Development and validation of a novel tool for identification and categorization of non-technical errors associated with surgical mortality.

BACKGROUND: Up to half of all surgical adverse events are due to non-technical errors, making non-technical skill assessment and improvement a priority. No specific tools are available to retrospectively identify non-technical errors that have occurred in surgical patient care. This original study aimed to develop and provide evidence of validity and inter-rater reliability for the System for Identification and Categorization of Non-technical Error in Surgical Settings (SICNESS). METHODS: A literature review, modified Delphi process, and two pilot phases were used to develop and test the SICNESS tool. For each pilot, 12 months of surgical mortality data from the Australian and New Zealand Audit of Surgical Mortality were assessed by two independent reviewers using the SICNESS tool. Main outcomes included tool validation through modified Delphi consensus, and inter-rater reliability for: non-technical error identification and non-technical error categorization using Cohen's κ coefficient, and overall agreement using Fleiss' κ coefficient. RESULTS: Version 1 of the SICNESS was used for pilot 1, including 412 mortality cases, and identified and categorized non-technical errors with strong-moderate inter-rater reliability. Non-technical error exemplars were created and validated through Delphi consensus, and a novel mental model was developed. Pilot 2 included an additional 432 mortality cases. Inter-rater reliability was near perfect for leadership (κ 0.92, 95% c.i. 0.82 to 1.00); strong for non-technical error identification (κ 0.89, 0.84 to 0.93), communication and teamwork (κ 0.89, 0.79 to 0.99), and decision-making (κ 0.85, 0.79 to 0.92); and moderate for situational awareness (κ 0.79, 0.71 to 0.87) and overall agreement (κ 0.69, 0.66 to 0.73). CONCLUSION: The SICNESS is a reliable and valid tool, enabling retrospective identification and categorization of non-technical errors associated with death, occurring in real surgical patient interactions.

Many errors in surgery occur because of poor non-technical skills. The aim of this study was to create a tool to identify this type of error using patient data so future errors may be prevented. The tool was designed through expert opinion and literature review. It was tested using surgical patient death data from Australia and New Zealand. The final tool was able to identify and group non-technical errors reliably. This tool makes it possible to identify non-technical errors so future errors may be reduced.

Understanding unplanned return to theatre in rural South Australia general surgery: review of four major hospitals over a six-year period.

BACKGROUND: Unplanned return to theatre (URTT) is associated with longer hospital stay and higher mortality rates, placing extra burden on hospital resources. There is a lack of literature analysing causes of URTT in a rural general surgery department. This knowledge may be important to help identify patients at risk of URTT. This study aims to identify causes of URTT in rural general surgical patients. METHODS: This is a retrospective multicenter cohort involving four rural South Australian (SA) hospitals: Mount Gambier (MGH), Whyalla (WH), Port Augusta (PAH), and Port Lincoln (PLH). All general surgical inpatients admitted from February 2014 to March 2020 were analysed to identify all-cause of URTT. RESULTS: Of the 44 191 surgical procedures performed, there were 67 (0.15%) URTT. The most common surgical subspecialty cases that resulted in URTT were Colorectal (47.1%), General surgery (33.2%) Plastics (9.8%), and Hepatopancreatico-biliary (3.9%). The three commonest operations during URTT were washouts 22 (32.8%), interventions for haemostasis 11 (16.4%) and bowel resections 9 (13.4%). Sixteen (24%) of URTT followed emergency surgery. When comparing between elective and emergency admissions needing URTT, there were no statistical difference in age, gender, speciality type, types of surgery performed, and median number of days until URTT. CONCLUSION: Rates of URTT are low in South Australian rural hospitals when compared to our overseas counterpart. A wide range of surgery is being performed in rural centres, further supporting the need for rural surgical trainees to have a tailored curriculum encompassing subspecialities and being competent in managing any potential complications.

Gallbladder Paraganglioma: A Mysterious Histological Finding.

