Background: Elective surgical postponements and cancellations adversely affect patient experience, clinical outcomes, and theatre efficiency within the UK NHS. The Postponement and Cancellations in Elective Care study aimed to establish the national incidence and underlying causes of elective surgical postponements at preoperative assessment and cancellations occurring within 24 h of planned surgery. Methods: This 7-day prospective service evaluation (November 11-18, 2024) collected data from participating NHS England trusts via an online platform. Preoperative assessment postponements were defined as any factor preventing a patient with a 'to come in' date from undergoing surgery as planned, or preventing preoperative assessment completion as 'good to go' within 2 weeks for those without a 'to come in' date. Cancellations were defined as a decision not to proceed within 24 h of planned surgery. Results: Seventy-eight trusts provided complete incidence data covering 22 573 preoperative assessment appointments and 19 905 planned procedures. The national preoperative assessment postponement incidence was 8.7% (95% confidence interval, 6.9-10.8%), most commonly attributable to further investigation or tests (n=595, 27.2%). The national cancellation incidence was 9.9% (95% confidence interval, 8.7-11.3%), most frequently associated with acute medical conditions (n=515, 23.8%) and list overruns (n=315, 14.5%). Conclusions: The Postponement and Cancellations in Elective Care study provides the first national overview of elective surgical pathway disruption in the UK. Nearly half of postponements were attributable to requirements for additional investigation or specialty review, indicating the importance of earlier optimisation and robust preoperative assessment fit to proceed criteria. Acute medical conditions continue to impact short-notice cancellations. Standardised pathways, improved scheduling, and strengthened perioperative coordination could reduce disruption and improve theatre utilisation.

INTRODUCTION:Quality indicators are essential for benchmarking, quality assurance and driving improvement in healthcare. Many indicators exist for peri-operative care but their relevance and evidence base vary. This systematic review updates a review published 10 years ago. It seeks to identify available structure and process indicators, and assess the level of evidence supporting them, with a view to informing the development of a core indicator set. METHODS:MEDLINE, Embase, CINAHL and the Cochrane Library were searched. English-language studies in adults were included, alongside grey literature from: clinical, professional and governmental organisations; quality standards; and guidelines. RESULTS:There were 657 included studies and grey literature sources, alongside indicators from a previously published review. Of a total 615 indicators (324 process indicators, 248 structure indicators and 43 indicators which were not defined clearly but relevant to process or structure), we identified 380 new indicators. Evidence supported 505 (82%) indicators, while 110 (18%) lacked clear evidence. This compared with 47% and 53%, respectively, in the previous review. Only 71 (12%) of the indicators were evaluated for validity. Inconsistencies were noted in definitions, with varying target thresholds reported for the same indicators. Many indicators were developed without the involvement of patients or carers. DISCUSSION:There is a need for standardisation in the development and naming of peri-operative quality indicators. Clear reporting, validation and patient involvement would improve their credibility and utility. Rationalising the current large, overlapping number of indicators is essential to enhance usability and ensure meaningful improvement in peri-operative care.

BACKGROUND:This study addresses the need for a comprehensive, evidence-informed conceptually based quality framework for structures and processes of perioperative care. METHODS:We combined a rapid review of international academic literature and UK grey literature with a participatory consultation. The review included primary studies, guidelines and grey literature identified through searches of PsycINFO, MEDLINE, CINAHL and institutional websites. Findings were synthesised across studies using an inductive process, with key concepts identified, mapped, refined and organised into a preliminary framework. We consulted with UK-based multidisciplinary professionals and patient/carer representatives (public contributors), who together formed a 14-person Expert Collaborative Group using a participatory exercise hosted on the Thiscovery online platform. Descriptive analysis was used for quantitative responses and content analysis was used for free text analysis. RESULTS:We were able to develop a 10-domain framework that encapsulates structural and process-related features important to high-quality perioperative care, using the rapid review to generate a preliminary framework and consultation with professionals and public contributors to refine it. The final framework, termed 'Perioperative Framework'(P-Frame), comprises domains covering environment and facilities, leadership and governance, organisational culture, shared decision-making, multidisciplinary working, patient optimisation, clinical protocols, post-operative support, staff education and workforce planning. Importantly, the framework integrates the perspectives of patients and carers and seeks to ensure relevance across clinical, operational and experiential dimensions of care. CONCLUSIONS:P-Frame, based on the available evidence and the views of UK clinicians and patients, offers a potentially valuable tool for monitoring and improving perioperative care quality as well as supporting research efforts. It will benefit from further evaluation and testing of use in practice in different contexts and countries.

