TRIPOM summarise recent papers and articles on perioperative medicine from across different medical publications.
- Dr Jaimin Arya, ST6, East Midlands Deanery
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As NELA enters its second decade, it's 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.
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’.
Dr Adrian Jennings, Consultant Anaesthetist, and Dr Kavaladeep Jabbal, ACCS CT4 Anaesthetics at Russels Hall Hospital, Dudley discuss their innovative ‘traffic light’ system.
When emergency cases are booked, they must be able to access theatre in an appropriate time frame. Assessing the operational pressure on the emergency theatre is a complex calculation considerate of the number of cases booked, their acuity, and expected duration.
The National Emergency Laparotomy Audit (NELA) uses a classification for surgical urgency based on the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) and Surviving Sepsis.1
- 1: Immediate (<2 hours)
- 2a: Urgent (2–6 hours)
- 2b: Urgent (6–18 hours)
- 3: Expedited (>18 hours).
This article explores shared decision-making, in which patients and clinicians collaborate to make the best evidence-based decision within the context of the patient’s values.
The success of an anaesthetic is traditionally judged by our ability to safely get our patient through an operation. Yet, the more evolving challenge of our specialty is identifying those patients at high risk of postoperative complications where the best course of action may be no surgery at all. A further challenge is that of empowering patients to consider the available evidence to make the best decision for their circumstances.
Shared decision-making, whereby patients and clinicians collaborate to make the best evidence-based decision within the context of the patients’ values, is recognised as a vital component of perioperative care. The benefits of shared decision-making are accepted by NICE and the Centre for Perioperative Care (CPOC), yet evidence suggests we may not be doing it as well as we should. A recent CPOC survey showed that 39% of patients desired more support or information regarding treatment choices. In another study, 14% of patients expressed regret, and said that they would not have had surgery had they understood the risks and alternatives. View the ‘three-talk’ model of shared decision-making suggested by CPOC.
Dr James Brunning provides some simple steps that are likely to pay real dividends and help you thrive through the long dark winter months.
Winter can be hard for many of us, with the combination of longer nights, shorter days and the rounds of respiratory infections that come our way.
It can help to think of wellbeing as a balance between restorative and protective activities and those activities that are draining or reinvigorating. These are, of course, different for each of us and so the best person to advise you on what works for you is yourself. That said, there are some simple steps that are likely to pay real dividends and help you thrive through the long dark winter months.
Dr Tara Keogh looks at how resident doctors can try to implement change and make meaningful contributions while training.
It is not an understatement to say that resident doctors in training often face significant challenges when attempting to implement change initiatives. As they rotate through multiple hospitals, they may struggle to establish rapport and trust with established staff, making it difficult to garner support for new ideas.
The fast-paced environment, heavy workload and burden of exams and portfolio, can leave little time for trainees to engage in the necessary discussions or meetings to advocate for change. Additionally, the hierarchical structure of medical training can inhibit resident doctors from voicing their ideas as they may not feel respected enough to have influence.
‘Safety and Quality Improvement’ is one of the generic professional domains throughout the anaesthetic training programme. Trainees are expected to conduct local quality-improvement projects, in addition to participation in regional or national projects.
Planning and implementing one of the new special interest areas (SIAs) available from the 2021 curriculum: a trainee’s and trainer’s perspective.
Planning and implementing one of the new special interest areas (SIAs) available from the 2021 curriculum: a trainee’s and trainer’s perspective.
Dr Cathryn Malins and Dr Madeleine Storey explain why formalising training time in regional anaesthesia will facilitate the learning of trainees at all stages.
Over the last five years, regional anaesthesia in clinical practice has been on a trajectory – growing in importance and prominence in the anaesthesia community. Efforts by the 8th National Audit Project and the BJA have helped further increase the publicity of regional anaesthesia. While we can all see the merit in this growth, is this the time for a more formalised place in the training programme for regional anaesthesia?
As with any practical procedure, there are many ways to learn, but it is practically impossible to become competent or excellent at regional anaesthesia without regular hands-on patient experience. Recent UK-wide surveys revealed a large proportion of Stage 3 trainees unable to perform all Plan A blocks independently, and found that only a small proportion of consultants and specialists felt confident teaching all these blocks to trainees. It has also been seen that the higher the number of blocks trainees perform, the more confident they feel. Currently, ‘getting numbers’ and achieving the required competence, feels challenging.
We acknowledge that there is an inevitable period of adjustment following curriculum transition, but many of our trainee colleagues still feel their current skills in this area are inadequate for their level of training. To prevent this becoming a perpetual challenge this issue must be proactively addressed across all stages of training.
Dr Pippa Pemberton and Dr Nathan Grower from the Royal Free Hospital, London tell us how they've managed the transformation to HALOs at Stages 1, 2 and 3.
Like Alexander of Macedon, the new curriculum has swept all before it. For Egypt, read regional anaesthesia; for the sacked cities of Tyre and Persepolis, read the subspecialties.
Although Pain may seem distant, much like Alexander reached India, the new curriculum has reached it.
In 2010 Pain featured as a module requiring a sign off (with 17 syllabus points) and Intermediate Level (18), and was optional at Higher and Advanced.
This has been replaced by compulsory HALOs at Stages 1, 2 and 3, with new and more generalised curriculum points.
Dr Mouton, a graduate from the Research Leader scheme, shares her positive experience of the scheme and why it's helped her development as a clinical researcher.
The Perioperative Medicine Clinical Trials Network (POMCTN) Research Leader scheme, previously named the Chief Investigator scheme, was founded with the aim of nurturing, training and supporting perioperative researchers to develop as future research leaders. Dr Mouton, a graduate from the Research Leader scheme, shares her experience.