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    ABSTRACT: To investigate the relationship between variability in surgical ward round (WR) quality and clinical outcomes. Evidence increasingly suggests that ward-based care plays a key role in surgical outcomes. The WR is the focal point of surgical inpatient care. Assimilating various sources of clinical information is necessary for thorough patient assessment during the WR; whether this relates to outcomes has not previously been examined. WRs were observed for patients on a surgical high-dependency unit in a tertiary academic surgical unit. All sources of clinical information (SCI) were considered. Thoroughness of assessment, defined as the percentage of SCI assessed by the clinician, was recorded as a marker of WR quality. Complications were recorded from patient records; preventability was based on Agency for Healthcare and Research Quality guidelines. The relationship between WR quality and incidence of preventable complications was analyzed. Sixty-nine WRs were observed over 37 days for 50 patients receiving care in the high-dependency unit. Observed morbidity rate was 60% (30/50). Seventy-four percent of all complications (35/46) occurred on the high-dependency unit. There was significant variability in WR quality: clinicians assessed 9% to 91% (mean = 55% ± 17%) of SCI (analysis of variance P = 0.025). Low-quality (% SCI assessed less than the mean) WRs resulted in a greater incidence of patients experiencing preventable complications [83% (10/12) vs 39% (7/18)] (P = 0.034), odds ratio = 6.43 (95% confidence interval = 1.05-39.3). Forty-one percent of complications (19/46) could have been diagnosed earlier or possibly prevented. Patient assessment during WRs is variable. Less thorough WRs result in delayed diagnoses and preventable complications, and they negatively affect outcomes. Focusing on WR quality and training may improve patient care.
    Annals of surgery 11/2013; 259(2). DOI:10.1097/SLA.0000000000000376
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    ABSTRACT: Ward-based care of surgical patients is a complex and variable process, centered on the surgical ward round (WR). The authors describe the development of an evidence-based curriculum to improve ward-based care in the form of surgical WRs. A modular, simulation-based curriculum was developed according to validated methods, incorporating the most recent evidence in the design of each educational module. A predevelopmental analysis questionnaire identified themes of patient assessment and management, communication skills, and teamwork as areas to be addressed. Curricular development incorporated knowledge and confidence assessment, lecture-based teaching, and simulated WR, followed by individualized assessment, debriefing, and feedback. Each module is evidence based and assesses trainees using validated tools. A comprehensive and cost-effective simulation-based curriculum, developed according to a validated framework, has been developed for surgical WRs and ward-based care. This may improve trainees' WR performance, improving patient care and surgical outcomes in turn.
    American journal of surgery 10/2013; 207(2). DOI:10.1016/j.amjsurg.2013.10.006
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    ABSTRACT: The information provided during the postoperative handover influences the delivery of care of patients in the postoperative recovery unit through their care on the ward. There is a need for a structured and systematic approach to postoperative handover. The aim of this study was to improve postoperative handover through the implementation of a new handover protocol, which involved a handover proforma and standardization of the handover process. This prospective pre-post intervention study demonstrated the improvement in postoperative handover through standardization. There was a significant reduction in information omissions and task errors and improvement in communication and teamwork with the new handover protocol. There was a significant reduction in overall information omissions from 9 to 3 (P < .001) omissions per handover and task errors from 2.8 to .8 (P < .001) with the new handover protocol. Teamwork and nurses' satisfaction score significantly improved from a median of 3 to 4 (P < .001) and median of 4 to 5 (P < .001). Duration of handover decreased from a median of 8 to 7 minutes (P < .376). The study demonstrates that standardization of postoperative handover improved communication and teamwork and reduced information omissions and task errors. There was an improvement in the quality of the handover after the introduction of the new handover protocol, which was easy and simple to use.