ObjectiveInternational health systems had the opportunity to assess the resilience of core health services to severe disruption following the onset of the COVID-19 pandemic. This paper examines the resilience of a core health service to shocks from COVID-19. We compare outcomes following emergency admissions in England during the second (Winter 2020/21) and third (Winter 2021/22) major waves of COVID-19 with the first wave and historic admissions from 2016 to 2019.MethodsThis cohort study included adult emergency admissions for five common acute surgical conditions: appendicitis, symptomatic gallstone disease, intestinal obstruction, symptomatic diverticular disease, and abdominal wall hernia in 122 acute hospital Trusts in England. Participants were 647,367 admissions in the hospital episode statistics (HES) inpatient database including 34,560 in the second wave and 36,628 in the third wave. Outcome was all-cause mortality at 90 days.ResultsThere were 1308 deaths in wave two (3.8% of admissions) and 1235 (3.4%) in wave three compared with 3431 (3.4%) in the historic cohort and 577 (4.7%) in wave one. Compared with pre-COVID admissions, we found weak evidence of increased mortality in the second wave. There was no evidence of increased mortality in the third wave, compared to historic cohorts the case-mix adjusted odds ratios were: appendicitis 0.96 (95% CI 0.49-1.87); gallstone disease 1.27 (95% CI 0.94-1.72); diverticular disease 1.04 (95% CI 0.79-1.36); hernia 1.06 (95% CI 0.76-1.47); and intestinal obstruction 1.02 (95% CI 0.87-1.19).ConclusionsBy the end of wave three, outcomes for emergency admissions with five common acute conditions had returned to pre-pandemic levels. Lessons learnt during the disruption of the first wave of COVID-19 helped the NHS in England adapt emergency surgical services during subsequent waves. These findings emphasise the importance of maintaining, or quickly restoring core service capacity to help patient outcomes return to pre-pandemic levels.

BACKGROUND:Major liver surgery is associated with significant physiological stress and a high rate of postoperative complications. Prehabilitation aims to enhance physiological reserve before surgery. Despite the growing volume of liver resections worldwide, the impact of prehabilitation on clinical and economic outcomes in patients undergoing elective liver resection is poorly understood. METHODS:A systematic review and meta-analysis was reported in accordance with PRISMA guidelines. MEDLINE, Embase, Web of Science and the Cochrane Library were searched in November 2025. Randomized controlled trials and comparative observational studies evaluating preoperative programs with a structured exercise component, with or without additional nutritional and psychological support in adult patients undergoing major elective liver surgery were included. RESULTS:Six studies (four RCTs and two comparative cohort studies) comprising 557 patients were included. Prehabilitation resulted in significantly fewer overall postoperative complications (OR 0.55; 95% CI, 0.37 to 0.84; p = 0.005). No significant differences were observed for length of stay (MD -0.38 days; 95% CI, -1.08 to 0.32; p = 0.29), major complications (OR 0.79; 95% CI, 0.50 to 1.27; p = 0.33), mortality (OR 0.40; 95% CI, 0.05 to 3.24; p = 0.39), readmission (OR 0.85; 95% CI, 0.47 to 1.55; p = 0.60) and hospitalization costs (MD = -137.13; 95% CI, -642.19, 367.93; p = 0.59). CONCLUSION:Prehabilitation significantly reduces overall postoperative complications following liver resection. The absence of standardized, liver-specific interventions limits the determination of effective program design. Future research should prioritize standardised protocols and evaluate post-hepatectomy functional recovery, patient-reported outcomes and cost-effectiveness.

