Management and outcomes of splenic injuries secondary to blunt trauma in patients presenting to major trauma hospitals in Aotearoa New Zealand.

BACKGROUND: Non-operative management of splenic injuries has significantly increased in the last decade with an increased emphasis on splenic preservation. This shift was assisted by increased availability of angioembolization, however, potential geographical variability in access exists in Aotearoa New Zealand (AoNZ). The aim of this study was to assess the management of splenic injury across AoNZ. METHOD: Five-year retrospective study of all patients admitted to AoNZ hospitals with blunt major trauma and a splenic injury. Patients were identified using the National Trauma Registry and cross-referenced with the National Minimum Data Set to determine their management. The primary outcome was the non-operative rate. RESULTS: Seven hundred seventy-three patients were included. Four hundred sixty-nine presented to a tertiary major trauma hospital and 304 to a secondary major trauma hospital. A difference was found in the rate of non-operative management between tertiary and secondary hospitals (P = 0.019). The rate of non-operative management was similar in mild (P = 0.814) and moderate (P = 0.825) injuries, however, significantly higher in severe injuries in tertiary hospitals (P = 0.009). No difference in mortality rate was found. CONCLUSION: This study found a difference in the management of splenic injuries between tertiary and secondary major trauma hospitals; predominantly due to a higher rate of operative management in patients with severe injuries at secondary hospitals. Despite this, no difference in mortality rate was found between tertiary and secondary hospitals.

Opioid prescribing patterns following common general surgery procedures in the Bay of Plenty, New Zealand.

BACKGROUND: Global increases in opioid prescribing and misuse have prompted calls for closer regulation. Opioid prescription following surgery may lead to long term opioid use. A study was conducted evaluating opioid prescriptions on hospital discharge following common general surgery operations in the Bay of Plenty. METHODS: Retrospective observational study over a two-year period in two regional New Zealand hospitals. Six hundred and eleven patients aged 18-64 years were assessed. Patients with complications, readmission, and a prescription of opioids in the preceding 3 months were excluded. RESULTS: A total of 460 patients (165 Laparoscopic Cholecystectomy (LC), 200 Laparoscopic Appendicectomy (LA) and 95 Open Inguinal Hernia Repair (OIHR)) were included in analysis. Opioids were prescribed to 53% of LC, 55% of LA, and 60% of OIHR patients, with a mean of 75.8 Morphine Milligram Equivalents (MMEs), 75.3 MMEs, and 82.8 MMEs respectively. Seven percent of patients (18/254) received a second opioid prescription within 3 months, and of those only 1.6% (4/254) received a further prescription between 3 and 6 months from discharge. Opioid prescribing did not correlate with operation, ethnicity, age, length of stay, or gender, except for males receiving a more MMEs than females following LC (mean 102.0 MMEs versus 65.4 MMEs, P = 0.017). CONCLUSION: This study shows a rate of opioid prescribing lower than the USA, and greater than seen in an Australian setting. Substantial amounts of opioids were prescribed following uncomplicated surgery, with significant variability. Improvements in training in post-operative opioid prescribing are needed. Fortunately, rates of ongoing opioid use were low.

Effect of ethnicity and rurality on treatment delays in patients with colorectal cancer in Northland, New Zealand.

BACKGROUND: Ethnic and rural disparities in medical treatment and outcomes have been demonstrated across a range of conditions, including colorectal cancer. Timely treatment and investigation of symptoms in patients with suspicion of cancer is likely to improve outcomes and patient experience. Achieving equity in timeliness of care is important in achieving the goal of equitable cancer outcomes outlined in the New Zealand cancer action plan. The aim of this study was to compare treatment times in patients with colorectal cancer, between Maori and non-Maori patients as well as urban and rural patients in Northland, New Zealand. METHODS: All adult patients diagnosed with colorectal adenocarcinoma from 2011 to 2016 were identified using hospital coding. Further information on the primary cohort was then obtained using the hospitals electronic results system, CONCERTO. The primary outcomes of interest were differences in delays to treatment between Maori and non-Maori as well as Urban versus rural residence. Secondary outcomes of interest included rate of emergency admission and treatment by curative intent in different groups. RESULTS: A total of 511 patients formed the primary cohort; 12% were Maori and were on average 6 years younger than non-Maori. Maori had a 6% higher emergency admission rate and a 5% higher rate of palliative treatment intent. No significant difference in treatment delay times was seen between different ethnicities or different domiciles. CONCLUSION: Ethnicity and rurality were not shown to affect treatment delays. Further research in this area is needed to help attain equitable outcomes for patients with colorectal cancer in New Zealand.

