors.initials: CA
authors.lastname: Vincent
mesh_terms: D015331:Cohort Studies; D004636:Emergency Service, Hospital / Q000592:standards*; D004638:Emergency Treatment / Q000401:mortality* / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D007902:Length of Stay; D008131:London; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D010343:Patient Admission; D011446:Prospective Studies; D015203:Reproducibility of Results; D012189:Retrospective Studies; D013222:State Medicine; D013514:Surgical Procedures, Operative / Q000706:statistics & numerical data*
keywords: Admission; Emergency; Process; Reliability; Surgery