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  • Journal article
    Johnston MJ, Arora S, Darzi A, 2017,

    Reply to "RE: Escalation of Care in Surgery: A Systematic Risk Assessment to Prevent Avoidable Harm in Hospitalized Patients."

    , Annals of Surgery, Vol: 266, Pages: e28-e28, ISSN: 0003-4932
  • Journal article
    D'Lima, Arnold G, Brett SJ, Bottle A, Smith A, Benn Jet al., 2017,

    Continuous monitoring and feedback of quality of recovery indicators for anaesthetists: A qualitative investigation of reported effects on professional behaviour

    , British Journal of Anaesthesia, Vol: 119, Pages: 115-124, ISSN: 1471-6771

    Background: Research suggests that providing clinicians with feedback on their performance can result in professional behaviour change and improved clinical outcomes. Departments would benefit from understanding which characteristics of feedback support effective quality monitoring, professional behaviour change and service improvement. This study aimed to report the experience of anaesthetists participating in a long-term initiative to provide comprehensive personalized feedback to consultants on patient-reported quality of recovery indicators in a large London teaching hospital.Methods: Semi-structured interviews were conducted with 13 consultant anaesthetists, six surgical nursing leads, the theatre manager and the clinical coordinator for recovery. Transcripts were qualitatively analysed for themes linked to the perceived value of the initiative, its acceptability and its effects upon professional practice.Results: Analysis of qualitative data from participant interviews suggested that effective quality indicators must address areas that are within the control of the anaesthetist. Graphical data presentation, both longitudinal (personal variation over time) and comparative (peer-group distributions), was found to be preferable to summary statistics and provided useful and complementary perspectives for improvement. Developing trust in the reliability and credibility of the data through co-development of data reports with clinical input into areas such as case-mix adjustment was important for engagement. Making feedback specifically relevant to the recipient supported professional learning within a supportive and open collaborative environment.Conclusions: This study investigated the requirements for effective feedback on quality of anaesthetic care for anaesthetists, highlighting the mechanisms by which feedback may translate into improvements in practice at the individual and peer-group level.

  • Journal article
    D'Lima D, Bottle A, Benn J, 2016,


  • Journal article
    Soukup T, Lamb BW, Sarkar S, Arora S, Shah S, Darzi A, Green JS, Sevdalis Net al., 2016,

    Predictors of Treatment Decisions in Multidisciplinary Oncology Meetings: A Quantitative Observational Study

    , Annals of Surgical Oncology, Vol: 23, Pages: 4410-4417, ISSN: 1534-4681

    BACKGROUND: In many healthcare systems, treatment recommendations for cancer patients are formulated by multidisciplinary tumor boards (MTBs). Evidence suggests that interdisciplinary contributions to case reviews in the meetings are unequal and information-sharing suboptimal, with biomedical information dominating over information on patient comorbidities and psychosocial factors. This study aimed to evaluate how different elements of the decision process affect the teams' ability to reach a decision on first case review. METHODS: This was an observational quantitative assessment of 1045 case reviews from 2010 to 2014 in cancer MTBs using a validated tool, the Metric for the Observation of Decision-making. This tool allows evaluation of the quality of information presentation (case history, radiological, pathological, and psychosocial information, comorbidities, and patient views), and contribution to discussion by individual core specialties (surgeons, oncologists, radiologists, pathologists, and specialist cancer nurses). The teams' ability to reach a decision was a dichotomous outcome variable (yes/no). RESULTS: Using multiple logistic regression analysis, the significant positive predictors of the teams' ability to reach a decision were patient psychosocial information (odds ratio [OR] 1.35) and the inputs of surgeons (OR 1.62), radiologists (OR 1.48), pathologists (OR 1.23), and oncologists (OR 1.13). The significant negative predictors were patient comorbidity information (OR 0.83) and nursing inputs (OR 0.87). CONCLUSIONS: Multidisciplinary inputs into case reviews and patient psychosocial information stimulate decision making, thereby reinforcing the role of MTBs in cancer care in processing such information. Information on patients' comorbidities, as well as nursing inputs, make decision making harder, possibly indicating that a case is complex and requires more detailed review. Research should further define case complexity a

  • Journal article
    Soukup Ascencao T, Petrides VK, Lamb BW, Sarkar S, Arora S, Darzi A, Green JSA, Sevdalis Net al., 2016,

    The anatomy of clinical decision-making in multidisciplinary cancer meetings: a cross-sectional observational study of teams in a natural context

