Primum Non Nocere: is shared decision-making the answer?

Surgical ambition is rising, with the Royal College of Surgeons reporting an increase in the number of procedures by a million over the past decade (Royal College of Surgeons. Surgery and the NHS in Numbers. Available from https://www.rcseng.ac.uk). Underpinning, this is a rapidly growing population, especially those in the over 85 age group, coupled with rising perioperative expertise; options for surgery are now present where conditions were once managed conservatively. Matching the right patient to the right procedure has never been so pertinent (Bader, Am Soc Anesthesiol 78(6), 2014). At the heart of these increasingly complex decisions, which may prove fatal or result in serious morbidity, lies the aspiration of shared decision-making (SDM) (Glance et al., N Engl J Med 370:1379–81, 2014). Shared decision-making is a patient-centred approach taking into account the beliefs, preferences and views of the patient as an expert in what is right for them, supported by clinicians who are the experts in diagnostics and valid therapeutic options (Coulter and Collins, Making shared decision-making a reality: no decision about me, without me, 2011). It has been described as the pinnacle of patient-centred care (Barry et al., N Engl J Med 366:780–1, 2012). In this commentary, we explore further the concept of shared decision-making, supported by a recent article which highlights critical deficits in current perioperative practice (Ankuda et al., Patient Educ Couns 94(3):328–33, 2014). This article was chosen for the purposes of this commentary as it is a large study across several surgical specialties investigating preoperative shared decision-making, and to our knowledge, the only of this kind

What does 'learning' and 'organisational learning' mean in the context of patient safety? Protocol for a systematic hermeneutic conceptual review

Introduction: Learning is essential for improving patient safety and is often cited as necessary following a patient safety incident (PSI). Both individual and organisational learning are needed to enable improvements in health systems. However, there is no clear consensus on what ‘learning’ or ‘organisational learning’ actually means in the context of a PSI. Learning theories can be applied to healthcare in order to improve patient safety interventions. In this systematic hermeneutic conceptual review, we aim to define learning and organisational learning in the context of patient safety and to identify the theoretical approaches to learning and interventions utilised. / Methods and analysis: This review will be undertaken in two phases, utilising a systematic hermeneutic approach. Phase one will focus on ascertaining taxonomy domains through identification of the concept and theoretical frameworks of ‘learning’ and ‘organisational learning’ from the literature. These taxonomy domains and the World Health Organisation’s World Alliance for Patient Safety International Classification for Patient Safety will inform a thematic framework for phase two. Phase two will be a more detailed search and focus on learning and related applied interventions in the context of patient safety incidents utilising the thematic framework from phase one. Data will be analysed using framework method analysis. / Ethics and dissemination: This review does not require ethical approval. The results will be published in a peer-reviewed journal

Opportunities for system level improvement in antibiotic use across the surgical pathway

Optimizing antibiotic prescribing across the surgical pathway (before, during, and after surgery) is a key aspect of tackling important drivers of antimicrobial resistance and simultaneously decreasing the burden of infection at the global level. In the UK alone, 10 million patients undergo surgery every year, which is equivalent to 60% of the annual hospital admissions having a surgical intervention. The overwhelming majority of surgical procedures require effectively limited delivery of antibiotic prophylaxis to prevent infections. Evidence from around the world indicates that antibiotics for surgical prophylaxis are administered ineffectively, or are extended for an inappropriate duration of time postoperatively. Ineffective antibiotic prophylaxis can contribute to the development of surgical site infections (SSIs), which represent a significant global burden of disease. The World Health Organization estimates SSI rates of up to 50% in postoperative surgical patients (depending on the type of surgery), with a particular problem in low- and middle-income countries, where SSIs are the most frequently reported healthcare-associated infections. Across European hospitals, SSIs alone comprise 19.6% of all healthcare-acquired infections. Much of the scientific research in infection management in surgery is related to infection prevention and control in the operating room, surgical prophylaxis, and the management of SSIs, with many studies focusing on infection within the 30-day postoperative period. However it is important to note that SSIs represent only one of the many types of infection that can occur postoperatively. This article provides an overview of the surgical pathway and considers infection management and antibiotic prescribing at each step of the pathway. The aim was to identify the implications for research and opportunities for system improvement