Importance:Older adults undergoing major noncardiac surgery experience substantial postoperative morbidity and health care use. The comparative effectiveness of total intravenous anesthesia (TIVA) vs volatile-based inhalational anesthesia on recovery and safety remains uncertain. Objectives:To determine whether TIVA improves days alive and at home at 30 days compared with inhalational anesthesia and to evaluate differences in patient-centered outcomes and recovery. Design, Setting, and Participants:Pragmatic, multicenter, open-label randomized clinical trial conducted in 49 UK National Health Service hospitals from January 2022 to April 2024 (final follow-up, October 2024) among patients aged 50 years or older scheduled for elective major noncardiac surgery. Interventions:Participants were randomized 1:1 to receive maintenance of general anesthesia with either TIVA (propofol infusion) (n = 1254) or volatile-based inhalational agents (n = 1254). All other perioperative care was at clinician discretion. Main Outcomes and Measures:The primary outcome was days alive and at home at 30 days. Secondary outcomes included days alive and at home at 90 days; mortality at 30 days, 90 days, and 6 months; Quality of Recovery-15 score at day 3; patient satisfaction (Bauer Patient Satisfaction Questionnaire) at day 1; delirium (4 As Test [4AT]) at day 3; unintentional awareness under anesthesia; and major postoperative complications within 30 days. Results:Among the 2508 randomized participants, the mean age was 67 (SD, 8.9) years, and 55% were male. Characteristics were balanced across randomized groups. Days alive and at home at 30 days were similar between groups (mean, 22.5 [SD, 6.8] days vs 22.4 [SD, 6.6] days for TIVA vs inhalational anesthesia, respectively; incidence rate ratio, 1.00; 95% CI, 0.99-1.02; adjusted P = .68). There were no differences in days alive and at home at 90 days; mortality at 30 days, 90 days, or 6 months; or Quality of Recovery-15 score at day 3. Lower rates of thirst, hoarseness, and nausea and vomiting were reported in the TIVA group. Levels of delirium were similar between groups, with the majority (87.6%) having no delirium at day 3. Major complications occurred in 12.4% of patients overall, with no significant between-group differences. Two cases of certain or probable unintentional awareness under anesthesia were reported, both in the TIVA group. Conclusions and Relevance:Among older adults undergoing major noncardiac surgery, TIVA did not improve days alive and at home at 30 days compared with inhalational anesthesia. Trial Registration:ISRCTN.org Identifier: ISRCTN62903453.

INTRODUCTION:Appendicitis is one of the most common emergency surgical pathologies in childhood. This study used data from the Children's Acute Surgical Abdomen Programme study to describe compliance with published standards of care and the relationship between care delivery and 30-day postoperative morbidity for children aged 1-16 y undergoing appendicectomy. METHODS:Data were collected from 80 hospitals and this included the type of care delivered, the setting in which care was provided and patient level factors. Bivariable and multivariable analysis was undertaken to identify associations between care delivery and outcome. RESULTS:Data collected from 2799 children highlighted variation in care provision related to the use of pre-operative imaging, multimodal analgesia and the proportion of children undergoing surgery within 24 h of presentation; compliance with these standards was 42.6%, 70.8% and 72.8%, respectively. Children managed in specialist paediatric centres were younger, with a higher burden of chronic disease and higher rates of complicated appendicitis. They were also less likely to have a negative appendicectomy but more likely to experience postoperative complications. DISCUSSION:Despite a high compliance with published recommendations for several aspects of care, deficiencies were identified. A focused effort is needed to improve diagnostic accuracy, optimise analgesia management and reduce the duration of time for which children are waiting for surgery. Similarly, further work is required to better understand the increased rates of postoperative morbidity seen in specialist paediatric centres. Addressing these factors may lead to discernible improvements in experience and outcomes for children with suspected appendicitis.

Aims:Obesity is associated with increased surgical complexity and poorer postoperative outcomes after primary total hip arthroplasty (THA), yet its impact on revision THA remains unclear. This study evaluates the relationship between BMI and outcomes following revision THA. Methods:We analyzed prospectively collected data from patients who consented to participation in the Perioperative Quality Improvement Programme (PQIP) research study. All patients undergoing revision THA from May 2018 to December 2022 were included. Patients were stratified into BMI categories, and outcomes were assessed using the EuroQol five-dimension five-level questionnaire (EQ-5D-5L) at baseline, six, and 12 months postoperatively. Statistical comparisons were performed to evaluate differences in health-related quality of life (HRQoL) between BMI groups. Results:Higher BMI was associated with lower preoperative EQ-5D scores. However, all BMI groups demonstrated significant postoperative improvement, with the greatest gains observed in patients with a BMI > 40 kg/m2. At six and 12 months, HRQoL improvements were comparable across BMI groups, with no significant difference in long-term outcomes between those living with and without obesity. Conclusion:Despite potentially increased intraoperative risks, high BMI patients experience meaningful functional improvement following revision THA. These findings challenge the rationale for BMI-based surgical restrictions, suggesting that high BMI alone should not be a contraindication for revision THA.

