Presentation slides from our first meeting, held on Tuesday 10th September 2013 at the Royal College of Surgeons.
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5. Trainee collaboration
• Difficult to do alone!
• Frustration at small projects
• Natural network.
• Requirement.
• Interest and enthusiasm.
6. Team leading
& working
Team leading
& working
Enhance CVEnhance CV
Write papersWrite papers
Publications
& Presentations
Publications
& Presentations
Transferable
skills
Transferable
skills
Data
Collection
& analysis
Data
Collection
& analysis
Project
Methodology
& design
Project
Methodology
& design
Trainee
Quality of
Research
Patients
Region
Benefits of
Research
Collaborative
More clinical
surgical trials
More clinical
surgical trials
Multicentre
Trials
Multicentre
Trials
Better
recruitment
Better
recruitment
7.
8.
9.
10.
11. Benefits
• Medical school network.
• All centres represented.
• Auditable & useful questions.
• PubMed citable co-authorship.
• Local, on-going networks.
• Participation in audit.
16. Clinical audit
“A quality improvement process that seeks to improve
patient care and outcomes through systematic review of care
against explicit criteria and the implementation of change”.
20. Common audits
• Venous thrombo-embolism prophylaxis.
• Fluid management.
• Medical record keeping.
• Anastomotic leaks.
21. Interventions
• Present at department/ MDT meeting.
• Create an induction for new doctors.
• Change documentation.
• Change procedures.
• Then re-audit!
28. NSAIDs
1
Gotissen, BJS, 2012, 2
Klein, BMJ, 2012
• Regularly used as post-operative analgesics as
part of ERAS, WHO pain ladder.
• Increasing evidence1,2
emerging that NSAIDs
may have a detrimental effect on post-operative
adverse events.
29. Aim
“To audit the safety profile of post-operative NSAIDs
in current British surgical practice.”
30. Primary questions
• Are post-operative NSAIDs associated with an
increase in the rate of post-operative adverse
effects
• What are the other risk factors for poor
outcome following bowel resection?
31. Inclusion criteria
• Consecutive patients undergoing bowel resection.
• Elective or emergency patients.
• Open, laparoscopic or lap assisted procedures.
• Age 18 years or over.
36. Data quality is key!
• Become familiar with the Clavien-Dindo
classification.
• Complete the e-learning module!
http://quizstar.4teachers.org/index.jsp
37. Pilot period
• Should take place post-audit approval.
• All team members should be involved.
• Get familiar with how to access/ record necessary
patient data .
38. Audit periods
• Period 1: 0800 Tuesday 24th September to 0759
Monday 14th October
• Period 2: 0800 Tuesday 1st October to 0759
Monday 14th October
• Period 3: 0800 Tuesday 8th October to 0759
Monday 21st October
39. Data sources
• Patient Notes/ nursing notes.
• Computer-based electronic records.
• Anaesthetic/ recovery notes.
• Operation notes.
• Outpatient records.
46. Definitions
I Any deviation from the normal postoperative course without the need
for pharmacological treatment [other than the “allowed therapeutic
regimens”], surgical, endoscopic or radiological interventions.
II Requiring pharmacological treatment with drugs other than the allowed
therapeutic regimens. Includes transfusions and TPN.
III Requiring surgical, endoscopic or radiological intervention.
IV Life-threatening complications requiring critical care management and
CNS complications.
V Death of a patient
The Clavien-Dindo classification
47. Case 1
Eligible? Classification?
A 52 year old man underwent gastrectomy for
malignancy. Six days post-operatively he had left sided
facial and limb weakness. His CT head scan showed no
acute changes. He was not thrombolysed. Several
hours later the weakness resolved spontaneously. A
diagnosis of TIA was made and aspirin 75mg OD was
started.
48. Case 2
Eligible? Classification?
A 76 year old lady who underwent emergency sigmoid
colectomy for an obstructing tumour failed to mobilise
post-operatively. She developed a chest infection.
Despite intravenous antibitiotics, physio and nebulisers
she deteriorated and developed respiratory failure.
She was taken for ventilation in ITU. Eventually she
was discharged.
49. Case 3
Eligible? Classification?
