Evaluation of a quality improvement intervention to reduce anastomotic leak following right colectomy (EAGLE): pragmatic, batched stepped-wedge, cluster-randomized trial in 64 countries
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1 January 2024Oxford University Press
British Journal of Surgery
2024#111Issue 1
Background: Anastomotic leak affects 8 per cent of patients after right colectomy with a 10-fold increased risk of postoperative death. The EAGLE study aimed to develop and test whether an international, standardized quality improvement intervention could reduce anastomotic leaks. Methods: The internationally intended protocol, iteratively co-developed by a multistage Delphi process, comprised an online educational module introducing risk stratification, an intraoperative checklist, and harmonized surgical techniques. Clusters (hospital teams) were randomized to one of three arms with varied sequences of intervention/data collection by a derived stepped-wedge batch design (at least 18 hospital teams per batch). Patients were blinded to the study allocation. Low- and middle-income country enrolment was encouraged. The primary outcome (assessed by intention to treat) was anastomotic leak rate, and subgroup analyses by module completion (at least 80 per cent of surgeons, high engagement; less than 50 per cent, low engagement) were preplanned. Results: A total 355 hospital teams registered, with 332 from 64 countries (39.2 per cent low and middle income) included in the final analysis. The online modules were completed by half of the surgeons (2143 of 4411). The primary analysis included 3039 of the 3268 patients recruited (206 patients had no anastomosis and 23 were lost to follow-up), with anastomotic leaks arising before and after the intervention in 10.1 and 9.6 per cent respectively (adjusted OR 0.87, 95 per cent c.i. 0.59 to 1.30; P = 0.498). The proportion of surgeons completing the educational modules was an influence: the leak rate decreased from 12.2 per cent (61 of 500) before intervention to 5.1 per cent (24 of 473) after intervention in high-engagement centres (adjusted OR 0.36, 0.20 to 0.64; P < 0.001), but this was not observed in low-engagement hospitals (8.3 per cent (59 of 714) and 13.8 per cent (61 of 443) respectively; adjusted OR 2.09, 1.31 to 3.31). Conclusion: Completion of globally available digital training by engaged teams can alter anastomotic leak rates. Registration number: NCT04270721 (http://www.clinicaltrials.gov).
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Etablissement Hospitalier et Universitaire, Algeria
University Hospital Center, Dr Tidjani Damerdji, Algeria
Churruca-Visca, Argentina
Grupo Galeno, Argentina
Hospital Universitario Cemic, Argentina
Nueva Proctologia, Argentina
Penna Hospital, Argentina
Hospital Español de Buenos Aires, Argentina
Hospital Universitario Austral, Argentina
Clinica Universitaria Reina Fabiola, Argentina
Hospital Privado de Comunidad, Argentina
Hospital Luis Lagomaggiore, Argentina
Sanatorio Laprida, Argentina
Dr. Horacio e Oduber Hospital, Aruba
Bendigo Health, Australia
Barmherzige Brüder Graz, Austria
Medical University of Graz, Austria
Leyla Medical Center, Azerbaijan
King Hamad University Hospital, Bahrain
University Clinical Center Tuzla, Bosnia and Herzegovina
Hospital Do Servidor Público Estadual-Francisco Morato de Oliveira, Brazil
Felicio Rocho, Brazil
Hospital das Clínicas da Universidade Federal de Minas Gerais/Ebserh, Brazil
Orizonti, Brazil
Policia Militar Do Estado de Minas Gerais, Oncomed, Brazil
Santa Casa de Misericórdia, Brazil
Hospital Universitário São Francisco de Assis Na Providência de Deus, Brazil
Hospital Universitário Professor Polydoro Ernani de São Thiago- Hu/Ufsc/Ebserh, Brazil
Hospital das Clinicas, Brazil
Hospital Universitário Professor Edgard Santos, Brazil
Notre Dame Intermédica-Hospital Salvalus, Brazil
University Hospital Dr Georgi Stranski, Bulgaria
University Hospital Eurohospital, Bulgaria
University Hospital Alexandrovska, Bulgaria
Zadar General Hospital, Croatia
University Hospital, Japan
