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Introduction The ongoing coronavirus disease 2019 (COVID-19) pandemic has impacted all aspects of clinical practice. A district general hospital's surgical department identified that ward rounds based on a paper-based handover system did not adhere to good COVID-19 pandemic infection control measures, including social distancing, reduction of footfall, and reducing contact events during documentation. Surgical E-Handover was introduced as a quality improvement project focussing on increasing efficiency and improving patient safety and compliance with COVID-19 social distancing measures. Other objectives were to reduce the risk of information governance breaches. During the COVID pandemic, there was a significant investment in digital technology, which supported rapid advancement in the use of electronic healthcare solutions to deliver new ways of working. We used the opportunity of the emergency situation to disrupt existing work patterns and introduce surgical E-Handover. Methods A quality improvement team of stakeholders was assembled, and a project to introduce E-Handover was carried out using the trust quality improvement methodology aligned to the Institute of Healthcare Improvement (IHI). Questionnaires were sent out pre- and post-implementation to evaluate the impact of using E-Handover during ward rounds. Results The efficiency of ward rounds was improved and improving compliance with COVID 19 social distancing measures was highly successful. These outcomes were achieved by reducing footfall during ward rounds, as key clinical information was available at the bedside (p<0.001). Doctors spent less time in crowded clinical multi-disciplinary team (MDT) rooms, and the integrated paper healthcare records were not accessed by multiple staff members simultaneously. The implementation of the E-Handover improved the safety and efficiency of the surgical department, particularly with reference to potential information governance breaches (p<0.001). Conclusion Surgical E-Handover, as compared to a printed patient list, significantly improved clinical efficiency and adherence to COVID-19 social distancing measures. E-Handover should be routinely used in surgical ward rounds.
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BACKGROUND: Whole-body MRI (WB-MRI) could be an alternative to multimodality staging of colorectal cancer, but its diagnostic accuracy, effect on staging times, number of tests needed, cost, and effect on treatment decisions are unknown. We aimed to prospectively compare the diagnostic accuracy and efficiency of WB-MRI-based staging pathways with standard pathways in colorectal cancer. METHODS: The Streamline C trial was a prospective, multicentre trial done in 16 hospitals in England. Eligible patients were 18 years or older, with newly diagnosed colorectal cancer. Exclusion criteria were severe systemic disease, pregnancy, contraindications to MRI, or polyp cancer. Patients underwent WB-MRI, the result of which was withheld until standard staging investigations were complete and the first treatment decision made. The multidisciplinary team recorded its treatment decision based on standard investigations, then on the WB-MRI staging pathway (WB-MRI plus additional tests generated), and finally on all tests. The primary outcome was difference in per-patient sensitivity for metastases between standard and WB-MRI staging pathways against a consensus reference standard at 12 months, in the per-protocol population. Secondary outcomes were difference in per-patient specificity for metastatic disease detection between standard and WB-MRI staging pathways, differences in treatment decisions, staging efficiency (time taken, test number, and costs), and per-organ sensitivity and specificity for metastases and per-patient agreement for local T and N stage. This trial is registered with the International Standard Randomised Controlled Trial registry, number ISRCTN43958015, and is complete. FINDINGS: Between March 26, 2013, and Aug 19, 2016, 1020 patients were screened for eligibility. 370 patients were recruited, 299 of whom completed the trial; 68 (23%) had metastasis at baseline. Pathway sensitivity was 67% (95% CI 56 to 78) for WB-MRI and 63% (51 to 74) for standard pathways, a difference in sensitivity of 4% (-5 to 13, p=0·51). No adverse events related to imaging were reported. Specificity did not differ between WB-MRI (95% [95% CI 92-97]) and standard pathways (93% [90-96], p=0·48). Agreement with the multidisciplinary team's final treatment decision was 96% for WB-MRI and 95% for the standard pathway. Time to complete staging was shorter for WB-MRI (median, 8 days [IQR 6-9]) than for the standard pathway (13 days [11-15]); a 5-day (3-7) difference. WB-MRI required fewer tests (median, one [95% CI 1 to 1]) than did standard pathways (two [2 to 2]), a difference of one (1 to 1). Mean per-patient staging costs were £216 (95% CI 211-221) for WB-MRI and £285 (260-310) for standard pathways. INTERPRETATION: WB-MRI staging pathways have similar accuracy to standard pathways and reduce the number of tests needed, staging time, and cost. FUNDING: UK National Institute for Health Research.