Progress Notes

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Perioperative Care

Perioperative care practices worldwide are in the midst of a seeing change with the implementation of multidisciplinary processes that improve surgical outcomes through (1) better patient education, engagement, and participation; (2) enhanced pre-operative, intra-operative, and post-operative care bundles; and (3) interactive audit programs that provide feedback to the surgical team. These improved outcomes include reductions in the frequency and severity of complications and improved throughput, which ultimately reduce operative stress. Practices in theatre as well as ward are becoming more collaborative and evidence-driven.This book is best utilized by perioperative care team members engaged in quality improvement, collaborative practice, and application of innovations in surgical care

Structural and Care Process Improvement of Ward-based Postoperative Care to Optimise Surgical Outcomes

Much of the variation seen in surgical outcomes can be explained by differences in the quality of management of post-operative complications and ward-based care. The surgical ward round (WR) is critical to determining post-operative care and serves as the primary point of interaction between clinician and patient. Despite this, it is an area not subject to training or assessment at present. This thesis demonstrates the high degree of variability which exists in the conduct of WRs. It establishes the link between suboptimal patient assessment and increased risk of preventable post-operative complications. These place patients not only at risk of short-term deterioration, but result in reduced long-term survival as well. In order to quantify WR quality, a novel assessment tool has been developed and validated within a simulated environment. Ward simulation is a nascent branch of simulation which has been only preliminarily explored to date. A simulation environment was developed to take advantage of the known benefits of simulation such as controllability, reproducibility, and recordability, whilst maintaining a high level of fidelity and realism. An evidence-based curriculum for surgical WR training was designed and implemented in a simulation-based course. By focusing on structured generic processes of patient assessment and management, this resulted in significant improvement of trainee performance in routine WRs. To ensure standardised and optimum management of specific conditions, checklists have proven themselves to be of great value in a number of surgical and medical disciplines. Surgical complications are common, yet their management often suboptimal. As part of this thesis, evidence-based protocols for the management of the six most common complications were designed and validated. The implementation of these in a simulation-based randomised, controlled trial has resulted in greatly increased adherence to evidence-based standards of care, as well as improved communication and clinician performance. This thesis explores the variance currently present in surgical ward rounds, and the potentially grave consequences of this for patient outcomes. To date, WRs have been one of the last areas of surgical care still dependent on the Halstedian principle of experiential learning alone. The tools have now been developed with which to assess, improve, and standardise critical structures and care processes in the assessment and management of the post-operative surgical patient. Future implementation of these and integration into surgical curricula will benefit clinician training, patient care, and surgical outcomes alike.Open Acces

Healthy snacks consumption and the Theory of Planned Behaviour. The role of anticipated regret

Two empirical studies explored the role of anticipated regret (AR) within the Theory of Planned Behavior (TPB) framework (Ajzen, 1991), applied to the case of healthy snacks consumption. AR captures affective reactions and it can be defined as an unpleasant emotion experienced when people realize or imagine that the present situation would be better if they had made a different decision. In this research AR refers to the expected negative feelings for not having consumed healthy snacks (i.e., inaction regret). The aims were: a) to test whether AR improves the TPB predictive power; b) to analyze whether it acts as moderator within the TPB model relationships. Two longitudinal studies were conducted. Target behaviors were: consumption of fruit and vegetables as snacks (Study 1); consumption of fruit as snacks (Study 2). At time 1, the questionnaire included measures of intention and its antecedents, according to the TPB. Both the affective and evaluative components of attitude were assessed. At time 2, self-reported consumption behaviors were surveyed. Two convenience samples of Italian adults were recruited. In hierarchical regressions, the TPB variables were added at the first step; AR was added at the second step, and the interactions at the last step. Results showed that AR significantly improved the TPB ability to predict both intentions and behaviours, also after controlling for intention. In both studies AR moderated the effect of affective attitude on intention: affective attitude was significant only for people low in AR

Exploring Interactive Survivorship Plans: Patient Perceived Value, Acceptance and Usability Evaluation of an Online Breast Cancer Survivorship Tool

Introduction: Having recently been discharged from the hospital, several breast cancer survivors find themselves unable to adjust to the transition and take charge of their own health, away from the confines of the hospital. With the rapid advancement in treatment methods and techniques, the rate of breast cancer survivors has grown exponentially. It is crucial to provide adequate means to support cancer survivors in an active manner. This includes regular monitoring for recurrence (or occurrence of new cancers), handling any related and non-related comorbidities, provide recommendations for preventive care as well as dealing with any long term side effects from the treatment. The specific objective of this research is to design and develop a personalized web application to support breast cancer survivors after treatment (chemotherapy and/or radiation), as they deal with post-treatment challenges, such as comorbidities and side-effects of treatment. Methodology: I used an iterative design and development approach to produce a web application for breast cancer survivors that help them monitor their quality of life, provide them with personalized alerts based on their breast cancer related medical history as well as timely alerts, to remind them of follow up visits. Finally, I utilized a combination of qualitative methodology (thematic analysis), as well as user task analysis to assess the acceptability and usability of the prototype among a group of breast cancer survivors. User feedback was gathered on their perceived value of the application, and any user-interface issues that may hinder the overall usability among lay users were identified. Results: Fifteen breast cancer survivors participated in the acceptability and usability testing of the prototype. The prototype was found to be perceived as unique and valuable among the participants, in its ability to utilize personalized breast cancer related medical history. The application’s portability and capability of organizing their entire breast cancer related medical history as well as the at-home tracking of various quality of life indicators were perceived to be valuable features. The application had an overall high usability, however certain sections of the application, such as viewing observations history were not as intuitive to locate. While participants appreciated the visual and graphical elements of the website, the overall experience of the application would benefit from incorporating some sociable elements that exhibit positive re-enforcement within the end user and provide a friendlier and fun experience. Conclusion: The results of the study showcase the need to provide more personalized tools and resources to breast cancer survivors to support them in self-management after completion of treatment. It also demonstrates the ability to integrate breast cancer survivorship plans from diverse providers and paves the way to add further value-added features in consumer health applications, such as personal decision support. The feedback received from end-users will be used in order to further improve the prototype and address any existing user-interface issues. It is hoped that making such tools more accessible could help in engaging survivors to play an active role in managing their health and also encourage shared-decision making with their providers

Medical device design within the ISO 13485 framework

The design and development of medical devices has become an increasing complex and regulated process. Little if any consideration is given to the regulatory requirements when developing medical devices in universities. This has resulted in an imposing barrier preventing academic innovation reaching clinical adoption. The scope of universities is not to become the legal manufacturer of medical devices. However, should the development of novel devices ever aim to benefit patient care and reach a clinical setting, design controls must be implemented throughout the project life cycle to demonstrate feasibility and safety. The aim of this thesis is to develop user-centred technologies which comply with industrial design control practices whilst helping to bolster and promote innovation within academia. Four projects relating to medical devices have been designed in response to well-defined and end-user-originated clinical needs. These devices can serve as the exemplar for the framework developed in this work with each reaching staggered phases of development within a controlled design process. Although unique, the devices have significant overlapping characteristics that lend the devices to parallel development, leveraging in-house know-how and ‘lessons learned’ into the process of innovation. This thesis focuses on the novelty and design of the aforementioned projects in a discrete structured approach and reflects on the development of each project within the context of a design control process which was developed as part of this work. It is the ultimate goal of this work to develop a flexible structured system compliant with the international requirements for product design and development which may be exported internationally. However, the full execution of this ambition was limited due physical, and financial limitations. This manuscript will describe the technical and commercial opportunity of devices and reflects on the success of developing same within a design control process developed as part of this work