Department of Surgery, Second Faculty of Medicine, Charles University and Motol University Hospital, Czech Republic
Odense and Svendborg University Hospital, Denmark
Alexandria Main University Hospital, Egypt
Misr Cancer Center, Egypt
Assiut University Hospital, Egypt
Ain Shams University Specialized Hospital, Cairo, Egypt
Ain Shams University Hospital(El-Demerdash Hospital)), Egypt
Gastrointestinal Surgery Center, Egypt
Oncology Center Mansoura University, Egypt
Mansoura University Hospital, Egypt
Maddawalabu University Goba Referral Hospital, Ethiopia
Kanta-Hame Central Hospital, Finland
Turku University Hospital, Finland
Chu Nantes, France
University Hospital Freiburg, Germany
Klinikum Karlsruhe, Germany
Mannheim University Medical Center (Universitätsmedizin Mannheim)), Germany
Klinikum Saarbruecken, Germany
Athens Euroclinic, Greece
Agios Savvas Anticancer Hospital, Greece
Aretaieion Hospital, Greece
Attikon University General Hospital, Greece
Evaggelismos General Hospital, Greece
Hippocratio General Hospital, Greece
Mitera Hospital, Greece
University Hospital of Heraklion Crete and Interclinic Hospital of Crete, Greece
General University Hospital of Larissa, Greece
General University Hospital of Patras, Greece
Metaxa Cancer Hospital, Greece
General Hospital of Nikaia, Greece
Tzaneio General Hospital, Greece
Papageorgiou General Hospital, Greece
George Papanikolaou General Hospital of Thessaloniki, Greece
Prince of Wales Hospital, Hong Kong
Szent Borbála Kórház, Hungary
All India Institute of Medical Science Bhopal, India
Synergy Institute of Medical Sciences, India
Basavatarakam Indo American Cancer Hospital and Research Institute, India
All India Institute of Medical Sciences (Aiims), Jodhpur, India
Institute of Postgraduate Medical Education and Research, India
Tata Medical Center, India
King Georges Medical University, India
Christian Medical College and Hospital, India
Kasturba Medical College Hospital, Manipal, India
Maulana Azad Medical College, India
Government Medical College Patiala, India
Laiko University Hospital, Greece
All India Institute of Medical Sciences, India
Acharya Vinoba Bhave Rural Hospital, India
Sher-I-Kashmir Institute of Medical Sciences, India
Thanjavur Medical College, India
Government Medical College Thiruvananthapuram, India
Ospedale S. Leonardo-Asl Napoli 3 Sud, Castellammare Di Stabia, Italy
University Hospital Waterford, University College Cork, Ireland
Lorenzo Bonomo, Italy
University of Bari Aldo Moro, Italy
Azienda Ospedaliera G. Brotzu, Italy
Cagliari University Hospital, Italy
Bernardino Ramazzini, Italy
Irccs Saverio de Bellis, Italy
Azienda Ospedaliera Pugliese-Ciaccio di Catanzaro, Italy
University Magna Graecia of Catanzaro, Italy
Santa Croce e Carle Hospital, Cuneo, Italy
Ospedale Sacra Famiglia, Italy
Azienda Unità Sanitaria Locale di Ferrara, University of Ferrara, Ospedale Del Delta, Italy
Azienda Ospedaliera Universitaria Careggi, Italy
Fujita Health University Bantane Hospital, Japan
P.O.Vito Fazzi, Italy
Policlinico Universitario G. Martino of Messina, Italy
Humanitas Research Hospital, Italy
Ospedale Luigi Sacco Milano, Italy
San Raffaele Scientific Institute, Milan, Italy
Santi Paolo E Carlo, Italy
Ospedale San Gerardo, Italy
Azienda Ospedaliera di Rilievo Nazionale Antonio Cardarelli, Italy
Irccs Azienda Ospedaliero-Universitaria di Bologna, Italy
Federico Ii University of Naples, Italy
Lithuanian University of Health Sciences Kaunas Clinical Hospital, Lithuania
Istituto Nazionale Tumori Fondazione, Pascale-I.R.C.C.S, Italy
Universitá della Campania Luigi Vanvitelli, Naples, Italy
San Luigi Gonzaga Hospital, Italy
Fbf Buccheri la Ferla Palermo, Italy
Policlinico San Matteo, Italy
Ospedale Santa Corona, Pietra Ligure, Italy
Edoardo Agnelli, Italy
Albayda Medical Center, Italy
Azienda Ospedaliero Universitaria Pisana, Italy
Fatebenefratelli Isola Tiberina, Italy
Fondazione Policlinico Universitario Agostino Gemelli, Italy
Madre Giuseppina Vannini, Italy
Policlinico Umberto I, Italy
Policlinico Universitario Campus Bio Medico of Rome, Italy
SantEugenio Hospital, Italy
San Pietro Fatebenefratelli, Italy