    , Medicine, Vol: 95, ISSN: 0025-7974

    Abstract: In the UK, treatment recommendations for patients with cancer are routinely made by multidisciplinary teams in weekly meetings. However, their performance is variable.The aim of this study was to explore the underlying structure of multidisciplinary decision-making process, and examine how it relates to team ability to reach a decision.This is a cross-sectional observational study consisting of 1045 patient reviews across 4 multidisciplinary cancer teams from teaching and community hospitals in London, UK, from 2010 to 2014. Meetings were chaired by surgeons.We used a validated observational instrument (Metric for the Observation of Decision-making in Cancer Multidisciplinary Meetings) consisting of 13 items to assess the decision-making process of each patient discussion. Rated on a 5-point scale, the items measured quality of presented patient information, and contributions to review by individual disciplines. A dichotomous outcome (yes/no) measured team ability to reach a decision. Ratings were submitted to Exploratory Factor Analysis and regression analysis.The exploratory factor analysis produced 4 factors, labeled “Holistic and Clinical inputs” (patient views, psychosocial aspects, patient history, comorbidities, oncologists’, nurses’, and surgeons’ inputs), “Radiology” (radiology results, radiologists’ inputs), “Pathology” (pathology results, pathologists’ inputs), and “Meeting Management” (meeting chairs’ and coordinators’ inputs). A negative cross-loading was observed from surgeons’ input on the fourth factor with a follow-up analysis showing negative correlation (r = -0.19, P < 0.001). In logistic regression, all 4 factors predicted team ability to reach a decision (P < 0.001).Hawthorne effect is the main limitation of the study.The decision-making process in cancer meetings is driven by 4 underlying factors representing the complete patient prof

  • Journal article
    Mamidanna R, Ni Z, Anderson O, Spiegelhalter D, Bottle A, Aylin P, Faiz O, Hanna GBet al., 2016,

    Surgeon Volume and Cancer Esophagectomy, Gastrectomy, and Pancreatectomy: A Population-based Study in England

    , Annals of Surgery, Vol: 263, Pages: 727-732, ISSN: 1528-1140

    Objective: The aim of the study was to assess whether there is a proficiency curve-like relationship between surgeon volume and operative mortality and determine the minimum surgeon volume for optimum operative mortality.Background: The inverse relationship between hospital volume and operative mortality is well-established for esophageal, gastric, and pancreatic cancer. The recommended minimum surgeon volumes are however uncertain.Methods: We retrieved data on esophagectomies, gastrectomies, and pancreatectomies for cancer from the NHS Hospital Episodes Statistics database from April 2000 to March 2010. We defined mortality as in-hospital death within 30 days of surgery. We determined whether there was a proficiency curve relationship by inspecting surgeon volume-mortality graphs after adjusting for patient age, sex, socioeconomic, and comorbidity indices. We then statistically determined the minimum surgeon volume that produced a mortality rate insignificantly different from the optimum of the curve.Results: Sixteen thousand five hundred seventy-two esophagectomies, 12,622 gastrectomies, and 9116 pancreatectomies were examined. Surgeon volume ranged from 2 to 29 esophagectomies, from 1 to 14 gastrectomies, and from 2 to 31 pancreatectomies per surgeon per year. We demonstrated a proficiency relationship between surgeon volume and mortality in esophageal, gastric, and pancreatic cancer surgery. Each additional case of esophagectomy, gastrectomy, and pancreatectomy would reduce 30-day mortality odds by 3.4%, 7.2%, and 4.1%, respectively. However, as surgeon volume increased, mortality rate continued to improve. Therefore, we were unable to recommend minimum surgeon volume.Conclusions: Mortality after resections for esophageal, gastric, and pancreatic cancer falls as surgeon volume rises up to 30 cases. Within this range, we did not demonstrate any statistical threshold that could be recommended as a minimum volume target.

  • Journal article
    Anderson O, Carr R, Harbinson M, Hanna GBet al., 2016,

    Development and validation of a lipase nasogastric tube position test

    , BMJ Open Gastroenterology, Vol: 2, ISSN: 2054-4774

    BackgroundNasogastric tube position should be checked every day by either aspirate pH or chest radiography to prevent fatal misplaced feeding into the lungs. Many patients do not have acidic gastric aspirates and require daily chest radiographs. We developed and validated a lipase test that was compatible with non-acidic gastric aspirates.MethodsWe conducted evaluations of diagnostic test accuracy at a teaching hospital in development and validation stages. Development: We collected gastric and lung aspirates from 34 consecutive patients. We measured pH and human gastric lipase activity in the laboratory. These data helped us develop the lipase test. Ingenza Ltd (Roslin, Scotland) created tributyrin-coated pH test paper, which human gastric lipase converted into butyric acid, thus correcting false negatives. Validation: We tested nasogastric feeding tube aspirates from 36 consecutive patients with pH and lipase tests, using chest radiography or trial by use as the reference standard.ResultsDevelopment: We demonstrated human gastric lipase activity in the non-acidic stomach aspirates. Validation: The accuracy of the lipase test (sensitivity 97.2%, specificity 100%) was significantly better than pH (sensitivity 65.7%, specificity 100%, p<0.05).ConclusionsWhen nasogastric tube stomach aspirates were not acidic and pH was falsely negative, the lipase test showed a true positive and was significantly more accurate.