    American journal of surgery 10/2013; 206(4):494-501. DOI:10.1016/j.amjsurg.2013.03.005
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    ABSTRACT: The mastery of manual skills that are indispensable for the performance of surgical tasks is a competence specific to surgery. One way of facilitating this acquisition is to move the training out of the operating room and all of its restrictions. Surgical training out of the operating room, also called simulation, has spread widely in the past decade, especially in laparoscopic and endoscopic surgery. This review assesses the role of virtual reality (VR) simulators in laparoscopic surgery and their actual impact on technical skills. There is a wealth of simulators, ranging from low- to high-fidelity simulators incorporating haptic feedback. They comprise basic tasks, procedural modules, and full procedures. Virtual reality simulators have shown acceptable fidelity and validity evidence. Moreover, training out of the operating room on virtual reality simulators has demonstrated its positive impact on basic skills during real laparoscopic procedures in patients. The benefit of virtual reality over simple video trainers remains unclear for teaching basic skills. However, virtual reality simulators provide automatic feedback that permitted to design structured competency-based curricula and allow deliberate practice. Finally, advanced procedures and patient-specific models have been designed on virtual reality simulators, and further investigations are still awaited to appraise their educational value.
    Scandinavian journal of surgery: SJS: official organ for the Finnish Surgical Society and the Scandinavian Surgical Society 09/2013; DOI:10.1177/1457496913496494
  • Colorectal Disease 09/2013; 15(9):1057. DOI:10.1111/codi.12347
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    ABSTRACT: Patients can make valuable contributions towards promoting the safety of their health care. Health care professionals (HCPs) could play an important role in encouraging patient involvement in safety-relevant behaviours. However, to date factors that determine HCPs' attitudes towards patient participation in this area remain largely unexplored. To investigate predictors of HCPs' attitudes towards patient involvement in safety-relevant behaviours. A 22-item cross-sectional fractional factorial survey that assessed HCPs' attitudes towards patient involvement in relation to two error scenarios relating to hand hygiene and medication safety. Four hospitals in London PARTICIPANTS: Two hundred sixteen HCPs (116 doctors; 100 nurses) aged between 21 and 60 years (mean: 32): 129 female. Approval of patient's behaviour, HCP response to the patient, anticipated effects on the patient-HCP relationship, support for being asked as a HCP, affective rating response to the vignettes. HCPs elicited more favourable attitudes towards patients intervening about a medication error than about hand sanitation. Across vignettes and error scenarios, the strongest predictors of attitudes were how the patient intervened and how the HCP responded to the patient's behaviour. With regard to HCP characteristics, doctors viewed patients intervening less favourably than nurses. HCPs perceive patients intervening about a potential error less favourably if the patient's behaviour is confrontational in nature or if the HCP responds to the patient intervening in a discouraging manner. In particular, if a HCP responds negatively to the patient (irrespective of whether an error actually occurred), this is perceived as having negative effects on the HCP-patient relationship.
    Journal of Evaluation in Clinical Practice 08/2013; DOI:10.1111/jep.12073
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    ABSTRACT: To develop novel metabolite-based models for diagnosis and staging in colorectal cancer (CRC) using high-resolution magic angle spinning nuclear magnetic resonance (HR-MAS NMR) spectroscopy. Previous studies have demonstrated that cancer cells harbor unique metabolic characteristics relative to healthy counterparts. This study sought to characterize metabolic properties in CRC using HR-MAS NMR spectroscopy. Between November 2010 and January 2012, 44 consecutive patients with confirmed CRC were recruited to a prospective observational study. Fresh tissue samples were obtained from center of tumor and 5 cm from tumor margin from surgical resection specimens. Samples were run in duplicate where tissue volume permitted to compensate for anticipated sample heterogeneity. Samples were subjected to HR-MAS NMR spectroscopic profiling and acquired spectral data were imported into SIMCA and MATLAB statistical software packages for unsupervised and supervised multivariate analysis. A total of 171 spectra were acquired (center of tumor, n = 88; 5 cm from tumor margin, n = 83). Cancer tissue contained significantly increased levels of lactate (P < 0.005), taurine (P < 0.005), and isoglutamine (P < 0.005) and decreased levels of lipids/triglycerides (P < 0.005) relative to healthy mucosa (RY = 0.94; QY = 0.72; area under the curve, 0.98). Colon cancer samples (n = 49) contained higher levels of acetate (P < 0.005) and arginine (P < 0.005) and lower levels of lactate (P < 0.005) relative to rectal cancer samples (n = 39). In addition unique metabolic profiles were observed for tumors of differing T-stage. HR-MAS NMR profiling demonstrates cancer-specific metabolic signatures in CRC and reveals metabolic differences between colonic and rectal cancers. In addition, this approach reveals that tumor metabolism undergoes modification during local tumor advancement, offering potential in future staging and therapeutic approaches.