Policlinico Tor Vergata Hospital, Rome, Italy
Cliniche San Pietro, A.O.U. Sassari, Italy
Azienda Ospedaliero Universitaria Senese, Italy
Santissima Annunziata, Italy
Ca Foncello, Italy
Kansai Medical University, Japan
King Hussein Cancer Center, Jordan
Prince Hamza Hospital, Jordan
Karasay Central District Hospital, Kazakhstan
Kazakh Institute of Oncology and Radiology, Kazakhstan
Yonsei University College of Medicine, Gangnam Severance Hospital, South Korea
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Gil Medical Center, South Korea
Kyung Hee University Hospital at Gangdong, South Korea
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Riga East Cuh Latvia Oncology Center, Latvia
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National Cancer Institute, United States
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Centro Hospitalar Universitario Do Algarve, Hospital Faro, Portugal
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Champalimaud Foundation, Portugal
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Hospital Do Divino Espírito Santo, Portugal
Centro Hospitalar Do Tamega e Sousa, Portugal
Centro Hospitalar Universitario Do Algarve-Unidade de Portimão, Portugal
Hospital de Santarem, Portugal
Unidade Local de Saúde Do Litoral Alentejano, Portugal
Centro Hospitalar de Setúbal, Portugal
Centro Hospitalar de Trás-Os-Montes e Alto Douro, E.P.e, Portugal
Coltea Clinical Hospital, Romania
Emergency Clinical Hospital Bucharest, Romania
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Clinica Chirurgie I, Spitalul Clinic Judetean de Urgenta, Romania
Cluj-Napoca Municipal Hospital, Romania
Regional Institute of Oncology Iasi, Romania
Regional Clinical Hospital, Immanuel Kant Baltic Federal University, Russian Federation
Moscow Research and Educational Center, Lomonosov Moscow State University, Russian Federation
Petrovsky National Research Centre of Surgery, Russian Federation
Clinic of Coloproctology and Minimally Invasive Surgery, Sechenov Medical State University, Russian Federation
Privolzhsky Research Medical University, Nizhny Novgorod Regional Clinical Hospital, Russian Federation
N.N. Petrov National Medical Research Center of Oncology, Russian Federation
Leningrad Regional Cliniical Oncology Dispencary, Russian Federation
Sokolovs N.-W. District Scientific and Clinical Center of Federal Medical and Biological Agency, Russian Federation
Saint Petersburg State University Hospital, Russian Federation
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Changi General Hospital, Singapore
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National Hospital of Sri Lanka, Sri Lanka
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Aleppo Private Hospital, Syrian Arab Republic
The Arabic Medicine, Syrian Arab Republic
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Kaohsiung Medical University Hospital, Taiwan
Gulhane Training and Research Hospital, Turkey
Bursa City Hospital, Turkey
Medicana Bursa Hospital, Turkey
Bursa Uludag University School of Medicine, Turkey
Pamukkale University School of Medicine, Turkey
Erzincan University Hospital, Turkey
Istanbul Education and Research Hospital, Turkey
Acibadem Atakent Hospital, Turkey
Bagcilar Research and Training Hospital, Turkey
Kartal Dr. Lutfi Kirdar Training and Research Hospital, Turkey
Sisli Hamidiye Etfal Training and Research Hospital, Turkey
University of Health Sciences Istanbul Umraniye Training and Research Hospital, Turkey
Istanbul Universty-Cerrahpaşa Medical Faculty, Turkey
Kanuni Sultan Suleyman Training and Research Hospital, Turkey
University of Health Sciences Tepecik Training and Research Hospital, Turkey
Medica Uruguaya, Uruguay
Dokuz Eylul Univ. Hospital, Turkey
Ege University Hospital, Turkey
Kocaeli University Teaching Hospital, Turkey
Sakarya Faculty of Medicine, Turkey
Samsun Training and Research Hospital, Turkey
Zonguldak Bulent Ecevit University School of Medicine Research and Training Hospital, Turkey
Kiryandongo Hospital, Uganda
Hospital Garcia de Orta, Portugal
Sheikh Shakhbout Medical City, United Arab Emirates
