125 results found
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
Chana P, Joy M, Casey N, et al., 2017, Cohort analysis of outcomes in 69 490 emergency general surgical admissions across an international benchmarking collaborative, BMJ Open, Vol: 7, ISSN: 2044-6055
Objective This study aims to use the Dr Foster Global Comparators Network (GC) database to examine differences in outcomes following high-risk emergency general surgery (EGS) admissions in participating centres across 3 countries and to determine whether hospital infrastructure factors can be linked to the delivery of high-quality care.Design A retrospective cohort analysis of high-risk EGS admissions using GC's international administrative data set.Setting 23 large hospitals in Australia, England and the USA.Methods Discharge data for a cohort of high-risk EGS patients were collated. Multilevel hierarchical logistic regression analysis was performed to examine geographical and structural differences between GC hospitals.Results 69 490 patients, admitted to 23 centres across Australia, England and the USA from 2007 to 2012, were identified. For all patients within this cohort, outcomes defined as: 7-day and 30-day inhospital mortality, readmission and length of stay appeared to be superior in US centres. A subgroup of 19 082 patients (27%) underwent emergency abdominal surgery. No geographical differences in mortality were seen at 7 days in this subgroup. 30-day mortality (OR=1.47, p<0.01) readmission (OR=1.42, p<0.01) and length of stay (OR=1.98, p<0.01) were worse in English units. Patient factors (age, pathology, comorbidity) were significantly associated with worse outcome as were structural factors, including low intensive care unit bed ratios, high volume and interhospital transfers. Having dedicated EGS teams cleared of elective commitments with formalised handovers was associated with shorter length of stay.Conclusions Key factors that influence outcomes were identified. For patients who underwent surgery, outcomes were similar at 7 days but not at 30 days. This may be attributable to better infrastructure and resource allocation towards EGS in the US and Australian centres.
Johnston MJ, Arora S, King D, et al., 2016, Improving the Quality of Ward-based Surgical Care With a Human Factors Intervention Bundle., Annals of Surgery, Vol: 267, Pages: 73-80, ISSN: 0003-4932
Objective: This study aimed to explore the impact of a human factors intervention bundle on the quality of ward-based surgical care in a UK hospital.Summary of Background Data: Improving the culture of a surgical team is a difficult task. Engagement with stakeholders before intervention is key. Studies have shown that appropriate supervision can enhance surgical ward safety.Methods: A pre-post intervention study was conducted. The intervention bundle consisted of twice-daily attending ward rounds, a "chief resident of the week" available at all times on the ward, an escalation of care protocol and team contact cards. Twenty-seven junior and senior surgeons completed validated questionnaires assessing supervision, escalation of care, and safety culture pre and post-intervention along with interviews to further explore the impact of the intervention. Patient outcomes pre and postintervention were also analyzed.Results: Questionnaires revealed significant improvements in supervision postintervention (senior median pre 5 vs post 7, P = 0.002 and junior 4 vs 6, P = 0.039) and senior surgeon approachability (junior 5 vs 6, P = 0.047). Both groups agreed that they would feel safer as a patient in their hospital postintervention (senior 3 vs 4.5, P = 0.021 and junior 3 vs 4, P = 0.034). The interviews confirmed that the safety culture of the department had improved. There were no differences in inpatient mortality, cardiac arrest, reoperation, or readmission rates pre and postintervention.Conclusion: Improving supervision and introducing clear protocols can improve safety culture on the surgical ward. Future work should evaluate the effect these measures have on patient outcomes in multiple institutions.
Bagnall NM, Pucher PH, Johnston MJ, et al., 2016, Informing the process of consent for surgery: identification of key constructs and quality factors, Journal of Surgical Research, Vol: 209, Pages: 86-92, ISSN: 0022-4804
BackgroundInformed consent is a fundamental requirement of any invasive procedure. Failure to obtain appropriate and informed consent may result in unwanted or unnecessary procedures, as well as financial penalty in case of litigation. The aim of this study was to identify key constructs of the consent process which might be used to determine the performance of clinicians taking informed consent in surgery.MethodsA multimodal methodology was used. A systematic review was conducted in accordance with PRISMA guidelines to identify evidence-based components of the consent process. Results were supplemented by semistructured interviews with senior trainees and attending surgeons which were transcribed and subjected to emergent theme analysis with repeated sampling until thematic saturation was reached.ResultsA total of 710 search results were returned, with 26 articles included in the final qualitative synthesis of the systematic review. Significant variation existed between articles in the description of the consent procedure. Sixteen semistructured interviews were conducted before saturation was reached. Key components of the consent process were identified with broad consensus for the most common elements. Trainers felt that experiential learning and targeted skills training courses should be used to improve practice in this area.ConclusionsKey components for obtaining informed consent in surgery have been identified. These should be used to influence curricular design, possible assessment methods, and focus points to improve clinical practice and patient experience in future.