Surgery with flap reconstruction is commonly utilised in the treatment of head and neck cancer (HNC). Following surgery, patients are made nil-by-mouth (NBM) and receive enteral tube feeding until they can recommence oral intake. Recent reviews have focussed on whether ‘early oral feeding’ (EOF) as part of enhanced recovery after surgery is beneficial. Limited literature has focussed on how patients are transitioned from tube to oral intake and nutritional implications. This review aims to map the evidence on postoperative feeding practices and nutritional intake of patients with HNC undergoing flap surgery. Titles, abstracts and subsequent full-text articles were screened from six databases: Embase, Medline, Scopus, Cochrane, CINAHL, Web of Science and grey literature by two independent researchers who both extracted data. A third reviewer was consulted when required. Inclusion criteria: all articles reporting on postoperative feeding practices in HNC flap surgery (RCTs, observational studies, case reports/series, guidelines). Findings were synthesised and presented using a narrative description approach. After searching 5093 citations and 405 full-texts, 36 articles were included. Enteral feeding tubes were either intraoperative nasogastric tube or gastrostomy pre-, intra- or postoperatively with feeds ideally commencing within 24 h of surgery. Gastrostomy placement was informed by disease, treatment and socio-demographic factors including age, tumour stage/site, prior/adjuvant radiotherapy and surgery extent. The timing/type to oral feeding was mainly surgeon-led ± speech and language therapy (SLT) and varied from postoperative day 1 (sterile water ± fluids ± smooth puree ± solid/semi-solid diet) to postoperative day 20 (fluids progressing to soft diet). EOF was defined as ≤5days and delayed/traditional feeding as >5days or after a 6–12 day nil-by-mouth period. Nutritional adequacy was mainly assessed by dietitians or nurses and thresholds varied between 60 and 100

BACKGROUND:Socioeconomic deprivation is associated with poor surgical outcomes. We assessed associations between deprivation and postoperative morbidity and mortality in a UK-wide surgical cohort. METHODS:We analysed UK data from the Second Sprint National Anaesthesia Project: Epidemiology of Critical Care provision after Surgery (SNAP-2: EpiCCS), a prospective non-consenting cohort study of adults undergoing elective and emergency inpatient noncardiac surgery. Socioeconomic deprivation was reported using the standardised aggregate scale, Index of Multiple Deprivation (IMD; IMD1: most deprived, IMD5: least deprived). Multivariable mixed effects logistic regression was used to model the association between deprivation and postoperative outcomes, adjusting for potential confounders. RESULTS:Of the 18 901 patients included, those in more deprived groups were younger, had higher disease prevalence, and had greater illness severity. Morbidity, as measured by the Post-Operative Morbidity Survey, was reported in 13.7% at day 7, and in-hospital 30-day mortality was 1.3%. Adjusting for patient characteristics and surgical factors, the odds ratios (ORs) for morbidity at day 7 were 1.26 (95% confidence interval [95% CI]: 1.09-1.47) for IMD2 and 1.32 (95% CI: 1.13-1.53) for IMD1, compared with IMD5. Mortality risk was also higher: OR 1.75 (95% CI: 1.12-1.73) for IMD2 and OR 1.90 (95% CI: 1.22-2.95) for IMD1. However, after adjusting for markers of preoperative physical status and comorbidities, the association between deprivation and outcomes was attenuated. CONCLUSIONS:Socioeconomic deprivation is associated with short-term postoperative morbidity and mortality. This association might relate to poorer baseline fitness among people living in socioeconomically deprived areas, highlighting opportunities for targeted preoperative optimisation.

INTRODUCTION:Pre-operative group sessions incorporating patient education and behaviour change interventions, known as 'surgery schools', are becoming increasingly common before major elective surgery across the world. However, there is a lack of conclusive evidence regarding the effectiveness of surgery schools, and the development and delivery of these complex interventions lacks standardisation. METHODS:In collaboration with the Perioperative Quality Initiative, we aimed to develop evidence- and expertise-based consensus statements and recommendations regarding the definition, design, content, and outcomes of surgery schools. Thirty-two international multidisciplinary experts in surgery school and pre-operative preparation attended a series of virtual meetings based on a modified Delphi methodology. A systematic review and additional targeted literature searches were used to propose statements for the definition, design, content and outcomes of surgery schools. Statements and recommendations were discussed iteratively and refined in multiple rounds, until agreement was reached. RESULTS:Consensus was reached on a definition of surgery school, as well as three statements and 18 recommendations in relation to: scope; outcomes; intervention development; delivery; inclusivity; and educational content of surgery schools. Seventeen areas were highlighted as priorities for future research. DISCUSSION:These consensus statements and recommendations are intended to help clinicians and service managers who plan to develop and implement surgery schools. They may improve the quality of those programmes and help to standardise their content. We also hope that this work will influence government strategy and policy in relation to the design, delivery and funding of peri-operative optimisation pathways.