Gallbladder paragangliomas are extremely rare with only a handful of cases reported so far. There are no definitive guidelines for the management of gallbladder paragangliomas due to their rarity. We present a case of a 53-year-old male who was found to have gallbladder paraganglioma post-laparoscopic cholecystectomy, performed for right upper abdominal pain. On review of the literature, all previously reported cases had been nonsecretory and benign. For patients who have no symptoms of secretory paragangliomas and no family history of endocrine syndromes, cholecystectomy and clinical follow-up may be a sufficient initial management following an incidental finding of gallbladder paraganglioma.

Patient focused interventions and communication in the surgical clinic: a systematic review and meta-analysis.

Background: Communication is the foundation of a strong doctor-patient relationship. Holistic care of the patient involves good communication and empathy. There are various tools and interventions aimed at increasing the Surgeon's performance, but these have the drawback of heavy cost and time commitments. In contrast, patient focused interventions are often simple and cheap. In surgery this is an evolving field, and little is known about the impact these interventions have on clinical encounters. The aim of this review is to determine how patient focussed interventions impact communication in the Surgical Outpatient Consultation. Methods: In this systematic review and meta-analysis, two reviewers independently searched MEDLINE (incl. PubMed), EMBASE, EMCARE, CINAHL, and the Cochrane Library for the period starting 01 February 1990 to 01 February 2022. Filtration and screening was performed in accordance with PRISMA guidelines. Conflicts were resolved by discussion. Risk of Bias was assessed using the RoB 2 tool. Meta-analyses were conducted by an independent statistician using Stata Statistical Software. This systematic review was prospectively registered with PROSPERO (ID CRD42022311112). Findings: After screening, 38 papers were included in the final analysis. These involved 6392 patients consisting of 32 randomised controlled trials (RCT), one crossover RCT, three non-randomised experimental studies, and three cohort studies. All articles were published between 1999 and 2022. Four types of intervention were identified: Patient Decision Aids, Educational Materials, Question Prompt Lists and Patient Reported Outcome Measures. There was much heterogeneity in the reported results but ultimately four recurring domains for assessing quality of communication were identified: Patient knowledge; decisional conflict; satisfaction; and anxiety. Meta-analyses showed that patient focussed interventions increased patient knowledge and reduced decisional conflict. Meta-regression demonstrated significant knowledge increases in females compared with males. Results regarding satisfaction and anxiety were not statistically significant. Interpretation: Our study suggested that patient focused interventions demonstrate promising results for increasing patient engagement and improving communication. Further multicentre randomised controlled trials with consistent validated endpoints should be conducted to evaluate this evolving field. Funding: There was no funding source for this study.

Extended scope of practice needed for Australian rural general surgeons: a review of South Australia's rural general surgical caseload and case mix.

BACKGROUND: There is a shortage of surgeons caring for the 33% of Australians residing in rural and regional areas. In order to help appreciate what rural general surgery entails and optimize training for aspiring rural surgeons, the aim of this study was to analyse the general surgical departments' procedural caseload and casemix in four rural South Australian hospitals. METHODS: This is a retrospective multi-centre study involving four rural surgical centres in South Australia (Mt Gambier, Whyalla, Port Augusta, and Port Lincoln). Surgical procedures performed from 2014-2020 were extracted from departmental audits. To identify trends of surgical procedure over time, the data was divided into three time periods (Period 1: February 2014-December 2015, Period 2: January 2016-December 2017, Period 3: January 2018-March 2020). RESULTS: A total of 44 191 surgical procedures were performed, 70.2% being day procedures. 54% were endoscopic procedures, 46% were operative procedures. 60.6% of the operative procedures were general surgery procedures. 28.5% were general surgery-based subspecialty (colorectal, hepato-pancreato-biliary, upper gastrointestinal, and breast). 10.9% were non-general surgery-based subspecialty (urology, plastics, vascular, orthopaedics, head and neck, and obstetrics and gynaecology). There were no statistically significant fluctuations in procedure caseload in all aspects (endoscopic and operative procedures) over the three time periods. CONCLUSION: The majority of a rural Australian general surgeon's procedures are endoscopic. Operative procedures are mainly general surgery based. It may be beneficial to equip aspiring rural general surgeons to manage basic non-general surgery procedures (urological, vascular, and orthopaedic).

Improving surgical excellence: first experience of a video-based intervention in outpatients.