Patel B, Johnston M, Cookson N, et al., 2016, Replacing the pager. Can interprofessional communication be improved using a smartphone application? A randomised crossover trial using simulated patients, International Surgical Congress of the Association-of-Surgeons-of-Great-Britain-and-Ireland, Publisher: WILEY-BLACKWELL, Pages: 86-86, ISSN: 0007-1323
Al-Hakim L, Arora S, Sevdalis N, 2016, Impact of disruptions on anaesthetic workflow during anaesthesia induction and patient positioning A prospective study, EUROPEAN JOURNAL OF ANAESTHESIOLOGY, Vol: 33, Pages: 581-587, ISSN: 0265-0215
Arora S, Darzi A, 2016, Introducing Technical Skills Assessment Into Certification: Closing the Implementation Gap, Annals of Surgery, Vol: 264, Pages: 7-9, ISSN: 1528-1140
Soukup T, Lamb BW, Sarkar S, et 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
Soukup Ascencao T, Petrides VK, Lamb BW, et 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
Patel B, Johnston M, Cookson N, et al., 2016, Interprofessional Communication of Clinicians Using a Mobile Phone App: A Randomized Crossover Trial Using Simulated Patients, JOURNAL OF MEDICAL INTERNET RESEARCH, Vol: 18, ISSN: 1438-8871
Background: Most hospitals use paging systems as the principal communication system, despite general dissatisfaction by end users. To this end, we developed an app-based communication system (called Hark) to facilitate and improve the quality of interpersonal communication.Objective: The objectives of our study were (1) to assess the quality of information transfer using pager- and app-based (Hark) communication systems, (2) to determine whether using mobile phone apps for escalation of care results in additional delays in communication, and (3) to determine how end users perceive mobile phone apps as an alternative to pagers.Methods: We recruited junior (postgraduate year 1 and 2) doctors and nurses from a range of specialties and randomly assigned them to 2 groups who used either a pager device or the mobile phone-based Hark app. We asked nurses to hand off simulated patients while doctors were asked to receive handoff information using these devices. The quality of information transfer, time taken to respond to messages, and users’ satisfaction with each device was recorded. Each participant used both devices with a 2-week washout period in between uses.Results: We recruited 22 participants (13 nurses, 9 doctors). The quality of the referrals made by nurses was significantly better when using Hark (Hark median 118, range 100–121 versus pager median 77, range 39–104; P=.001). Doctors responded to messages using Hark more quickly than when responding to pagers, although this difference was not statistically significant (Hark mean 86.6 seconds, SD 96.2 versus pager mean 136.5 seconds, SD 201.0; P=.12). Users rated Hark as significantly better on 11 of the 18 criteria of an information transfer device (P<.05) These included “enhances interprofessional efficiency,” “results in less disturbance,” “performed desired functions reliably,” and “allows me to clearly transfer information.”Conclusions: Hark
Morar P, Mainta E, Arora S, et al., 2016, Predicting surgical strategy in ileal Crohn's disease: the construction and validation of an evidence-based, end-user informed radiological staging tool, JOURNAL OF CROHNS & COLITIS, Vol: 10, Pages: S190-S190, ISSN: 1873-9946
Johnston MJ, Arora S, Pucher PH, et 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
Johnston MJ, Arora S, Pucher PH, et 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.