Bronglais General Hospital, United Kingdom
Furness General Hospital, United Kingdom
Heartlands Hospital, United Kingdom
Pilgrim Hospital, United Kingdom
University Hospitals of Derby and Burton, United Kingdom
West Suffolk Hospital, United Kingdom
Addenbrookes Hospital, United Kingdom
Ninewells Hospital, United Kingdom
Western General Hospital, United Kingdom
Royal Devon and Exeter Hospital, United Kingdom
James Paget Univeristy Nhs Foundation Trust Hospital, United Kingdom
East Sussex Healthcare Conquest Hospital and Eastbourne District General Hospital), United Kingdom
King George Hospital, United Kingdom
East Kent Hospitals Nhs Foundation Trust, United Kingdom
Kettering General Hospital, United Kingdom
Lincoln County Hospital, United Kingdom
Newham University Hospital, United Kingdom
Royal London Hospital, United Kingdom
Whittington Hospital, United Kingdom
Luton and Dunstable University Hospital, United Kingdom
Tunbridge Wells Hospital, United Kingdom
Royal Lancaster Infirmary, United Kingdom
Churchill Hospital, United Kingdom
Jersey General Hospital, United Kingdom
Morriston Hospital Swansea, United Kingdom
Musgrove Park Hospital, United Kingdom
Royal Cornwall Hospital, United Kingdom
Wrightington, Wigan & Leigh Nhs Foundation Trust, United Kingdom
Wirral University Teaching Hospital, United Kingdom
Yeovil District Hospital, United Kingdom
Al-Thawra Modern General Hospital, Yemen
Etablissement Hospitalier et Universitaire
University Hospital Center
Churruca-Visca
Grupo Galeno
Hospital Universitario Cemic
Nueva Proctologia
Penna Hospital
Hospital Español de Buenos Aires
Hospital Universitario Austral
Clinica Universitaria Reina Fabiola
Hospital Privado de Comunidad
Hospital Luis Lagomaggiore
Sanatorio Laprida
Dr. Horacio e Oduber Hospital
Bendigo Health
Barmherzige Brüder Graz
Medical University of Graz
Leyla Medical Center
King Hamad University Hospital
University Clinical Center Tuzla
Hospital Do Servidor Público Estadual-Francisco Morato de Oliveira
Felicio Rocho
Hospital das Clínicas da Universidade Federal de Minas Gerais/Ebserh
Orizonti
Policia Militar Do Estado de Minas Gerais
Santa Casa de Misericórdia
Hospital Universitário São Francisco de Assis Na Providência de Deus
Hospital Universitário Professor Polydoro Ernani de São Thiago- Hu/Ufsc/Ebserh
Hospital das Clinicas
Hospital Universitário Professor Edgard Santos
Notre Dame Intermédica-Hospital Salvalus
University Hospital Dr Georgi Stranski
University Hospital Eurohospital
University Hospital Alexandrovska
Zadar General Hospital
University Hospital
Department of Surgery
Odense and Svendborg University Hospital
Alexandria Main University Hospital
Misr Cancer Center
Assiut University Hospital
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Ain Shams University Hospital(El-Demerdash Hospital))
Gastrointestinal Surgery Center
Oncology Center Mansoura University
Mansoura University Hospital
Maddawalabu University Goba Referral Hospital
Kanta-Hame Central Hospital
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Klinikum Saarbruecken
Athens Euroclinic
Agios Savvas Anticancer Hospital
Aretaieion Hospital
Attikon University General Hospital
Evaggelismos General Hospital
Hippocratio General Hospital
Mitera Hospital
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General University Hospital of Larissa
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Metaxa Cancer Hospital
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George Papanikolaou General Hospital of Thessaloniki
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Synergy Institute of Medical Sciences
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All India Institute of Medical Sciences (Aiims)
Institute of Postgraduate Medical Education and Research
Tata Medical Center
King Georges Medical University
Christian Medical College and Hospital
Kasturba Medical College Hospital
Maulana Azad Medical College
Government Medical College Patiala
Laiko University Hospital
All India Institute of Medical Sciences
Acharya Vinoba Bhave Rural Hospital
Sher-I-Kashmir Institute of Medical Sciences
Thanjavur Medical College
