STARSurgUK
STUDENT AUDIT AND RESEARCH IN SURGERY
Introduction
• Who we are.
Aneel, Chetan, Dmitri, Ed, James, Mike, Steve.
• How we met.
• Our aim.
Blank canvas
Collaborative Research
Aneel Bhangu
General Surgery Registrar, West Midlands
Trainee collaboration
• Difficult to do alone!
• Frustration at small projects
• Natural network.
• Requirement.
• Interes...
Team leading
& working
Team leading
& working
Enhance CVEnhance CV
Write papersWrite papers
Publications
& Presentations
P...
Benefits
• Medical school network.
• All centres represented.
• Auditable & useful questions.
• PubMed citable co-authorsh...
Factors leading to success
• Enthusiastic network.
• Communications.
• Leaders.
• Supporters.
• Ideas:
- simple, broadly a...
First project
• Simple.
• Broadly applicable to every hospital.
• To establish network.
• Test the network.
• Final outcom...
The future
1. First project > committee > annual report.
2. Align support > RCS, ASGBI, surgical societies
3. Pan-European...
Surgical Audit
Dmitri Nepogodiev
FY2, Norfolk & Norwich University Hospital
Clinical audit
“A quality improvement process that seeks to improve
patient care and outcomes through systematic review of...
Audit versus research
Audit cycle
Gold standard
Common audits
• Venous thrombo-embolism prophylaxis.
• Fluid management.
• Medical record keeping.
• Anastomotic leaks.
Interventions
• Present at department/ MDT meeting.
• Create an induction for new doctors.
• Change documentation.
• Chang...
Surgeon level data
STARSurgUK
• Gold standard.
• No change to patient management.
HRA decision tool
http://www.hra-decisiontools.org.uk/research/
STARSurgUK
STARSurgUK thanks RCSE for their support
http://www.rcseng.ac.uk
http://surgicalcareers.rcseng.ac.uk
STARSurgUK Protocol
Chetan Khatri
Imperial College London Medical School
NSAIDs
1
Gotissen, BJS, 2012, 2
Klein, BMJ, 2012
• Regularly used as post-operative analgesics as
part of ERAS, WHO pain l...
Aim
“To audit the safety profile of post-operative NSAIDs
in current British surgical practice.”
Primary questions
• Are post-operative NSAIDs associated with an
increase in the rate of post-operative adverse
effects
• ...
Inclusion criteria
• Consecutive patients undergoing bowel resection.
• Elective or emergency patients.
• Open, laparoscop...
Exclusion criteria
• Appendicecotomy for acute appendicitis.
• Bowel repair without resection.
• Wedge resection.
• Trauma...
Patient identification
• Daily review of:
• Elective theatre lists.
• Theatre logbooks.
• Handover sheets (emergency/ ward...
STARSurgUK Protocol
Michael Kelly
Liverpool Medical School
Data quality is key!
• Become familiar with the Clavien-Dindo
classification.
• Complete the e-learning module!
http://qui...
Pilot period
• Should take place post-audit approval.
• All team members should be involved.
• Get familiar with how to ac...
Audit periods
• Period 1: 0800 Tuesday 24th September to 0759
Monday 14th October
• Period 2: 0800 Tuesday 1st October to ...
Data sources
• Patient Notes/ nursing notes.
• Computer-based electronic records.
• Anaesthetic/ recovery notes.
• Operati...
The Clavien-Dindo
Classification
James Glasbey
Cardiff University Medical School
Overview
• What it is.
• Why it’s good.
• Why it’s important to STARSurgUK.
• How we can make sure it is used accurately.
“any deviation from the normal postoperative
course”
Why is it good?
• Measure of MORBIDITY.
• Classification via therapeutic consequence.
• Validated.
• Internationally repro...
Data sources
• Patient Notes/ nursing notes.
• Computer-based electronic records.
• Anaesthetic/ recovery notes.
• Operati...
Dindo et al., 2004, Annals of Surgery
Definitions
I Any deviation from the normal postoperative course without the need
for pharmacological treatment [other tha...
Case 1
Eligible? Classification?
A 52 year old man underwent gastrectomy for
malignancy. Six days post-operatively he had ...
Case 2
Eligible? Classification?
A 76 year old lady who underwent emergency sigmoid
colectomy for an obstructing tumour fa...
Case 3
Eligible? Classification?
A 41 year old man underwent anterior resection for a
rectal tumour. On the first post-ope...
Take home messages!
• Internationally validated classification of morbidity
via therapeutic consequence.
• Primary outcome...
James Glasbey
Association of Surgeons in Training
http://www.asit.org
Any questions?
Star surg uk presentation
Star surg uk presentation
Star surg uk presentation
Star surg uk presentation
Star surg uk presentation
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Star surg uk presentation

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Presentation slides from our first meeting, held on Tuesday 10th September 2013 at the Royal College of Surgeons.