    Annals of surgery 07/2013; 259(6). DOI:10.1097/SLA.0b013e31829d5c45
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    ABSTRACT: BACKGROUND: Continuing medical education and objective performance assessment remain the key components of recertification. Objective skills assessment in routine practice remains challenging due to extensive variations in case selection and treatments. This study explores expert opinions regarding objective skills assessment for specialists within the framework of recertification. METHODS: We used a qualitative, semi-structured interview-based approach to obtain information and suggestions about key issues and recommendations relating to specialists' skills assessment. Twenty-two face-to-face interviews were conducted. Interviews were transcribed and analysed by two reviewers. RESULTS: The information from the interviews was categorized under the headings of: (1) the components of specialist-level skills, (2) the methods for assessing specialist skills, (3) the types of tools and procedures used during observational assessment, (4) the unsuccessful specialists, and (5) the selection and training of assessors for specialist assessment. CONCLUSIONS: Outcome-based assessment of performance followed by observation of practice, were recommended as effective modes of evaluation of performance.
    The surgeon: journal of the Royal Colleges of Surgeons of Edinburgh and Ireland 03/2013; 11(3). DOI:10.1016/j.surge.2012.12.004
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    ABSTRACT: OBJECTIVE:: The outcome of pelvic exenteration was compared in patients with locally advanced primary (LAP) cancer and recurrent rectal cancer (RRC). BACKGROUND:: There are few reports comparing the results of pelvic exenteration for primary advanced rectal cancer and RRC. METHODS:: Consecutive patients undergoing pelvic exenteration between 2006 and 2011 were identified from a prospectively maintained database. The main endpoints were 3-year disease-free survival (DFS) and local recurrence-free survival (LRFS). RESULTS:: Of 100 exenterative operations, 55 were for LAP cancer and 45 for RRC. Exenteration of 1 pelvic compartment was required in 30 cases, 2 compartments in 49 cases, and 3 of 4 compartments in 21 cases. R0, R1, and R2 resections were achieved in 78, 15, and 7 cases, respectively. R0 rates were significantly higher in LAP cancer than in RRC (91% vs 62%, P = 0.001). Three-year DFS for R0, R1, and R2 resections was 67%, 49%, and 0%, respectively (P < 0.001). For R0 resections only, DFS in LAP cancer was 76% and 57% in RRC (P = 0.212). On multivariate analysis, a positive resection margin (hazard ratio, 4.04; P < 0.001) and positive lymph node staging (hazard ratio, 2.43; P = 0.022) were significant predictors of reduced DFS. Three-year LRFS for R0 resection was 86% for LAP cancer and 84% for RRC (P = 0.817). On multivariate analysis, only a positive resection margin was a significant predictor of reduced LRFS (hazard ratio, 5.48; P = 0.002). CONCLUSIONS:: Resection margin status is more important than primary or recurrent cancer in predicting long-term outcome.
    Annals of surgery 03/2013; 259(2). DOI:10.1097/SLA.0b013e31828a0d22
  • Colorectal Disease 02/2013; 15(2):137-8. DOI:10.1111/codi.12098
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