Government Medical College Thiruvananthapuram
Ospedale S. Leonardo-Asl Napoli 3 Sud
University Hospital Waterford
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University of Bari Aldo Moro
Azienda Ospedaliera G. Brotzu
Cagliari University Hospital
Bernardino Ramazzini
Irccs Saverio de Bellis
Azienda Ospedaliera Pugliese-Ciaccio di Catanzaro
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Santa Croce e Carle Hospital
Ospedale Sacra Famiglia
Azienda Unità Sanitaria Locale di Ferrara
Azienda Ospedaliera Universitaria Careggi
Fujita Health University Bantane Hospital
P.O.Vito Fazzi
Policlinico Universitario G. Martino of Messina
Humanitas Research Hospital
Ospedale Luigi Sacco Milano
San Raffaele Scientific Institute
Santi Paolo E Carlo
Ospedale San Gerardo
Azienda Ospedaliera di Rilievo Nazionale Antonio Cardarelli
Irccs Azienda Ospedaliero-Universitaria di Bologna
Federico Ii University of Naples
Lithuanian University of Health Sciences Kaunas Clinical Hospital
Istituto Nazionale Tumori Fondazione
Universitá della Campania Luigi Vanvitelli
San Luigi Gonzaga Hospital
Fbf Buccheri la Ferla Palermo
Policlinico San Matteo
Ospedale Santa Corona
Edoardo Agnelli
Albayda Medical Center
Azienda Ospedaliero Universitaria Pisana
Fatebenefratelli Isola Tiberina
Fondazione Policlinico Universitario Agostino Gemelli
Madre Giuseppina Vannini
Policlinico Umberto I
Policlinico Universitario Campus Bio Medico of Rome
SantEugenio Hospital
San Pietro Fatebenefratelli
Policlinico Tor Vergata Hospital
Cliniche San Pietro
Azienda Ospedaliero Universitaria Senese
Santissima Annunziata
Ca Foncello
Kansai Medical University
King Hussein Cancer Center
Prince Hamza Hospital
Karasay Central District Hospital
Kazakh Institute of Oncology and Radiology
Yonsei University College of Medicine
Chonnam National University Hospital
Gil Medical Center
Kyung Hee University Hospital at Gangdong
Pusan National University Yangsan Hospital
Riga East Cuh Latvia Oncology Center
Lithuanian University of Health Sciences Kaunas Clinics
National Cancer Institute
Vilnius University Hospital
Hospital Universiti Sains Malaysia
University Kebangsaan Malaysia Medical Centre
University Malaya Medical Centre
Selayang Hospital
Hospital Pengajar Universiti Putra Malaysia
Mater Dei Hospital
Hospital Civil Dr. Juan i Menchaca
Hospital General de México Dr Eduardo Liceaga
Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán
Hospital de Alta Especialidad de Veracruz
University Hospital Hassan Ii
Institut National dOncologie
Viecuri Medisch Centrum
Auckland City Hospital
Dunedin Public Hospital
Wellington Regional Hospital
Alex-Ekwueme Federal University Teaching Hospital Abakaliki Nigeria
Abubakar Tafawa Balewa University Teaching Hospital Bauchi
Federal Teaching Hospital
Federal Teaching Hospital
University College Hospital
University of Ilorin Teaching Hospital
Barau Dikko Teaching Hospital
Aminu Kano Teaching Hospital
Nnamdi Azikiwe University Teaching Hospital
Federal Medical Centre
Ahmadu Bello University Teaching Hospital
Aga Khan University
Cancer Foundation Hospital
Lahore General Hospital
King Edward Medical University
N.N.Blokhin Russian Cancer Research Center
Bahria International Hospital
Al-Ahli Hospital
Hospital Regional Rafael Hernandez Css
Military Institute of Medicine
Wroclaw Regional Hospital
Unidade Local de Saude Do Baixo Alentejo
Instituto Português de Oncologia de Coimbra Francisco Gentil
Hospital Do Espirito Santo
Centro Hospitalar Universitario Do Algarve
Hospital Sao Francisco Xavier
Centro Hospitalar Universitário Lisboa Central
Champalimaud Foundation
Centro Hospitalar Vila Nova de Gaia/Espinho
Hospital Do Divino Espírito Santo
Centro Hospitalar Do Tamega e Sousa
Centro Hospitalar Universitario Do Algarve-Unidade de Portimão
Hospital de Santarem
Unidade Local de Saúde Do Litoral Alentejano
Centro Hospitalar de Setúbal
Centro Hospitalar de Trás-Os-Montes e Alto Douro
Coltea Clinical Hospital
Emergency Clinical Hospital Bucharest
Saint John Emergency Hospital
Prof. Dr. Ion Chiricuta Institute of Oncology
Clinica Chirurgie I
Cluj-Napoca Municipal Hospital
