Enhanced Peri-Operative Care for High-risk patients (EPOCH) Trial



EPOCH is a randomised stepped-wedge cluster trial. The primary objective is to confirm whether fewer patients die within 90 days of surgery in hospitals where the quality improvement initiative is in place. The EPOCH investigators will use patient-level data from the National Emergency Laparotomy Audit (NELA), linked with ONS/HES/NSS data, to perform analyses for the trial.


Around two million patients undergo surgery each year in the NHS, following which 30,000 patients die without leaving hospital. Advancing age, abdominal surgery and the need for emergency surgery are among the strongest factors associated with poor post-operative outcome. Around 35,000 patients present to NHS hospitals each year with precisely this pattern of risk and undergo a procedure termed emergency laparotomy (major surgery to treat a life threatening problem within the abdomen). Almost 9,000 of these patients will die within three months of surgery. Recent evidence shows that basic standards of care for this patient group vary widely between hospitals.


An evidence-based quality improvement intervention has been developed which will enable local staff to deliver the highest possible standard of care for emergency laparotomy patients. A dedicated quality improvement team have developed training programmes consisting of workshop style meetings and educational tools.

We have recruited 92 hospitals across the UK which have been grouped into 15 geographical clusters. Every five weeks, a cluster is activated into the intervention in a random order. To date, eight clusters have been activated.

A parallel ethnographic study (a study involving in-depth observations and interviews with staff) is also underway to find out how we can further improve uptake of the pathway.

The EPOCH protocol was published in The Lancet in May 2014.