BackgroundMeasles-containing vaccines (MCV), by training innate immune cells, are hypothesized to prevent severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and coronavirus disease 2019 (COVID-19).MethodsIn this international, double-blind, placebo-controlled trial, we randomly assigned adults, 18 years and older, to receive MCV or saline. The primary outcome was polymerase chain reaction (PCR) confirmed symptomatic COVID-19, up to 60 days after intervention. Secondary outcomes were PCR-confirmed symptomatic COVID-19 and serologically confirmed SARS-CoV-2 infection, up to 150 days after intervention.ResultsOf 3411 randomised participants, the modified intention-to-treat population included 1607 in the MCV and 1545 in the saline group. The estimated risk of symptomatic COVID-19 by 60 days was 1.5% in the MCV and 1.2% in the saline group (risk difference, 0.3 percentage points, 95% CI, -0.5 to 1.1; p=0.52). At 150 days, these percentages were 4.1% (65/1585) and 4.1% (64/1544) in the MCV and saline groups, respectively (risk difference, 0.04 percentage points, 95% CI, -1.4 to 1.3; p=0.95). Based on serology results available at 0 and 150 days, 10.6% (100/945) of participants in the MCV and 10.3% (98/951) in the saline group had infection with SARS-CoV-2 over the course of the trial (risk difference, 0.3 percentage points, 95% CI, -2.6 to 3.1; p=0.84). Three patients were hospitalised with COVID-19 disease in the MCV and one in the saline group.ConclusionsAdministering MCVs to stimulate trained immunity did not prevent COVID-19 or SARS-CoV2 infection. Stimulating trained immunity might not be useful for preventing respiratory illness during future pandemics.Clinical trial registrationhttps://clinicaltrials.gov/, identifier NCT04333732.

Introduction Caesarean birth (CB) under neuraxial anaesthesia (NA) is the most performed inpatient operation in the UK. The incidence of intraoperative pain during caesarean delivery performed under neuraxial anaesthesia is unclear, with limited data that used patient-reported measures to investigate intraoperative pain. The short- and medium-term impacts on patients of this adverse event are unknown. Methods and analysis We will undertake a multicentre, prospective observational cohort study to evaluate the incidence and impact of pain experienced by patients during CB performed under neuraxial anaesthesia. Routine audit data will be collected for all patients undergoing caesarean delivery for any indication during a 1 week window at participating hospitals within the UK and Queensland, Australia. The dataset will include patient, anaesthetic, obstetric and neonatal risk factors for intraoperative pain. Local investigators will then seek informed consent from patients either before or within 24 hours of delivery to record patient experience and patient-reported outcomes at 24 hours and 6 weeks postdelivery. Local investigators at participating hospitals will also complete a survey evaluating compliance with evidence-based structural standards at their sites. The patient characteristics, structures, processes and outcomes will be described. Inferential techniques will be used to evaluate the relationship between risk factors and postoperative outcomes. Ethics and dissemination This study received ethical approval from the Leicester Health Research Authority and Care Research Wales, REC reference 24/EM/0084) on 24 May 24. The study received ethical approval from the Human Research Ethics Committee of Metro North Health in Australia on 25 March 2024 (REC Ref HREC/2024/MNHA/103767). The results of the study will be reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology statement. The results will be disseminated via conference presentations, peer-reviewed academic journals and reports prepared for patients, the public and policy makers. Trial registration number ISRCTN15269213 .