The Perioperative Quality Improvement Programme

How is the programme improving surgical care and how can you get involved

Socioeconomic deprivation and surgical outcomes: ISOS and VISION-UK sub-study (Statistical Analysis Plan)

In this paper, we aim to determine if socioeconomic deprivation in England is associated with outcomes after surgery: mortality, in-hospital complications at 30 days, and hospital length of stay. We will also identify clinical factors associated with social deprivation and assess whether adjustment for these factors modify the effect of socioeconomic deprivation on outcomes for a range of surgical categories

Cancelled operations: a 7-day cohort study of planned adult inpatient surgery in 245 UK National Health Service hospitals.

BACKGROUND: Cancellation of planned surgery impacts substantially on patients and health systems. This study describes the incidence and reasons for cancellation of inpatient surgery in the UK NHS. METHODS: We conducted a prospective observational cohort study over 7 consecutive days in March 2017 in 245 NHS hospitals. Occurrences and reasons for previous surgical cancellations were recorded. Using multilevel logistic regression, we identified patient- and hospital-level factors associated with cancellation due to inadequate bed capacity. RESULTS: We analysed data from 14 936 patients undergoing planned surgery. A total of 1499 patients (10.0%) reported previous cancellation for the same procedure; contemporaneous hospital census data indicated that 13.9% patients attending inpatient operations were cancelled on the day of surgery. Non-clinical reasons, predominantly inadequate bed capacity, accounted for a large proportion of previous cancellations. Independent risk factors for cancellation due to inadequate bed capacity included requirement for postoperative critical care [odds ratio (OR)=2.92; 95% confidence interval (CI), 2.12-4.02; P CONCLUSIONS: A significant proportion of patients presenting for surgery have experienced a previous cancellation for the same procedure. Cancer surgery is relatively protected, but bed capacity, including postoperative critical care requirements, are significant risk factors for previous cancellations

A novel inpatient complex pain team: protocol for a mixed-methods evaluation of a single-centre pilot study

Introduction Complex pain is a debilitating condition that is responsible for low quality of life and significant economic impacts. Although best practice in the treatment of complex pain employs a multidisciplinary team, many patients do not have access to this care, leading to poor outcomes

Perioperative Care Pathways in Low- and Lower-Middle-Income Countries: Systematic Review and Narrative Synthesis

BACKGROUND: Safe and effective care for surgical patients requires high-quality perioperative care. In high-income countries (HICs), care pathways have been shown to be effective in standardizing clinical practice to optimize patient outcomes. Little is known about their use in low- and middle-income countries (LMICs) where perioperative mortality is substantially higher. METHODS: Systematic review and narrative synthesis to identify and describe studies in peer-reviewed journals on the implementation or evaluation of perioperative care pathways in LMICs. Searches were conducted in MEDLINE, EMBASE, CINAHL Plus, WHO Global Index, Web of Science, Scopus, Global Health and SciELO alongside citation searching. Descriptive statistics, taxonomy classifications and framework analyses were used to summarize the setting, outcome measures, implementation strategies, and facilitators and barriers to implementation. RESULTS: Twenty-seven studies were included. The majority of pathways were set in tertiary hospitals in lower-middle-income countries and were focused on elective surgery. Only six studies were assessed as high quality. Most pathways were adapted from international guidance and had been implemented in a single hospital. The most commonly reported barriers to implementation were cost of interventions and lack of available resources. CONCLUSIONS: Studies from a geographically diverse set of low and lower-middle-income countries demonstrate increasing use of perioperative pathways adapted to resource-poor settings, though there is sparsity of literature from low-income countries, first-level hospitals and emergency surgery. As in HICs, addressing patient and clinician beliefs is a major challenge in improving care. Context-relevant and patient-centered research, including qualitative and implementation studies, would make a valuable contribution to existing knowledge. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s00268-022-06621-x