  • Journal article
    Johnston MJ, Arora S, Pucher PH, McCartan N, Reissis Y, Chana P, Darzi Aet al., 2016,

    Improving Escalation of Care A Double-blinded Randomized Controlled Trial

    , ANNALS OF SURGERY, Vol: 263, Pages: 421-426, ISSN: 0003-4932

    Objective: This study aimed to determine whether an intervention could improve the escalation of care skills of junior surgeons.Summary Background Data: Escalation of care involves the recognition, communication, and response to patient deterioration until a satisfactory outcome has been achieved. Although failure to escalate care can lead to increased morbidity and mortality, there is no formal training in how to perform this vital process safely.Methods: This randomized controlled trial recruited postgraduate year (PGY)-1 and PGY-2 surgeons to participate in 2 scenarios involving simulated patients requiring escalation of care. A control group performed both scenarios before receiving the intervention; the intervention group received the educational intervention before their second scenario. Scenarios were video recorded and rated by 2 independent, blinded assessors using validated scales to measure patient assessment, communication, management and nontechnical skills of participants, and the number of medical errors they detected.Results: A total of 33 PGY-1 and PGY-2 surgeons, all with equivalent skill at baseline, participated. Postintervention, the intervention group demonstrated significantly better patient assessment (P < 0.001), communication (P < 0.001), and nontechnical skills (P < 0.001). They also detected more medical errors (P < 0.05).Conclusions: Teaching junior surgeons a systematic approach to escalation of care improved multiple core skills required to maintain patient safety and avoid preventable harm.

  • Journal article
    Johnston MJ, Arora S, Pucher PH, Reissis Y, Hull L, Huddy JR, King D, Darzi Aet al., 2016,

    Improving Escalation of Care Development and Validation of the Quality of Information Transfer Tool

    , ANNALS OF SURGERY, Vol: 263, Pages: 477-486, ISSN: 0003-4932

    Objective: To develop and provide validity and feasibility evidence for the QUality of Information Transfer (QUIT) tool.Background: Prompt escalation of care in the setting of patient deterioration can prevent further harm. Escalation and information transfer skills are not currently measured in surgery.Methods: This study comprised 3 phases: the development (phase 1), validation (phase 2), and feasibility analysis (phase 3) of the QUIT tool. Phase 1 involved identification of core skills needed for successful escalation of care through literature review and 33 semistructured interviews with stakeholders. Phase 2 involved the generation of validity evidence for the tool using a simulated setting. Thirty surgeons assessed a deteriorating postoperative patient in a simulated ward and escalated their care to a senior colleague. The face and content validity were assessed using a survey. Construct and concurrent validity of the tool were determined by comparing performance scores using the QUIT tool with those measured using the Situation-Background-Assessment-Recommendation (SBAR) tool. Phase 3 was conducted using direct observation of escalation scenarios on surgical wards in 2 hospitals.Results: A 7-category assessment tool was developed from phase 1 consisting of 24 items. Twenty-one of 24 items had excellent content validity (content validity index >0.8). All 7 categories and 18 of 24 (P < 0.05) items demonstrated construct validity. The correlation between the QUIT and SBAR tools used was strong indicating concurrent validity (r = 0.694, P < 0.001). Real-time scoring of escalation referrals was feasible and indicated that doctors currently have better information transfer skills than nurses when faced with a deteriorating patient.Conclusions: A validated tool to assess information transfer for deteriorating surgical patients was developed and tested using simulation and real-time clinical scenarios. It may improve the quality and safety of patient care on

  • Journal article
    Pinto A, faiz O, davis R, almoudaris A, vincent Cet al., 2016,

    Surgical complications and their impact on patients’ psychosocial wellbeing: A systematic review and meta-analysis

    , BMJ Open, Vol: 6, ISSN: 2044-6055

    Objective Surgical complications may affect patients psychologically due to challenges such as prolonged recovery or long-lasting disability. Psychological distress could further delay patients’ recovery as stress delays wound healing and compromises immunity. This review investigates whether surgical complications adversely affect patients’ postoperative well-being and the duration of this impact.Methods The primary data sources were ‘PsychINFO’, ‘EMBASE’ and ‘MEDLINE’ through OvidSP (year 2000 to May 2012). The reference lists of eligible articles were also reviewed. Studies were eligible if they measured the association of complications after major surgery from 4 surgical specialties (ie, cardiac, thoracic, gastrointestinal and vascular) with adult patients’ postoperative psychosocial outcomes using validated tools or psychological assessment. 13 605 articles were identified. 2 researchers independently extracted information from the included articles on study aims, participants’ characteristics, study design, surgical procedures, surgical complications, psychosocial outcomes and findings. The studies were synthesised narratively (ie, using text). Supplementary meta-analyses of the impact of surgical complications on psychosocial outcomes were also conducted.Results 50 studies were included in the narrative synthesis. Two-thirds of the studies found that patients who suffered surgical complications had significantly worse postoperative psychosocial outcomes even after controlling for preoperative psychosocial outcomes, clinical and demographic factors. Half of the studies with significant findings reported significant adverse effects of complications on patient psychosocial outcomes at 12 months (or more) postsurgery. 3 supplementary meta-analyses were completed, 1 on anxiety (including 2 studies) and 2 on physical and mental quality of life (including 3 studies). The latter indicated statistically signi

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