INTRODUCTION:Racial and ethnic disparities in obstetrics persist globally despite improvements in maternal mortality rates and are related to access, experience and outcomes. We aimed to elucidate the racial and ethnic disparity in obstetric analgesia and anaesthesia. METHODS:Databases were searched and we included studies published in the English language conducted in all countries. Search terms included terminology concerning obstetric anaesthesia related to race or ethnicity. Included papers were assessed for risk of bias. Studies were included for detailed review if they described disparities relating to obstetric anaesthesia between two or more racial or ethnic groups. RESULTS:In total, 1806 abstracts were screened of which 25 articles were included and data from 19 could be pooled for meta-analysis using a random effects model. Outcome measures included disparities in labour neuraxial analgesia utilisation and general anaesthesia use for caesarean delivery. Sixteen observational studies examined labour neuraxial analgesia, representing data from 13,398,421 patients in the USA and UK. Patients categorised as Asian or Black had lower odds of receiving neuraxial analgesia when compared with those from White backgrounds (odds ratios (95%CI) 0.80 (0.65-0.99) and 0.72 (0.61-0.85), respectively). Six studies examined the use of general anaesthesia for caesarean delivery in 2,139,763 patients. Black patients were more likely to receive general anaesthesia compared with White patients (odds ratio (95%CI) 1.60 (1.15-2.22)). Risk of bias assessments showed high or very high risk of bias in 13 of the 25 included studies. DISCUSSION:Racial and ethnic disparities exist in obstetric anaesthesia. Further research to elucidate causes and ongoing action to minimise them are crucial.

BACKGROUND:This study investigates the role of metabolic flexibility in determining perioperative outcomes. Metabolic flexibility, a key feature of metabolic health, is the ability to efficiently switch between different fuel sources (predominantly carbohydrates and fats) depending on energy demands and availability. Given the rapidly changing physiological conditions in the perioperative period, we hypothesized that good metabolic adaptability could mitigate postoperative complications. METHODS:We conducted a retrospective observational study utilizing a prospectively collected, single-center preoperative cardiopulmonary exercise testing (CPET) database of patients undergoing a range of major surgeries between 2012 and 2022. On day 3, patients were categorized into 3 groups based on their Postoperative Morbidity Survey (POMS) scores: 0 to 1, 2, and 3 to 6. Metabolic flexibility was evaluated through measurements of fat and carbohydrate oxidation during exercise testing (CPET). Associations were explored between metabolic flexibility, cardiorespiratory fitness, and postoperative outcomes. RESULTS:Of 585 patients, those with no or low postoperative day 3 morbidity (POMS 0-1; n = 204) demonstrated significantly higher fat oxidation early in exercise before anaerobic threshold (fatty acid oxidation [FATox] area under the curve [AUC] 826 [578-1147]) compared to both POMS 2 (658 [448-922; n = 268]) and POMS 3 to 6 (608 [414-845; n = 113]); both P < .001. POMS 0 to 1 patients also had more effective carbohydrate utilization at peak exercise intensity. Higher postoperative morbidity (POMS) categories were associated with diminished metabolic flexibility characterized by a reduced ability to switch between metabolic substrates-carbohydrate oxidation (CHOox) POMS 0 to 1 group AUC 10277 (interquartile range [IQR] 7773-13358) compared to POMS 2 AUC 8356 (IQR 6548-10377) and POMS 3 to 6 AUC 6696 (IQR 473-9392); both P < .001. Reduced metabolic flexibility correlated with increased postoperative complications and an extended hospital stay. CONCLUSIONS:Metabolic flexibility may be a pivotal factor in determining postoperative outcomes. Patients with greater metabolic adaptability had fewer complications and shorter hospitalization by 4 days on average. This suggests that preoperative metabolic conditioning-something potentially achieved by targeted prehabilitation-could be linked to surgical recovery. Future research should focus on prospective studies to confirm these relationships and explore underlying mechanisms. If confirmed, metabolic flexibility assessments could be integrated into routine preoperative evaluation to better predict and improve patient outcomes.

