ABSTRACT
Introduction The National Bowel Cancer Audit (NBOCA) is the largest database in the United Kingdom that audits real-world data and allows comparison of the quality of care for colorectal cancer patients. This study aimed to highlight relevant clinical factors in the NBOCA that contribute to variation in the quality of care provided in different hospitals. Methods Data from 36,116 patients with colorectal cancer who had undergone surgery were obtained from the NBOCA. These were patients from 145 and 146 hospitals from the years 2016 and 2017, respectively. A validated multiple linear regression was performed to compare the identified clinical factors with various quality outcomes. The quality outcomes defined in this study were the length of hospital stay of more than five days, two-year mortality, 30-day unplanned readmission rate, 90-day mortality, and 18-month stoma rate. Results Four clinical factors (laparoscopy rate, abdominal-perineal-resection-of-rectum, pre-operative radiotherapy, and patients with distant metastases) were shown to have a significant (p < 0.05) impact on the length of hospital stay of more than five days and the 18-month stoma rate. The 18-month stoma rate was also a significant predictor (p < 0.001) with two-year mortality. Conclusion The NBOCA should consider adjusting for these factors when reporting the quality of care provided in hospitals. Hospitals should monitor the four clinical factors for colorectal cancer patients during perioperative care. When formulating a management plan for patients with colorectal cancer, clinicians should consider these factors along with the individual patient's history.
ABSTRACT
The 'Sepsis Six' bundle was promoted as a deliverable tool outside of the critical care settings, but there is very little data available on the progress and change of sepsis care outside the critical care environment in the UK. Our aim was to compare the yearly prevalence, outcome and the Sepsis Six bundle compliance in patients at risk of mortality from sepsis in non-intensive care environments. Patients with a National Early Warning Score (NEWS) of 3 or above and suspected or proven infection were enrolled into four yearly 24-h point prevalence studies, carried out in fourteen hospitals across Wales from 2016 to 2019. We followed up patients to 30 days between 2016-2019 and to 90 days between 2017 and 2019. Out of the 26,947 patients screened 1651 fulfilled inclusion criteria and were recruited. The full 'Sepsis Six' care bundle was completed on 223 (14.0%) occasions, with no significant difference between the years. On 190 (11.5%) occasions none of the bundle elements were completed. There was no significant correlation between bundle element compliance, NEWS or year of study. One hundred and seventy (10.7%) patients were seen by critical care outreach; the 'Sepsis Six' bundle was completed significantly more often in this group (54/170, 32.0%) than for patients who were not reviewed by critical care outreach (168/1385, 11.6%; p < 0.0001). Overall survival to 30 days was 81.7% (1349/1651), with a mean survival time of 26.5 days (95% CI 26.1-26.9) with no difference between each year of study. 90-day survival for years 2017-2019 was 74.7% (949/1271), with no difference between the years. In multivariate regression we identified older age, heart failure, recent chemotherapy, higher frailty score and do not attempt cardiopulmonary resuscitation orders as significantly associated with increased 30-day mortality. Our data suggests that despite efforts to increase sepsis awareness within the NHS, there is poor compliance with the sepsis care bundles and no change in the high mortality over the study period. Further research is needed to determine which time-sensitive ward-based interventions can reduce mortality in patients with sepsis and how can these results be embedded to routine clinical practice.Trial registration Defining Sepsis on the Wards ISRCTN 86502304 https://doi.org/10.1186/ISRCTN86502304 prospectively registered 09/05/2016.
