Experience from a Singapore tertiary hospital with restructuring of a vascular surgery practice in response to national and institutional policies during the COVID-19 pandemic.

Singapore was one of the first countries to be affected by COVID-19, with the index patient diagnosed on January 23, 2020. For 2 weeks in February, we had the highest number of COVID-19 cases behind China. In this article, we summarize the key national and institutional policies that were implemented in response to COVID-19. We also describe in detail, with relevant data, how our vascular surgery practice has changed because of these policies and COVID-19. We show that with a segregated team model, the vascular surgery unit can still function while reducing risk of cross-contamination. We explain the various strategies adopted to reduce outpatient and inpatient volume. We provide a detailed breakdown of the type of vascular surgical cases that were performed during the COVID-19 pandemic and compare it with preceding months. We discuss our operating room and personal protective equipment protocols in managing a COVID-19 patient and share how we continue surgical training amid the pandemic. We also discuss the challenges we might face in the future as COVID-19 regresses.

The multi-disciplinary team - Who is liable when things go wrong?

The question of culpability over decisions made by the multi-disciplinary team (MDT) is a contentious one. Currently, all members present remain responsible for the MDT's decision, but it is unclear whether the onus of decision making lies with the patient's "lead clinician", and how straight to test pathways (bypassing a consultation with a specialist prior to MDT discussion) impact on this. Additionally, should a non-consensus recommendation be reached, it remains undetermined how dissenting members of the MDT would be viewed in a court of law. Given these uncertainties, there remains a substantial risk of legal action against the MDT as a group. Until case law materialises to provide clarification on these issues, clinicians should improve their awareness over their medico-legal responsibilities and proceed with caution.

The Helsinki approach to face transplantation.

AIM: We herein describe the establishment of the Helsinki Vascularized Composite Allotransplantation (VCA) program and its execution in the first two face transplant cases. METHODS & PATIENTS: The Helsinki VCA program initially required the fulfillment of legal, hospital, financial, and ethical requirements. Thereafter, the assembling of a multidisciplinary team commenced. A team of Plastic, maxillofacial and ENT surgeons comprise the facial VCA team. The protocol involves collaboration with the Solid Organ Transplant (SOT) team, transplant immunology, immunosuppression, microbiology, psychiatric evaluation, well-defined VCA indications and informed consent. Between 2011 and 2017 two patients were selected for transplantation. Both patients had a severe composite facial deformity involving the maxilla and mandible following earlier ballistic injury. RESULTS: Patient 1 was a 35 year-old male who underwent successful near total face transplantation in February 2016 and at 30 months he has a good aesthetic outcome with symmetrical restoration of the central face and good sensory and symmetrical motor functional outcomes. Patient 2 was a 58 year-old male who underwent full face transplantation in March 2018 and at 5 months he has recovered without major problems. CONCLUSION: A successful facial VCA program requires a well-prepared research protocol, experts from multiple specialties and careful patient selection. The establishment of the Helsinki VCA program required long and thorough planning and resulted in the first two Nordic face transplantation cases. This protocol now forms the platform (as a proof of concept) for other types of vascularized composite allotransplantations.

Is the team leading surgeon criminally liable for his collaborators' errors? Judges confirm responsibility and condemn an otorhinolaryngologist.

SUMMARY: In current healthcare, delivery of medical and surgical treatment takes place in a multidisciplinary manner. This raises the problem of distinguishing the conditions under which the person who has properly carried out his duties, respecting the related leges artis, can be held responsible for damages materially caused by another member of the medical team. Jurisprudence has developed the so-called "principle of trust" for which every member of the team can rely on the fact that other members are acting in compliance with the leges artis of their specialisation. The Supreme Court has limited the application of this principle. The authors examine the jurisprudence on responsibility of the team in otolaryngology and conclude that individual liability should be limited to the specific expertise of the individual specialist.

[The latest best practice guidelines relating to seclusion and restraint]. / Les dernières recommandations de bonnes pratiques sur l'isolement et la contention.

Several measures relating to seclusion and restraint are included in the French public health code. The best practice guidelines of the French National Health Authority, published in 2017, define these two notions and advise on the behaviour to adopt with regard to their implementation and monitoring. Likewise, informing and supporting the patient when these measures are lifted are critical moments which the teams must also be able to manage correctly.

[Surgeons-anesthetists relations: From an individual responsibility of the surgeon to a shared responsibility with the anesthetist]. / Relations chirurgiens/anesthésistes-réanimateurs : d'une responsabilité individuelle du chirurgien à une responsabilité partagée avec l'anesthésiste-réanimateur.