BACKGROUND:Approximately half of all antimicrobial prescriptions in intensive care units (ICUs) may be inappropriate, including those prescribed when not needed, in unnecessary combinations or for longer durations than needed. Inappropriate prescribing is costly, exposes patients to unnecessary side-effects and drives population-level antimicrobial resistance, the prevalence and consequences of which are greatest in low- and middle-income countries. However, the implementation of interventions to improve the appropriateness of antimicrobial prescribing has been variable and requires further study. METHODS:We propose a type III hybrid implementation/effectiveness interventional cohort trial in 35 ICUs in up to 11 low- and middle- income countries. The study intervention is a structured review of antimicrobial prescriptions as recommended by the World Health Organisation. Strategies to support stakeholder-led implementation include development of local protocols, registry-enabled audit and feedback, and education. Evaluation of implementation, and the determinants of its success, is informed by the RE-AIM framework and the Consolidated Framework for Implementation Research respectively. The primary outcome is a composite measure of fidelity, reach and adoption. Secondary outcomes describe the effectiveness of the intervention on improving antimicrobial prescribing. Qualitative interviews will assess relevant implementation acceptability, adaptations and maintenance. A baseline survey will investigate ICU-level antimicrobial stewardship structures and processes. DISCUSSION:This study addresses global policy priorities by supporting implementation research of antimicrobial stewardship, and strengthening associated healthcare professional competencies. It does this in a setting where improvement is sorely needed: low- and middle- income country ICUs. The study will also describe the influence of pre-existing antimicrobial stewardship structures and processes on implementation and improve understanding about the efficacy of strategies to overcome barriers to implementation in these settings. TRIAL REGISTRATION:This study protocol has been registered with ClinicalTrials.gov (ref NCT06666738) on 31 Oct 2004. https://clinicaltrials.gov/study/NCT06666738?term=NCT06666738&rank=1 .

IntroductionA 50:50 nitrous oxide/oxygen mix is commonly used for labour analgesia in the UK; however, nitrous oxide is associated with comparatively high environmental impact and potential exposure risks to staff if appropriate measures are not taken. Reduction of the impact of nitrous oxide in line with net zero emissions targets would require widespread changes in the way nitrous oxide is administered or in the availability of alternative options for labour analgesia. The aims of this qualitative study were to understand nitrous oxide use from the perspective of the parturient in the context of concerns regarding the environment and occupational exposure, and to provide evidence to guide the development of patient-centred nitrous oxide mitigation strategies.MethodsWe conducted semi-structured interviews with participants who had used nitrous oxide for labour analgesia. Participants were recruited purposively. Data were analysed using reflexive thematic analysis.ResultsWe conducted 12 interviews and identified three themes: nitrous oxide is the default for labour analgesia in the UK; mitigating nitrous oxide harm depends on personal priorities; and institutions have a responsibility to mitigate nitrous oxide harm. Participants viewed nitrous oxide as a safe option, readily available in the context of limited choices for labour analgesia. They would be interested to know about the environmental risk of nitrous oxide, though this would not necessarily influence their choice to use it. They were less interested in its occupational risks and considered institutions, rather than individuals in labour, to have a responsibility to mitigate these. Though they felt that investment in reducing NHS emissions is important, participants also felt there may be other more pressing financial priorities.DiscussionThis study provides evidence to support the development of strategies to reduce nitrous oxide emissions, which consider the views of people who have used nitrous oxide for labour analgesia.

( Anaesthesia . 2023;78(9):1071–1080) The peripartum period, encompassing childbirth and its aftermath, involves the administration of anesthesia or analgesia to ∼65% of patients, a substantial portion necessitated by urgent surgical interventions. The imperative to enhance surgical recovery and ensure patient satisfaction postpartum is crucial for delivering high-quality clinical care, as it has the potential to positively influence maternal physical and psychological well-being. Despite the escalating focus on postpartum-related research, prior studies on recovery have been predominantly confined to single-center endeavors with limited sample sizes, deploying disparate outcome measures or unvalidated metrics, primarily evaluating inpatient recovery with insufficient scrutiny of outpatient recovery.

BackgroundImproving outcomes after surgery is a major public health research priority for patients, clinicians and the NHS. The greatest burden of perioperative complications, mortality and healthcare costs lies amongst the population of patients aged over 50 years who undergo major non-cardiac surgery. The Volatile vs Total Intravenous Anaesthesia for major non-cardiac surgery (VITAL) trial specifically examines the effect of anaesthetic technique on key patient outcomes: quality of recovery after surgery (quality of recovery after anaesthesia, patient satisfaction and major post-operative complications), survival and patient safety.MethodsA multi-centre pragmatic efficient randomised trial with health economic evaluation comparing total intravenous anaesthesia with volatile-based anaesthesia in adults (aged 50 and over) undergoing elective major non-cardiac surgery under general anaesthesia.DiscussionGiven the very large number of patients exposed to general anaesthesia every year, even small differences in outcome between the two techniques could result in substantial excess harm. Results from the VITAL trial will ensure patients can benefit from the very safest anaesthesia care, promoting an early return home, reducing healthcare costs and maximising the health benefits of surgical treatments.Trial registrationISRCTN62903453. September 09, 2021.