Sevdalis N, Arora S, 2016, Safety standards for invasive procedures, BMJ-BRITISH MEDICAL JOURNAL, Vol: 352, ISSN: 1756-1833
Chana P, Burns EM, Arora S, et al., 2016, A Systematic Review of the Impact of Dedicated Emergency Surgical Services on Patient Outcomes, Annals of Surgery, Vol: 263, Pages: 20-27, ISSN: 1528-1140
Seymour NE, Paige JT, Arora S, et al., 2016, Putting the MeaT into TeaM Training: Development, Delivery, and Evaluation of a Surgical Team-Training Workshop, Journal of Surgical Education, Vol: 73, Pages: 136-142, ISSN: 1931-7204
Hull L, Arora S, Stefanidis D, et al., 2015, Facilitating the implementation of the American College of Surgeons/Association of Program Directors in Surgery phase III skills curriculum: training faculty in the assessment of team skills, AMERICAN JOURNAL OF SURGERY, Vol: 210, Pages: 933-+, ISSN: 0002-9610
Reissis Y, Johnston M, Davis R, et al., 2015, Identifying Factors Affecting Patients' Willingness to Call for Help on Hospital Wards, International Surgical Congress of the Association-of-Surgeons-of-Great-Britain-and-Ireland, Publisher: WILEY-BLACKWELL, Pages: 159-159, ISSN: 0007-1323
Johnston MJ, Paige JT, Aggarwal R, et al., 2015, An overview of research priorities in surgical simulation: what the literature shows has been achieved during the 21st century and what remains, American Journal of Surgery, Vol: 211, Pages: 214-225, ISSN: 0002-9610
BackgroundKey research priorities for surgical simulation have been identified in recent years. The aim of this study was to establish the progress that has been made within each research priority and what still remains to be achieved.MethodsMembers of the Association for Surgical Education Simulation Committee conducted individualized literature reviews for each research priority that were brought together by an expert panel.ResultsExcellent progress has been made in the assessment of individual and teamwork skills in simulation. The best methods of feedback and debriefing have not yet been established. Progress in answering more complex questions related to competence and transfer of training is slower than other questions. A link between simulation training and patient outcomes remains elusive.ConclusionsProgress has been made in skills assessment, curricula development, debriefing and decision making in surgery. The impact of simulation training on patient outcomes represents the focus of simulation research in the years to come.
Cheng A, Grant V, Dieckmann P, et al., 2015, Faculty Development for Simulation Programs Five Issues for the Future of Debriefing Training, SIMULATION IN HEALTHCARE-JOURNAL OF THE SOCIETY FOR SIMULATION IN HEALTHCARE, Vol: 10, Pages: 217-222, ISSN: 1559-2332
Pucher PH, Johnston MJ, Aggarwal R, et al., 2015, Effectiveness of interventions to improve patient handover in surgery: a systematic review, Surgery, Vol: 158, Pages: 85-95, ISSN: 0039-6060
Background:Handover of patient care is a critical process in the transfer of information between clinical teams and clinicians during transitions in patient care. The handover process may take many forms and is often unstructured and unstandardized, potentially resulting in error and the potential for patient harm. The Joint Commission has implicated such errors in up to 80% of sentinel events and has published guidelines (using an acronym termed SHARE) for the development of intervention tools for handover. This study aims to review interventions to improve handovers in surgery and to assess compliance of described methodologies with the guidelines of the Joint Commission for design and implementation of handover improvement tools.Methods:A systematic review was conducted in line with MOOSE guidelines. Electronic databases Medline, EMBASE, and PsyInfo were searched and interventions to improve surgical handover identified. Intervention types, development methods, and outcomes were compared between studies and assessed against SHARE criteria.Results:Nineteen studies were included. These studies included paper and computerized checklists, proformas, and/or standardized operating protocols for handover. All reported some degree of improvement in handover. Description of development methods, staff training, and follow-up outcome data was poor. Only a single study was able to demonstrate compliance with all 5 domains guidelines of the of Joint Commission.Conclusion:Improvements in information transfer may be achieved through checklist- or proforma-based interventions in surgical handover. Although initial data appear promising, future research must be backed by robust study design, relevant outcomes, and clinical implementation strategies to identify the most effective means to improve information transfer and optimize patient outcomes.
Johnston MJ, Singh P, Pucher PH, et al., 2015, Systematic review with meta-analysis of the impact of surgical fellowship training on patient outcomes, BRITISH JOURNAL OF SURGERY, Vol: 102, Pages: 1156-1166, ISSN: 0007-1323
BackgroundThe number of surgeons entering fellowship training before independent practice is increasing. This may have a negative impact on surgeons in training. The impact of fellowship training on patient outcomes is not yet known. This review aimed to investigate the impact of fellowship training in surgery on patient outcomes.MethodsA systematic review of the literature was conducted to identify studies exploring the structural and surgeon‐specific characteristics of fellowship training on patient outcomes. Data from these studies were extracted, synthesized and reported qualitatively, or quantitatively through meta‐analysis.ResultsTwenty‐three studies were included. The mortality rate for patients in centres with an affiliated fellowship programme was lower than that for centres without (odds ratio 0·86, 95 per cent c.i. 0·84 to 0·88), as was the rate of complications (odds ratio 0·90, 0·78 to 1·02). Surgeons without fellowship training converted more laparoscopic operations to open surgery than those with fellowship training (risk ratio (RR) 1·04, 95 per cent c.i. 1·03 to 1·05). Comparison of outcomes for senior surgeons versus current fellows showed no differences in rates of mortality (RR 1·00, 1·00 to 1·01), complications (RR 1·03, 0·98 to 1·08) or conversion to open surgery (RR 1·01, 1·00 to 1·01).ConclusionFellowship training appears to have a positive impact on patient outcomes.