A 41 year old man underwent anterior resection for a
rectal tumour. On the first post-operative night he
spiked a temperature and was given intravenous
paracetamol. On day 2 he was hypokalaemic and was
administered oral potassium supplementation.
50. Take home messages!
• Internationally validated classification of morbidity
via therapeutic consequence.
• Primary outcome measure for the STARSurgUK
audit this September/October.
• Quality assurance – please complete the online
e-learning module prior to commencing your data
collection.
http://quizstar.4teachers.org/index.jsp
• Patients • Quality of Research • Region • Trainee
You will soon receive our uniform excel form/audit tool. There are 30 datapoints to be filled out per patient and we are insistent on at least 95% completeness of these data fields before you are awarded authorship. During the course of the data collection periods, the excel data entry form should be stored on a secure NHS computer. Remember to anonymise your data sheet by deleting the patient ID column before sending it to us via a.nhs email address.
Both the volume and quality of the data collection is vital for success of any study of this sort. As our primary outcome measure it is important that post-operative adverse event rates are not under-estimated or classified wrongly using the Clavien-Dindo scale. It ’ s vital that all team members involved in collecting follow-up data are familiar with the Clavien-Dindo by completing the e-learning module we have provided. It ’ s fun.
This is a prospective audit and a certain amount of daily presence is required on the ward. You are required to collect data from consecutive patients undergoing gastrointestinal resection. Remember two separate lots of data can be sent from each centre by teams working in both period 1 and 2. The total audit, including follow-up will run for a period of two months. We hope to have the completed audit forms back from you on the 1 st of December.
May have noticed we sent around an invitation to join a mandatory e-learning module about this – important that we explain more about why it is so relevant
What is it? Prof. Pierre-Alain Clavien, Transplant Surgeon, University Hospital of Zurich, Switzerland AIM of 2004 paper: Reach a consensus for a grading system for postoperative complications. Complication = “ any deviation from the normal postoperative course ” NOT SEQUELAE e.g. inability to walk after a leg amputation NOT FAILURE TO CURE e.g. residual tumour after a technically successful surgery
Why is it good? What they came up with was a unique and unparalelled means of measuring MORBIDITY in follow-up of general surgical patients. This is essential as a marker of QUALITY of health delivery and is thus essential for changing practise measures and audit. The validated this with a large patient cohort and across multiple centres internationally. Has been widely validated and utility demonstrated in a 2009 Annals of Surgery paper - since been cited in approximately 300 original research papers. Grades of therapeutic intervention required – prevents down-rating of major negative outcomes
Don ’ t worry too much about the smaller detail here and if you ’ re interested I urge you to read the original paper. White = least complex procedure Black = most complex procedure Three points to draw from this: Clavien-dindo ’ s morbidity score correlated well to length of inpatient stay – a widely used marker of morbidity prior to this paper More complications occurred with the most complicated operations Less serious complications occurred more than more serious complications Thus we have a simple, objective, reproducible set of scalar values from which to draw conclusions about patient outcomes in any particular centre, under any particular surgeon using any particular technique.
Importance: PRIMARY OUTCOME MEASURE FOR STARSurgUK AUDIT – Important we get this right or our data set will lose strength Simplified this a little for our purposes here. I = Allowed therapeutic regimens are: drugs as antiemetics, antipyretics, analgesics, diuretics and electrolytes. This grade also includes physiotherapy and wound infections opened at the bedside but not treated with antibiotics. Examples: Ileus, thrombophlebitis II = Examples: Surgical site infection treated with antibiotics, myocardial infarction treated medically, deep venous thrombosis treated with clexane, pneumonia or urinary tract infection treated with antibiotics III = Examples: Return to theatre for any reason, endoscopic therapy, interventional radiology IV = Examples: Single or multiorgan dysfunction requiring critical care management, e.g. pneumonia with ventilator support, renal failure with filtration
May have seen these before if you have completed the e-learning module Eligible = YES Classification = II
Eligible = YES Classification = IV
Eligible = YES Classification = I
Online e-learning module – much more detail about classifications, finer points and inclusion/exclusion criteria which will be essential for the success of the audit – PLEASE COMPLETE