Search

The National Emergency Laparotomy Audit (NELA) has been a real success story – engaging with clinical teams and feeding back high-quality comparative process and outcomes data to improve care.^1,2,3 As NELA enters its second decade, it is important to look at persisting challenges as well as successes, and consider where improvement efforts should now be concentrated. This article highlights three areas of emphasis from Year 10 (2023) of the audit.

Infection and sepsis management

Successive NELA reports have highlighted failings in this area – with many patients recorded as having sepsis at admission and/or at time of the decision to operate (DTO), but seemingly poor timeliness of care in terms of both antibiotic administration and definitive source control. Closer examination reveals potentially missed opportunities to streamline decision-making ‘upstream’ of the DTO. Year 8 data³ shows that the median time from arrival in hospital to arrival in theatre for those with sepsis at time of arrival was 15.6 hours. Fewer than a quarter of those with sepsis on arrival at hospital received antibiotics within an hour. This finding might be partially explained by an over-interpretation of the term ‘sepsis’.

Anaesthetists are familiar with the ‘Schimmlebusch Mask’. This article evolves from Arusha, Tanganyika and a small boy’s memory of a white mask descending over his face circa 1963, having fallen while climbing the household log heap and splitting his eyebrow open, requiring sutures by the local doctor.

Open-ether-mask anaesthesia was a common and safe technique utilised in many countries at the time. Tadeusz Szreter’s recollections of performing ether anaesthesia for children in the late 1950s in Poland is an illuminating read. He describes how two facemasks had to be prepared for each procedure, and how when one became covered in frost, it was replaced by the other. Each mask had to be covered with several layers of gauze neatly trimmed to prevent cheek frostbite. With regard to the safety of ether, Perndt in 2010 and Chang et al in 2015 wrote papers advocating a rethink of this abandoned agent.^1,2,3

Numerous articles have been written about Curt Theodor Schimmelbusch (1860–1895) and his eponymous mask; this article is not attempting to review them all, the intention is to stimulate colleagues to explore for themselves.

Delivering training is a complex process. One of the disconnects that crops up between the FICM and intensivists in training is fuelled by the constraints of how the curriculum is delivered. While there are aspects of training that we can adjust, we are very much constrained by the GMC, which is our statutory body for training.

Read the latest letters submitted by members in April's Digital Bulletin.

Authors

• Dr Anna Greenwood, ST7 Anaesthetics, Leeds Teaching Hospitals NHS Trust
• Dr Sue Walwyn, Consultant Anaesthetist, Mid-Yorkshire NHS Trust; Regional Advisor West Yorkshire
• Dr Joe Lipton, Consultant Anaesthetist, Guy’s and St Thomas’ NHS Foundation Trust;
• RCoA Lead for Assessment Anaesthetics Curriculum Development and Assurance Group

The concept of entrustment is as ancient as apprenticeship. Anaesthetists reeling from the effects of the pandemic are adjusting to the logistics of the new curriculum, and with it a paradigm shift in workplace-based assessment. 

Cynics may well have thought that it is all a rebranding exercise, yet it is a considered outcomes-based holistic approach to training. The old ‘tick-box’ process has been replaced by qualitative faculty judgements of capability, anchored to more clearly articulated learning outcomes. Progression is explicitly framed around increasing practice autonomy through ‘entrustment’ of responsibility for patient care. Entrustment-based assessment moves beyond the spiral curriculum and being ‘good enough’, replaced instead by promotion of the ideal of an excellent all-round professional anaesthetist.

The following new appointments were approved, and with sadness we record the deaths of some of our fellows. 

Author: Dr Olivia Coombs, ST5, North West Deanery

Perioperative Journal Watch is written by TRIPOM (trainees with an interest in perioperative medicine) and is a brief distillation of recent important papers and articles on perioperative medicine from across the spectrum of medical publications.

Authors:

• Dr Rachael Brooks and Dr Eleanor Warwick, PQIP Fellows and Anaesthetic Registrars, University College London Hospital
• Dr James Bedford, former PQIP fellow and Consultant Anaesthetist, University College Hospital NHS Foundation Trust
• Professor Ramani Moonesinghe, PQIP Chief Investigator

In 2023, the Perioperative Quality Improvement Programme (PQIP) is launching new postoperative morbidity variable life adjusted display charts (pomVLAD) for all sites recruiting patients undergoing colorectal surgery. Having previously been run as a pilot study in 10 hospitals, the quality-improvement dashboard has been refined and will now provide all sites with near-real time, risk-adjusted morbidity monitoring accompanied by the display of a number of key enhanced-recovery quality-improvement (QI) targets. 

For sites recruiting patients of other surgical specialties, there is also a newly developed QI dashboard which does not incorporate risk-adjustment. Dr James Bedford explains how they can be used to stimulate QI initiatives in your local hospital.

We would like to use this Bulletin article to focus on setting up a Personal Development Plan (PDP), some guidance on what should and should not get included, and to address a query about using your PDP in the Lifelong Learning Platform. In providing this advice we are making reference to the Mythbusters¹ guidance which has been produced by the Academy of Medical Royal Colleges.

The goals within the PDP should be taken from your appraisal, and should meet your needs and the context within which you work. It is recommended that goals are developed with your appraiser using SMART (Specific, Measurable, Achievable, Relevant and Timely) objectives, and it often helps to work out how you can demonstrate that a change planned as one of your goals has made a difference, by considering its impact on patients.