Chana P, Casey N, Chang D, et al., 2015, The delivery of high-risk emergency general surgery across the dr foster global comparators network: an examination of international outcomes, 2nd Digestive-Disorders-Federation Conference, Publisher: BMJ PUBLISHING GROUP, Pages: A48-A48, ISSN: 0017-5749
Introduction The Dr Foster Global Comparators Network (GC) aims to improve quality in healthcare by promoting inter-hospital collaboration through sharing of outcome data and benchmarking standards.This study aims to utilise the GC database to establish whether geographical differences in outcomes exist following high-risk emergency general surgery (EGS) admissions, whilst determining if structural differences between healthcare systems can be linked to high-quality care.Method Discharge data for a cohort of EGS patients were collated using a pre-determined protocol. Hierarchical logistic regression analysis was performed to examine geographical and structural differences between GC hospitals.Results 69,490 patients, admitted to 23 centres across Australia, England and the USA with high-risk EGS diagnoses from 2007–2012 were identified. Outcomes including: seven/thirty-day mortality, readmission and length of stay were all superior in the USA.19,082 patients (27%) underwent emergency abdominal surgery. No geographical differences in mortality were seen at seven-days in this subgroup. Thirty-day mortality (OR = 1.47) readmission (OR = 1.42) and length of stay (OR = 1.98) were all worse in the UK.Across this cohort, patient factors, (age, pathology and co-morbidity) were significantly associated with worse outcome as were structural factors including: low ITU bed ratios, high unit volume and inter-hospital transfers. Having dedicated EGS teams cleared of elective commitments with formalised handover of patients was associated with shorter length of stay.Conclusion Post-operative outcomes were similar at seven but not at thirty-days. This may be attributable to better infrastructure and resource allocation towards EGS in the US. The costs associated with this healthcare gain were not measured.
Wheelock A, Suliman A, Wharton R, et al., 2015, The Impact of Operating Room Distractions on Stress, Workload, and Teamwork, ANNALS OF SURGERY, Vol: 261, Pages: 1079-1084, ISSN: 0003-4932
Morar P, Sevdalis N, Read J, et al., 2015, ESTABLISHING ELIGIBILITY FOR CASE DISCUSSION IN MULTIDISCIPLINARY TEAM CARE WITHIN AN INFLAMMATORY BOWEL DISEASE SERVICE PROVISION - RESULTS FROM A QUALITATIVE TWO-STAGE EXPERT BASED STUDY, 2nd Digestive-Disorders-Federation Conference, Publisher: BMJ PUBLISHING GROUP, Pages: A184-A184, ISSN: 0017-5749
Johnston MJ, Davis RE, Arora S, et al., 2015, Raising the Alarm: A Cross-Sectional Study Exploring the Factors Affecting Patients' Willingness to Escalate Care on Surgical Wards, WORLD JOURNAL OF SURGERY, Vol: 39, Pages: 2207-2213, ISSN: 0364-2313
BackgroundDelays in escalation of care for patients may contribute to poor outcome. The factors that influence surgical patients’ willingness to call for help on wards are currently unknown. This study explored the factors that affect patients’ willingness to call for help on surgical wards; how patients call for help and to whom; how to encourage patients to call for help, and the barriers to patients calling for help.MethodsA cross-sectional study was conducted in three London hospitals using a questionnaire designed through expert opinion and the published literature. A total of 155 surgical patients (83 % response rate) participated.ResultsPatients were more willing to call for help using the bedside buzzer or by calling a nurse compared to a doctor (p < 0.001). The prompts to calling for help patients were most likely to act on were bleeding and pain. Patients were more willing to call for help if encouraged by a healthcare professional than a relative or fellow patient (p < 0.01). Patients were more likely to worry about taking up too much time when calling for help than being perceived as difficult (p < 0.001). For some prompts, male patients were more willing to call for help (p < 0.05).ConclusionsThis is the first study to identify factors affecting patients’ willingness to call for help on surgical wards. Interventions that take these factors into account can be developed to encourage patients to call for help and may avoid delays in treatment.
