Perioperative shared decision making - How do we train clinicians?

Objective: Decision making about high-risk surgery can be complex, particularly when outcomes may be uncertain. Clinicians have a legal and ethical responsibility to support decision making which fits with patients' values and preferences. In the UK, preoperative assessment and optimisation is led by Anaesthetists in clinic several weeks prior to planned surgery. Training in supporting shared decision making (SDM) has been identified as an area of need among UK anaesthetists with leadership roles in perioperative care. Methods: We describe adaptation of a generic SDM workshop to perioperative care, in particular to decisions on high-risk surgery, and its delivery to UK healthcare professionals over a two-year period. Feedback from workshops were thematically analysed. We explored further improvements to the workshop and ideas for development and dissemination. Results: The workshops were well received, with high satisfaction for techniques used, including video demonstrations, role-play and discussions. Thematic analysis identified a desire for multidisciplinary training and training in using patient aids. Conclusion: Qualitative findings suggest workshops were considered useful with perceived improvement in SDM awareness, skills and reflective practice. Innovation: This pilot introduces a new modality of training in the perioperative setting providing physicians, particularly Anaesthetists, with previously unavailable training needed to facilitate complex discussions.

The Perioperative Quality Improvement Programme (PQIP patient study): protocol for a UK multicentre, prospective cohort study to measure quality of care and outcomes after major surgery.

INTRODUCTION: Major surgery accounts for a substantial proportion of health service activity, due not only to the primary procedure, but the longer-term health implications of poor short-term outcome. Data from small studies or from outside the UK indicate that rates of complications and failure to rescue vary between hospitals, as does compliance with best practice processes. Within the UK, there is currently no system for monitoring postoperative complications (other than short-term mortality) in major non-cardiac surgery. Further, there is variation between national audit programmes, in the emphasis placed on quality assurance versus quality improvement, and therefore the principles of measurement and reporting which are used to design such programmes. METHODS AND ANALYSIS: The PQIP patient study is a multi-centre prospective cohort study which recruits patients undergoing major surgery. Patient provide informed consent and contribute baseline and outcome data from their perspective using a suite of patient-reported outcome tools. Research and clinical staff complete data on patient risk factors and outcomes in-hospital, including two measures of complications. Longer-term outcome data are collected through patient feedback and linkage to national administrative datasets (mortality and readmissions). As well as providing a uniquely granular dataset for research, PQIP provides feedback to participating sites on their compliance with evidence-based processes and their patients' outcomes, with the aim of supporting local quality improvement. ETHICS AND DISSEMINATION: Ethical approval has been granted by the Health Research Authority in the UK. Dissemination of interim findings (non-inferential) will form a part of the improvement methodology and will be provided to participating centres at regular intervals, including near-real time feedback of key process measures. Inferential analyses will be published in the peer-reviewed literature, supported by a comprehensive multi-modal communications strategy including to patients, policy makers and academic audiences as well as clinicians.

Human factors/ergonomics to support the design and testing of rapidly manufactured ventilators in the UK during the COVID-19 pandemic.

BACKGROUND: This paper describes a rapid response project from the Chartered Institute of Ergonomics & Human Factors (CIEHF) to support the design, development, usability testing and operation of new ventilators as part of the UK response during the COVID-19 pandemic. METHOD: A five-step approach was taken to (1) assess the COVID-19 situation and decide to formulate a response; (2) mobilise and coordinate Human Factors/Ergonomics (HFE) specialists; (3) ideate, with HFE specialists collaborating to identify, analyse the issues and opportunities, and develop strategies, plans and processes; (4) generate outputs and solutions; and (5) respond to the COVID-19 situation via targeted support and guidance. RESULTS: The response for the rapidly manufactured ventilator systems (RMVS) has been used to influence both strategy and practice to address concerns about changing safety standards and the detailed design procedure with RMVS manufacturers. CONCLUSION: The documents are part of a wider collection of HFE advice which is available on the CIEHF COVID-19 website (https://covid19.ergonomics.org.uk/).

Transitions of care in the perioperative period - a review.

The perioperative period extends from the moment of contemplation of surgery through to recovery at home. Patients on a surgical pathway will experience multiple transition points in their care. As we move to more collaborative working and caring for increasingly medically complex patients, we must establish robust processes to mitigate against the potential for patient harm posed by these multiple transition points. This article reviews best practice and guidance on handover of care throughout the perioperative period. We will look at models of transition of care beyond the hospital environment and how better use of community resources can smooth the transition of care out of hospital for ongoing rehabilitation.

Delivering perioperative care in integrated care systems.

In 2016, NHS England set up 10 integrated care systems (ICSs) which aim to devolve some responsibility for delivery of health and social care services to local healthcare providers in partnership with local government, social care, primary care networks, and voluntary and charitable organisations. These are new ways of working and provide an opportunity to better integrate perioperative care across the entire pathway from the moment of contemplation of surgery through to recovery at home. This review describes the ways in which the aims of many ICS plans can be met with good perioperative care, and how clinicians can use this opportunity to make significant progress in improving outcomes for patients. We describe examples of initiatives in cancer pathways which are already proving successful and have caught the imagination of the local community at all levels, as well as examples of integrated perioperative care across the country which can be applied to other systems. We hope to demonstrate ways in which perioperative care can add value to a local health population given the right support and chance to deliver it.