Regional Institute of Oncology Iasi
Regional Clinical Hospital
Moscow Research and Educational Center
Petrovsky National Research Centre of Surgery
Clinic of Coloproctology and Minimally Invasive Surgery
Privolzhsky Research Medical University
N.N. Petrov National Medical Research Center of Oncology
Leningrad Regional Cliniical Oncology Dispencary
Sokolovs N.-W. District Scientific and Clinical Center of Federal Medical and Biological Agency
Saint Petersburg State University Hospital
Siberian State Medical University
King Saud Medical City
Zvezdara University Medical Center
Changi General Hospital
National University Hospital
Hospital Germans Trias i Pujol
Hospital de Igualada
Hospital Del Mar
Vall dHebron University Hospital
Hospital Clinic Barcelona
Hospital General de Valdepeñas
Hospital General Universitario de Elche
Getafe University Hospital
Hospital Universitario de Guadalajara
Hospital Universitario Jerez de la Frontera
Complejo Asistencial Universitario de Leon
Hospital General Universitario Gregorio Marañón
Infanta Leonor University Hospital
Hospital Clinico San Carlos
Hospital Universitario la Paz
Hospital Universitario Del Sureste
Hospital Universitario Principe de Asturias
Hospital Del Henares
Hospital de Manacor
Fundació Althaia-Xarxa Assistencial Universitària de Manresa
Hospital Universitario de Móstoles
Hospital General Reina Sofía
Morales Meseguer University Hospital
Hospital Universitario Central de Asturias Huca
Hospital Universitario Infanta Cristina
Infanta Sofía University Hospital
Hospital General de Segovia
Hospital Universitario Virgen Macarena
Hospital Universitario y Politécnico la Fe
Hospital Clínico Universitario de Valencia
Consorcio Hospital General Universitario
Hospital Clínico Universitario de Valladolid
Álvaro Cunqueiro Hospital
Hospital Universitario Miguel Servet
National Hospital of Sri Lanka
University Hospital Kdu
North Colombo Teaching Hospital
Ibrahim Malik Teaching Hospital
Skane University Hospital Malmö
Visby Hospital
Geneva University Hospitals
Ente Ospedaliero Cantonale
Aleppo Private Hospital
The Arabic Medicine
Aleppo University Hospital
Tishreen University Hospital
Kaohsiung Medical University Hospital
Gulhane Training and Research Hospital
Bursa City Hospital
Medicana Bursa Hospital
Bursa Uludag University School of Medicine
Pamukkale University School of Medicine
Erzincan University Hospital
Istanbul Education and Research Hospital
Acibadem Atakent Hospital
Bagcilar Research and Training Hospital
Kartal Dr. Lutfi Kirdar Training and Research Hospital
Sisli Hamidiye Etfal Training and Research Hospital
University of Health Sciences Istanbul Umraniye Training and Research Hospital
Istanbul Universty-Cerrahpaşa Medical Faculty
Kanuni Sultan Suleyman Training and Research Hospital
University of Health Sciences Tepecik Training and Research Hospital
Medica Uruguaya
Dokuz Eylul Univ. Hospital
Ege University Hospital
Kocaeli University Teaching Hospital
Sakarya Faculty of Medicine
Samsun Training and Research Hospital
Zonguldak Bulent Ecevit University School of Medicine Research and Training Hospital
Kiryandongo Hospital
Hospital Garcia de Orta
Sheikh Shakhbout Medical City
Bronglais General Hospital
Furness General Hospital
Heartlands Hospital
Pilgrim Hospital
University Hospitals of Derby and Burton
West Suffolk Hospital
Addenbrookes Hospital
Ninewells Hospital
Western General Hospital
Royal Devon and Exeter Hospital
James Paget Univeristy Nhs Foundation Trust Hospital
East Sussex Healthcare Conquest Hospital and Eastbourne District General Hospital)
King George Hospital
East Kent Hospitals Nhs Foundation Trust
Kettering General Hospital
Lincoln County Hospital
Newham University Hospital
Royal London Hospital
Whittington Hospital
Luton and Dunstable University Hospital
Tunbridge Wells Hospital
Royal Lancaster Infirmary
Churchill Hospital
Jersey General Hospital
Morriston Hospital Swansea
Musgrove Park Hospital
Royal Cornwall Hospital
Wrightington
Wirral University Teaching Hospital
Yeovil District Hospital
Al-Thawra Modern General Hospital
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