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Twitter @STARSurgUK
Facebook.com/STARSurgUK
Email: STARSurgUK@gmail.com

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  • • 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
  • Star surg uk presentation

    1. 1. STARSurgUK STUDENT AUDIT AND RESEARCH IN SURGERY
    2. 2. Introduction • Who we are. Aneel, Chetan, Dmitri, Ed, James, Mike, Steve. • How we met. • Our aim.
    3. 3. Blank canvas
    4. 4. Collaborative Research Aneel Bhangu General Surgery Registrar, West Midlands
    5. 5. Trainee collaboration • Difficult to do alone! • Frustration at small projects • Natural network. • Requirement. • Interest and enthusiasm.
    6. 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. 7. Benefits • Medical school network. • All centres represented. • Auditable & useful questions. • PubMed citable co-authorship. • Local, on-going networks. • Participation in audit.
    8. 8. Factors leading to success • Enthusiastic network. • Communications. • Leaders. • Supporters. • Ideas: - simple, broadly applicable, common.
    9. 9. First project • Simple. • Broadly applicable to every hospital. • To establish network. • Test the network. • Final outcome not reliant on result.
    10. 10. The future 1. First project > committee > annual report. 2. Align support > RCS, ASGBI, surgical societies 3. Pan-European. 4. Strengthen local links > Sepsis. 5. Global study 2014.
    11. 11. Surgical Audit Dmitri Nepogodiev FY2, Norfolk & Norwich University Hospital
    12. 12. 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”.
    13. 13. Audit versus research
    14. 14. Audit cycle
    15. 15. Gold standard
    16. 16. Common audits • Venous thrombo-embolism prophylaxis. • Fluid management. • Medical record keeping. • Anastomotic leaks.
    17. 17. Interventions • Present at department/ MDT meeting. • Create an induction for new doctors. • Change documentation. • Change procedures. • Then re-audit!
    18. 18. Surgeon level data
    19. 19. STARSurgUK • Gold standard. • No change to patient management.
    20. 20. HRA decision tool http://www.hra-decisiontools.org.uk/research/
    21. 21. STARSurgUK
    22. 22. STARSurgUK thanks RCSE for their support http://www.rcseng.ac.uk http://surgicalcareers.rcseng.ac.uk
    23. 23. STARSurgUK Protocol Chetan Khatri Imperial College London Medical School
    24. 24. 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.
    25. 25. Aim “To audit the safety profile of post-operative NSAIDs in current British surgical practice.”
    26. 26. 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?
    27. 27. Inclusion criteria • Consecutive patients undergoing bowel resection. • Elective or emergency patients. • Open, laparoscopic or lap assisted procedures. • Age 18 years or over.
    28. 28. Exclusion criteria • Appendicecotomy for acute appendicitis. • Bowel repair without resection. • Wedge resection. • Trauma laparotomy. • Gynaecological primary indication. • Urological primary indication.
    29. 29. Patient identification • Daily review of: • Elective theatre lists. • Theatre logbooks. • Handover sheets (emergency/ ward lists).
    30. 30. STARSurgUK Protocol Michael Kelly Liverpool Medical School
    31. 31. Data quality is key! • Become familiar with the Clavien-Dindo classification. • Complete the e-learning module! http://quizstar.4teachers.org/index.jsp
    32. 32. Pilot period • Should take place post-audit approval. • All team members should be involved. • Get familiar with how to access/ record necessary patient data .
    33. 33. 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
    34. 34. Data sources • Patient Notes/ nursing notes. • Computer-based electronic records. • Anaesthetic/ recovery notes. • Operation notes. • Outpatient records.
    35. 35. The Clavien-Dindo Classification James Glasbey Cardiff University Medical School
    36. 36. Overview • What it is. • Why it’s good. • Why it’s important to STARSurgUK. • How we can make sure it is used accurately.
    37. 37. “any deviation from the normal postoperative course”
    38. 38. Why is it good? • Measure of MORBIDITY. • Classification via therapeutic consequence. • Validated. • Internationally reproducible.
    39. 39. Data sources • Patient Notes/ nursing notes. • Computer-based electronic records. • Anaesthetic/ recovery notes. • Operation notes. • Outpatient records.
    40. 40. Dindo et al., 2004, Annals of Surgery
    41. 41. 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
    42. 42. 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.
    43. 43. 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.
    44. 44. 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.
    45. 45. 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
    46. 46. James Glasbey Association of Surgeons in Training http://www.asit.org
    47. 47. Any questions?

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