Throughout the perioperative period, anesthetists and surgeons jointly provide care for patients. The advances in medicine and surgery, the practice of perioperative quality medicine and the recent application of enhanced recovery program after surgery have necessitated strengthening the place of each in its area of expertise while developing the spirit team and communication. Thus, alongside the surgeon who was once considered the head of the surgical team, the anesthetist's role has been to consolidate for the management of the surgical patient and had his spot empower themselves in the eye of the patient with the birth an own contract with the patient (due in particular to the obligation to preanesthetic consultation by the decree of December 5, 1994). This has led to a new division of responsibility between these actors: jurisprudence has abandoned the exclusive responsibility of the surgeon, devoted own responsibility of the anesthetist with a division (if any) of responsibility between the anesthetist and the surgeon.

Multidisciplinary perioperative protocol in patients undergoing acute high-risk abdominal surgery.

BACKGROUND: Acute high-risk abdominal (AHA) surgery carries a very high risk of morbidity and mortality and represents a massive healthcare burden. The aim of the present study was to evaluate the effect of a standardized multidisciplinary perioperative protocol in patients undergoing AHA surgery. METHODS: The AHA study was a prospective single-centre controlled study in consecutive patients undergoing AHA surgery, defined as major abdominal pathology requiring emergency laparotomy or laparoscopy including reoperations after elective gastrointestinal surgery. Consecutive patients were included after initiation of the AHA protocol as standard care. The intervention cohort was compared with a predefined, consecutive historical cohort of patients from the same department. The protocol involved continuous staff education, consultant-led attention and care, early resuscitation and high-dose antibiotics, surgery within 6 h, perioperative stroke volume-guided haemodynamic optimization, intermediate level of care for the first 24 h after surgery, standardized analgesic treatment, early postoperative ambulation and early enteral nutrition. The primary outcome was 30-day mortality. RESULTS: Six hundred patients were included in the study and compared with 600 historical controls. The unadjusted 30-day mortality rate was 21·8 per cent in the control cohort compared with 15·5 per cent in the intervention cohort (P = 0·005). The 180-day mortality rates were 29·5 and 22·2 per cent respectively (P = 0·004). CONCLUSION: The introduction of a multidisciplinary perioperative protocol was associated with a significant reduction in postoperative mortality in patients undergoing AHA surgery. NCT01899885 (http://www.clinicaltrials.gov).

[Constitution of a New Specialised Pediatric Home Care Team - First Year Experience]. / Aufbau eines Palliativteams für Kinder und Jugendliche (SAPV-KJ).

BACKGROUND: Since the amendment of the Social Law V in Germany in 2007 the financial basis for a Specialised Home Palliative Care for Children (SHPC) for children was established. In Hesse 3 different SHPC teams entered into collective negotiations with health insurance companies. In 2014, the team of the University Children's Hospital in Giessen started to treat the first patient with a lead time of two months. METHODS: Thus in this paper the development of a SHPC team is described. After the first year anonymized patients data were retrospectively analyzed. RESULTS: Within 12 months 35 patients, 24 females and 11 males, were treated. All of the 6 patients who died, died at home. Calculated 48 weeks survival was 78%. 45% of the patients suffered from malignancies, 34% of malformations and 34% had metabolic disorders. 51% needed crisis intervention and 51% infusion therapy. Only 26% of parents denied cardiopulmonary resuscitation (CPR). Only 10% of the patients or their families received professional psychological care. CONCLUSION: Formation of a SHPC is feasible within a short time period once a financial basis is established. So, empathic guidance of families to help decision making for emergency situations are considered to be important. Analysis of patient's data after one year could help to improve the quality of care. Our data provides information for developing a palliative care team und could motivate colleagues to start the job.

Hereditary breast and gynecological tumors: Italian legal issues.

The availability of diagnostic and therapeutic procedures that lower the risk for developing hereditary family-related tumors is weighed against Italian ethical and legal provisions. The healthcare environment in which a professional works should require that he possess specific technical, relational and medical competencies based upon legal orientation in addition to scientific evidence. Particular emphasis is attributed to the doctor-patient relationship, with explicit reference to the following: 1) all of the information at hand that is required to achieve a "therapeutic alliance" that combines the best interests of the patient with treatment options; 2) the completeness and intelligibility of health records, as they are likely to explain the background logic and the following of scientific clinical procedure; 3) the observance of guidelines and protocols, and their relevance to the legal responsibility of the individual and health care companies; 4) the need of a multidisciplinary approach in the treatment of these patients and the obligation of the team to have malpractice insurance. Advances on "provisions concerning liability of health personnel", which is currently awaiting approval, allows the professional to protect the patient's health without the fear of being unnecessarily censured, and unjustified from a penal or civil point of view which can deteriorate the relationship of trust and cooperation established.

[Patients' Rights Act - Relevance for surgical disciplines]. / Das Patientenrechtegesetz.

The new Patients' Rights Act does not reflect rights of patients as professional obligations of physicians for the first time. It adopted common longtime jurisdiction, but in some respects it is going beyond. This law clearly extends the documentation requirements of physicians, especially concerning the extent of documentation. In surgical fields the requirements for enlightening physicians were more strongly worded than in previous jurisdiction. In medical facilities it is now mandatory to establish an internal quality management system.