Checklists for image-guided interventions: a systematic review.

OBJECTIVES: Safety checklists have improved safety in patients undergoing surgery. Checklists have been designed specifically for use in image-guided interventions. This systematic review aimed to identify checklists designed for use in radiological interventions and to evaluate their efficacy for improving patient safety. Secondary aims were to evaluate attitudes toward checklists and barriers to their use. METHODS: OVID, MEDLINE, CENTRAL and CINAHL were searched using terms for "interventional radiology" and "checklist". Studies were included if they described pre-procedural checklist use in vascular/body interventional radiology (IR), paediatric IR or interventional neuro-radiology (INR). Data on checklist design, implementation and outcomes were extracted. RESULTS: Sixteen studies were included. Most studies (n = 14, 87.5%) focused on body IR. Two studies (12.5%) measured perioperative outcome after checklist implementation, but both had important limitations. Checklist use varied between 54 and 100% and completion of items on the checklists varied between 28 and 100%. Several barriers to checklist use were identified, including a lack of leadership and education and cultural challenges unique to radiology. CONCLUSIONS: We found few reports of the use of checklists in image-guided interventions. Approaches to checklist implementation varied, and several barriers to their use were identified. Evaluation has been limited. There seems to be considerable potential to improve the effective use of checklists in radiological procedures. ADVANCES IN KNOWLEDGE: There are few reports of the use of checklists in radiological interventions, those identified reported significant barriers to the effective use of checklists.

Effect of a See and Treat clinic on skin cancer treatment time.

BACKGROUND: Many plastic surgery departments in Australasia have experienced increasing referrals for management of skin lesions. This has driven a demand for new strategies to decrease patient waiting time and administrative costs. The aim of this study was to determine if a purpose-built See and Treat skin cancer clinic could provide a faster skin cancer treatment pathway with comparable clinical outcomes and acceptability to patients. METHODS: This was a prospective observational study of patients treated through the See and Treat clinic with a retrospective control cohort. The prospective 'See and Treat' cohort included a consecutive series of 106 patients, while the retrospective cohort included a consecutive series of 200 patients. Patient demographics, time from referral to surgery and operative measures were analysed. One hundred patients in the prospective cohort completed an anonymous satisfaction survey regarding their treatment. RESULTS: The average time from referral to surgery was reduced from 121 days in the retrospective cohort to 60 days in the See and Treat cohort (P < 0.001). Rates of complete excision of malignant and premalignant lesions were not different between the two groups, being 93% (178/191) and 91% (76/84), respectively (P = 0.609). Ninety-five percent (95/100) of patients were satisfied with their See and Treat experience overall. CONCLUSION: We show that a considerable reduction in the time between referral and surgery can be achieved through a See and Treat clinic without compromise of the success of surgical treatment. Moreover, such a treatment pathway has been shown to be acceptable, and largely preferable, to patients.

A behaviourally anchored rating scale for evaluating the use of the WHO surgical safety checklist: development and initial evaluation of the WHOBARS.

BACKGROUND: Realising the full potential of the WHO Surgical Safety Checklist (SSC) to reduce perioperative harm requires the constructive engagement of all operating room (OR) team members during its administration. To facilitate research on SSC implementation, a valid and reliable instrument is needed for measuring OR team behaviours during its administration. We developed a behaviourally anchored rating scale (BARS) for this purpose. METHODS: We used a modified Delphi process, involving 16 subject matter experts, to compile a BARS with behavioural domains applicable to all three phases of the SSC. We evaluated the instrument in 80 adult OR cases and 30 simulated cases using two medical student raters and seven expert raters, respectively. Intraclass correlation coefficients were calculated to assess inter-rater reliability. Internal consistency and instrument discrimination were explored. Sample size estimates for potential study designs using the instrument were calculated. RESULTS: The Delphi process resulted in a BARS instrument (the WHOBARS) with five behavioural domains. Intraclass correlation coefficients calculated from the OR cases exceeded 0.80 for 80% of the instrument's domains across the SSC phases. The WHOBARS showed high internal consistency across the three phases of the SSC and ability to discriminate among surgical cases in both clinical and simulated settings. Fewer than 20 cases per group would be required to show a difference of 1 point between groups in studies of the SSC, where α=0.05 and ß=0.8. CONCLUSION: We have developed a generic instrument for comprehensively rating the administration of the SSC and informing initiatives to realise its full potential. We have provided data supporting its capacity for discrimination, internal consistency and inter-rater reliability. Further psychometric evaluation is warranted.