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RCS Quality Improvement collaborative reduces time to surgery for patients with gallstones

18 Oct 2019

A quality improvement (QI) collaborative setup by the Royal College of Surgeons of England (RCS) has significantly improved early surgery rates for patients with gallstone-related conditions according to a study published in BJS Open this week. Gallstone-related conditions can be very painful, reducing quality of life for patients awaiting surgery, and have the potential to lead to serious complications, such as pancreatitis. Removal of the gallbladder and stones, an operation called a cholecystectomy, soon after diagnosis, is the recommend treatment for symptomatic patients.

 

Current guidance from the National Institute for Health and Care Excellence (NICE) states patients should have a laparoscopic cholecystectomy within 7 days of diagnosis of acute cholecystitis, and during the same hospital admission for pancreatitis2. Despite this, there is wide variation between NHS hospitals in the management of these patients and in cholecystectomy rates3. Patients in the UK wait longer for surgery, and are more likely to be readmitted with gallstone related problems whilst waiting for surgery, than in many other countries.

 

Gallstone-related diseases account for approximately one third of emergency general surgery admissions and referrals across the UK4. These patients present with acute biliary pain (56%), acute cholecystitis (36%), and gallstone pancreatitis (4%). The majority of patients attending hospital with gallstone-related conditions will go on to have a cholecystectomy as the appropriate clinical treatment. Currently, around 20–33% of patients will make repeat visits to hospital with gallstone-related symptoms before they have a cholecystectomy5,6,7.

 

The RCS’s Cholecystectomy Quality Improvement Collaborative (Chole-QuIC) ran from October 2016 to January 2018. The aim of the collaborative was to reduce the time to emergency cholecystectomy for patients with acute biliary pain, cholecystitis or gallstone pancreatitis, by using quality improvement methodologies to enable clinicians to drive change within their own hospitals. Surgery within 8 days of presentation was chosen as the measurement, to match the current NICE guidelines for acute cholecystitis (which is surgery within 7 days of diagnosis, plus one additional day from presentation to allow time for diagnosis).

 

Eight out of twelve hospitals participating in the RCS’s Chole-QuIC project significantly reduced the time taken for patients to have their surgery. Of the 7,944 patients admitted as part of the study, 1,160 patients had a cholecystectomy within 8 days of their admission, a significant improvement from baseline performance.  Four of these hospitals at least doubled their emergency cholecystectomy rates, increasing the number of eligible patients having their surgery within 8 days of presentation to at least 20%, compared with the national average of just 15%.8

 

Factors that influenced these improvements varied depending on the hospital and its needs, but hospitals that improved the most tended to take a team approach to improvement, with junior and senior doctors, nurses and managers all working together on the project. Hospitals that improved the most were also creative in the ways they found or repurposed operating theatre time to prioritise emergency gallstone cases. Technological solutions, such as ‘virtual wards’, where patients return home under close monitoring prior to surgery,  or new e-mail referral systems, were also helpful in some cases.

 

Mr Ian Beckingham, a Consultant Laparoscopic and Hepatobiliary Surgeon, was clinical lead for the Chole-QuIC project. He said:

 

“We wanted to use quality improvement methodology to empower clinicians to lead change in their own hospital trusts. By following these methods, the Chole-QuIC project demonstrated that gallstone care can be improved.

 

The paper published today demonstrates that even in hospitals showing below average cholecystectomy times, a surgeon-led quality improvement collaborative approach is effective at improving care for patients requiring emergency cholecystectomy.”

 

Northern Devon Healthcare NHS Trust (North Devon District Hospital) took part in the project. Before the project, 9% of their gallstone patients received a cholecystectomy within 8 days of presentation, below the national average. They were able to improve this rate to 26% of gallstone patients by the end of the project, and over 60% of eligible patients. This is within the top 10% across England.

 

David Sanders from Northern Devon Healthcare NHS Trust (North Devon District Hospital), said:

 

“North Devon had the ambition of setting up an acute gallbladder service and this coincided with the launch of Chole-QuIC. The project gave us the quality improvement support in order to track our progress and constantly improve the service. We now treat >80% of all acute gallstone presentations with a laparoscopic cholecystectomy within 2 weeks of admission.”

 

The RCS has recently launched Cholecystectomy Quality Improvement Collaborative – Extended Reach (CholeQuIC-ER).The project is working with 25 trusts/health boards across the UK to radically improve outcomes for their patients with gallstone disease by implementing the learning from Chole-QuIC.

Notes to editors

  1. https://bjssjournals.onlinelibrary.wiley.com/doi/full/10.1002/bjs5.50221

  2. National Institute for Health and Care Excellence. Gallstone Disease. NICE Guidelines CG188. NICE: London, 2014. https://www.nice.org.uk/guidance/cg188  [last accessed 8 October 2018].

  3. CholeS Study Group WMRC. Population-based cohort study of variation in the use of emergency cholecystectomy for benign gallbladder diseases. Br J Surg. 2016;103(12):1716–26.

  4. Association of Upper Gastrointestinal Surgeons. Pathway for the management of acute gallstone diseases. 2015.  http://www.augis.org/wp-content/uploads/2014/05/Acute-Gallstones-Pathway-Final-Sept-2015.pdf [last accessed 8 October 2018].

  5.  Sanders, G, Kingsnorth AN. Gallstones. BMJ. 2007 Aug 11;335(7614):295–299.

  6.  Glasgow RE, Cho M, Hutter MM, Mulvihill SJ. The spectrum and cost of complicated gallstone disease in California. Arch Surg. 2000 Sep;135(9):1021-5; discussion 1025-

  7. Wu XD, Tian X, Liu MM, Wu L, Zhao S, Zhao L. Meta-analysis comparing early versus delayed laparoscopic cholecystectomy for acute cholecystitis. British Journal of Surgery. 2015 Oct;102(11):1302–1313.

  8. Association of Upper Gastrointestinal Surgeons. Pathway for the management of acute gallstone diseases. 2015.  http://www.augis.org/wp-content/uploads/2014/05/Acute-Gallstones-Pathway-Final-Sept-2015.pdf [last accessed 8 October 2018].

  9. The Royal College of Surgeons of England is a professional membership organisation and registered charity, which exists to advance surgical standards and improve patient care.

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