Kirkman MA, Sevdalis N, Arora S, et al., 2015, The outcomes of recent patient safety education interventions for trainee physicians and medical students: a systematic review, BMJ Open, Vol: 5, ISSN: 2044-6055
Objective To systematically review the latest evidence for patient safety education for physicians in training and medical students, updating, extending and improving on a previous systematic review on this topic.Design A systematic review.Data sources Embase, Ovid Medline and PsycINFO databases.Study selection Studies including an evaluation of patient safety training interventions delivered to trainees/residents and medical students published between January 2009 and May 2014.Data extraction The review was performed using a structured data capture tool. Thematic analysis also identified factors influencing successful implementation of interventions.Results We identified 26 studies reporting patient safety interventions: 11 involving students and 15 involving trainees/residents. Common educational content included a general overview of patient safety, root cause/systems-based analysis, communication and teamwork skills, and quality improvement principles and methodologies. The majority of courses were well received by learners, and improved patient safety knowledge, skills and attitudes. Moreover, some interventions were shown to result in positive behaviours, notably subsequent engagement in quality improvement projects. No studies demonstrated patient benefit. Availability of expert faculty, competing curricular/service demands and institutional culture were important factors affecting implementation.Conclusions There is an increasing trend for developing educational interventions in patient safety delivered to trainees/residents and medical students. However, significant methodological shortcomings remain and additional evidence of impact on patient outcomes is needed. While there is some evidence of enhanced efforts to promote sustainability of such interventions, further work is needed to encourage their wider adoption and spread.
Johnston M, Arora S, Anderson O, et al., 2015, Escalation of care in surgery: a systematic risk assessment to prevent avoidable harm in hospitalized patients, Annals of Surgery, Vol: 261, Pages: 831-838, ISSN: 0003-4932
Objective: To systematically risk assess and analyze the escalation of care process in surgery so as to identify problems and provide recommendations for intervention.Background: The ability to escalate care appropriately when managing deteriorating patients is a hallmark of surgical competence and safe postoperative care. Healthcare-Failure-Mode-Effects-Analysis (HFMEA) is a methodology adapted from safety-critical industries, which allows for hazardous process failures to be prospectively identified and solutions to be recommended.Methods: Forty-two hours of ethnographic observations on surgical wards in 3 London hospitals (phase 1) formed the basis of an escalation process diagram. A risk-assessment survey identified failures associated with process steps and attributed hazard scores (phase 2). Patient safety and clinical risk experts validated hazard scores through a group consensus meeting (phase 3). Hazardous failures were taken forward to multidisciplinary HFMEA where cause analysis was applied and interventions were recommended (phase 4).Results: Observations identified 33 steps in the escalation process. The risk-assessment survey (30 surgical staff members, 100% response) and expert consensus group identified 18 hazardous failures associated with these steps. The HFMEA team identified 3 adequately controlled failures; therefore, 15 were subjected to cause analysis. Outdated communication technology, understaffing, and hierarchical barriers were identified as root causes of failure. Participants recommended interventions based on these findings including defined escalation protocols, human factors education, enhanced communication technology, and improved clinical supervision.Conclusions: Failures in the escalation process amenable to intervention were systematically identified. This mapping of the escalation process will allow tailored interventions to enhance surgical training and patient safety.
Arora S, Hull L, Fitzpatrick M, et al., 2015, Crisis Management on Surgical Wards A Simulation-based Approach to Enhancing Technical, Teamwork, and Patient Interaction Skills, ANNALS OF SURGERY, Vol: 261, Pages: 888-893, ISSN: 0003-4932
Johnston MJ, Arora S, King D, et al., 2015, A systematic review to identify the factors that affect failure to rescue and escalation of care in surgery, Surgery, Vol: 157, Pages: 752-763, ISSN: 0039-6060
BackgroundThe relationship between the ability to recognize and respond to patient deterioration (escalate care) and its role in preventing failure to rescue (FTR; mortality after a surgical complication) has not been explored. The aim of this systematic review was to determine the incidence of, and factors contributing to, FTR and delayed escalation of care for surgical patients.MethodsA search of MEDLINE, EMBASE PsycINFO, the Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials was conducted to identify articles exploring FTR, escalation of care, and interventions that influence outcomes. Screening of 19,887 citations led to inclusion of 42 articles.ResultsThe reported incidence of FTR varied between 8.0 and 16.9%. FTR was inversely related to hospital volume and nurse staffing levels. Delayed escalation occurred in 20.7–47.1% of patients and was associated with greater mortality rates in 4 studies (P < .05). Causes of delayed escalation included hierarchy and failures in communication. Of five interventional studies, two reported a significant decrease in intensive care admissions (P < .01) after introduction of escalation protocols; only 1 study reported an improvement in mortality.ConclusionThis systematic review explored factors linking FTR and escalation of care in surgery. Important factors that contribute to the avoidance of preventable harm include the recognition and communication of serious deterioration to implement definitive treatment. Targeted interventions aiming to improve these factors may contribute to enhanced patient outcome.
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