BACKGROUND: There are limited opportunities for surgeons to engage in active learning programs once they achieve Fellowship, especially for non-technical skills such as communication. This study aims to address this gap by evaluating a peer-based coaching program in non-technical skill using video-recorded patient consultations from a routine outpatient clinic. METHODS: Standard outpatient consultations between consultant surgeons and patients were video recorded. The surgeon viewed the videos with a peer-coach (senior surgeon) who helped identify areas of strength and areas for improvement. To test the effect of the coaching session, outpatient consultations were recorded roughly 1 month later. Pre and post-coaching videos were assessed using the Maastricht History-Taking and Advice Scoring - Global Rating List (MAAS), a common tool for evaluating non-technical skills in clinicians. RESULTS: A total of 12 surgeons consented to participate. Coaching significantly improved MAAS scores (mean difference = -0.61; 95% CI (-0.88, -0.33); P < 0.0001). Surgeons were generally positive about the experience. All found the method of learning suitable, and most thought the process improved their skills. Most thought that coaching would improve patient outcomes and the majority thought they would participate in ongoing coaching as part of their employment. CONCLUSION: This supports the concept of surgical coaching as an effective tool to improve communication skills and the quality of surgical consultation. The next step is to expand beyond a voluntary cohort and link surgical coaching to improved patient outcomes.

Hybrid laparoscopic and open repair of post-nephrectomy flank hernia.

Surgical repair of flank hernia is not routinely performed, due to perceived technical difficulties with the surgery and risk of recurrence, or the misconception that flank hernia is solely due to a denervation injury. Due to the rareness of flank hernia in the literature, there is no general consensus on the best method of surgical repair. We present the case of a patient with a symptomatic large flank hernia following open nephrectomy, in which a hybrid technique of open and laparoscopic flank hernia repair with sublay mesh and bone anchor fixation was successfully performed with good outcome. This case highlights the benefits of the hybrid approach, which allowed a laparoscopic assessment of the defect and adhesiolysis, followed by the open repair which enabled adequate mesh overlap, fixation to surrounding tissues and bone anchor fixation.

Rural surgery: the Australian experience.

A significant proportion of the Australian population resides nonmetropolitan regions. For the majority of these smaller regional centers, the surgical service delivery has been traditionally provided by either solo or two-person surgical practices. As medical students' interest in rural practice declined, new models were created to ensure medical care in these areas. This article outlines the past and current state of medical care in rural areas, highlighting models used in Port Augusta, Mount Gambier, and Port Lincoln. It concludes that these models are successful and should be further developed.

Who will do general surgery?

Advantages to patients of a single anaesthetic for more than one operation are obvious; attracting generalist surgeons, training them and ensuring they have adequate credentials remain hurdles.

Is laparoscopic intraoperative cholangiogram a matter of routine?

BACKGROUND: Intraoperative cholangiography during laparoscopic cholecystectomy reveals the anatomy of the biliary tree and any stones contained within it. The use of intraoperative cholangiography may be routine for all laparoscopic cholecystectomy. An alternative approach is a selective policy, performing intraoperative cholangiography only for those cases in which choledocholithiasis is suspected on clinical grounds, or those for which the anatomy appears unclear at operation. The literature pertaining to both approaches is reviewed, to delineate their respective merits. METHODS: Relevant articles in English were identified from the Medline database, and reviewed. RESULTS: The literature reviewed consisted of retrospective analyses. Overall the incidence of unsuspected retained stones was 4%, but only 15% of these would go on to cause clinical problems. The incidence of complete transection of the common bile duct was rare for both routine and selective intraoperative cholangiography policies, and did not differ between them. Rates of minor bile duct injury did not differ between groups, but was more likely to be recognized in the routine group than the selective (P = 0.01). CONCLUSIONS: Routine intraoperative cholangiography yields very little useful clinical information over and above that which is obtained with selective policies. Large numbers of unnecessary intraoperative cholangiography are performed under routine intraoperative cholangiography policy, and therefore a selective policy is advocated.

Student attitudes to surgical teaching in provincial hospitals.

OBJECTIVE: The ever-increasing pressure on metropolitan teaching hospitals to rationalise budgets and increase productivity has resulted in a dwindling amount of teaching opportunity for the medical student population. One solution to the problem was to utilise a largely untapped resource in South Australia, namely the provincial hospitals, however, student opinion regarding such a radical change had yet to be determined. DESIGN: A questionnaire was circulated among an entire year group of medical students who would be undertaking the revised surgical curriculum with rural attachments. SETTING: In October 1997, a decision was made by the Department of Surgery at the University of Adelaide to proceed with optional rural surgical attachments in 1998. SUBJECTS: The survey was distributed to the 125 members of the 1997 fifth year medical student group. RESULTS: A total of 92 questionnaires were returned giving a response rate of 75%. Thirty-nine students ranked a rural term in their top half of preferences, while a further 18 indicated that they would go to a rural centre if they had to. CONCLUSION: Despite having little warning of the impending changes to their surgical curriculum, the majority of students who responded to the questionnaire stated that they would be willing to venture to the country locations. Before planning significant changes to an established curriculum, the student group should be consulted to gauge their opinion.

Surgical rotations in provincial South Australia: the trainees' perspective.

BACKGROUND: Rural general surgery is faced with a shortage of resident surgeons in many parts of Australia. Although it is accepted that an undergraduate rural exposure favourably influences graduates to undertake rural practice, it is not known whether postgraduate terms exert a similar effect. METHOD: Advanced general surgical trainees in 2000 were rotated for 1-month terms to Whyalla, a major provincial centre in South Australia. The trainees were asked to complete a questionnaire before and after the rotation. RESULTS: A total of nine trainees completed a rural term in Whyalla. Eight questionnaires were returned prior to the rotation and seven following the time in Whyalla. The overall experience, and the teaching standards and pathology experienced were rated highly but the term had little effect in changing trainee's attitudes towards eventual practice location. CONCLUSION: Postgraduate surgical terms in South Australia are a relatively new phenomenon compared to other states in Australia. Without a foundation in rural surgery at an undergraduate level, surgical terms for trainees, despite being of high quality, might not be very successful in influencing graduates to practise surgery in rural locations.

Management of liver trauma with implications for the rural surgeon.

BACKGROUND: The majority of patients with liver trauma can be managed conservatively. However, the unstable patient requires emergency laparotomy to control bleeding. Controversy exists regarding the primary surgical management of these injuries. This is of particular relevance for the isolated rural general surgeon. METHODS: The literature was reviewed by searching MEDLINE databases from 1966 to the present time. The majority of the evidence presented is level 3, with interpretations and recommendations based on the experience of the senior authors. RESULTS: In the majority of patients, conservative management remains the mainstay of treatment. However, haemodynamic -instability requires urgent laparotomy. Perihepatic packing should be used to arrest bleeding. Primary anatomical resection is rarely indicated, especially in non-specialist centres. CONCLUSION: In the remote rural setting, severe liver trauma remains a daunting condition for the general surgeon to manage. Primary surgical treatment should be perihepatic packing, stabilization and urgent transfer; there is no place for primary anatomical resection outside specialist units.

Surgical undergraduate education in rural Australia.

HYPOTHESIS: Surgical undergraduate education in a rural setting is feasible and sound in terms of educational outcomes. DESIGN: The final-year surgical curriculum at the University of Adelaide, Adelaide, South Australia, was restructured to include the option of a rural surgical term. SETTING: Five provincial center hospitals in rural South Australia. INTERVENTIONS: Forty-three final-year medical students undertook rural surgical clerkships in 1998. MAIN OUTCOME MEASURES: End-of-year results and subjective ward assessments were compared between the group of students who completed rural surgical terms and the remainder of the student group who participated in tertiary hospital-based electives. Subjective student feedback was obtained in a survey conducted by the Clinical Education Development Unit at the University of Adelaide. RESULTS: No significant (P =.45) differences in examination results were noted between the rural and city groups. A significant (P<.01) finding was observed in the subjective assessments, indicating that it was more difficult for the rural group to obtain an A grade compared with the city group. The rural students ranked the level of teaching and supervision highly and enjoyed the overall rural experience. CONCLUSION: Surgical undergraduate education is practical in a rural setting and, for educational outcome, seems to be at least as effective as city-based surgical clerkships in preparing students for final examinations.