Surgery (Austin & Northern Health) - Research Publications
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ItemUnderstanding the determinants of antimicrobial prescribing within hospitals: the role of "prescribing etiquette".(Oxford University Press (OUP), 2013-07)BACKGROUND: There is limited knowledge of the key determinants of antimicrobial prescribing behavior (APB) in hospitals. An understanding of these determinants is required for the successful design, adoption, and implementation of quality improvement interventions in antimicrobial stewardship programs. METHODS: Qualitative semistructured interviews were conducted with doctors (n = 10), pharmacists (n = 10), and nurses and midwives (n = 19) in 4 hospitals in London. Interviews were conducted until thematic saturation was reached. Thematic analysis was applied to the data to identify the key determinants of antimicrobial prescribing behaviors. RESULTS: The APB of healthcare professionals is governed by a set of cultural rules. Antimicrobial prescribing is performed in an environment where the behavior of clinical leaders or seniors influences practice of junior doctors. Senior doctors consider themselves exempt from following policy and practice within a culture of perceived autonomous decision making that relies more on personal knowledge and experience than formal policy. Prescribers identify with the clinical groups in which they work and adjust their APB according to the prevailing practice within these groups. A culture of "noninterference" in the antimicrobial prescribing practice of peers prevents intervention into prescribing of colleagues. These sets of cultural rules demonstrate the existence of a "prescribing etiquette," which dominates the APB of healthcare professionals. Prescribing etiquette creates an environment in which professional hierarchy and clinical groups act as key determinants of APB. CONCLUSIONS: To influence the antimicrobial prescribing of individual healthcare professionals, interventions need to address prescribing etiquette and use clinical leadership within existing clinical groups to influence practice.
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ItemThe influence of time pressure on adherence to guidelines in primary care: an experimental study.(BMJ, 2013)OBJECTIVES: Evidence from cognitive sciences has systematically shown that time pressure influences decision-making processes. However, very few studies have examined the role of time pressure on adherence to guidelines in clinical practice. The aim of this study was to examine the influence of time pressure on adherence to guidelines in primary care concerning: history taking, clinical examination and advice giving. DESIGN: A within-subjects experimental design was used. SETTING: Academic. PARTICIPANTS: 34 general practitioners (GPs) were assigned to two experimental conditions (time pressure vs no time pressure) consecutively, and presented with two scenarios involving virus respiratory tract infections. PRIMARY AND SECONDARY OUTCOME MEASURES: Outcome measures included adherence to guidelines on history taking, clinical examination and advice giving. RESULTS: Under time pressure, GPs asked significantly less questions concerning presenting symptoms, than the ones indicated by the guidelines, (p=0.019), conducted a less-thorough clinical examination (p=0.028), while they gave less advice on lifestyle (p=0.05). CONCLUSIONS: As time pressure increases as a result of high workload, there is a need to examine how adherence to guidelines is affected to safeguard patient's safety.
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ItemImpact of the World Health Organization's Surgical Safety Checklist on safety culture in the operating theatre: a controlled intervention study.(Elsevier BV, 2013-05)BACKGROUND: Positive changes in safety culture have been hypothesized to be one of the mechanisms behind the reduction in mortality and morbidity after the introduction of the World Health Organization's Surgical Safety Checklist (SSC). We aimed to study the checklist effects on safety culture perceptions in operating theatre personnel using a prospective controlled intervention design at a single Norwegian university hospital. METHODS: We conducted a study with pre- and post-intervention surveys using the intervention and control groups. The primary outcome was the effects of the Norwegian version of the SSC on safety culture perceptions. Safety culture was measured using the validated Norwegian version of the Hospital Survey on Patient Safety Culture. Descriptive characteristics of operating theatre personnel and checklist compliance data were also recorded. A mixed linear regression model was used to assess changes in safety culture. RESULTS: The response rate was 61% (349/575) at baseline and 51% (292/569) post-intervention. Checklist compliance ranged from 77% to 85%. We found significant positive changes in the checklist intervention group for the culture factors 'frequency of events reported' and 'adequate staffing' with regression coefficients at -0.25 [95% confidence interval (CI), -0.47 to -0.07] and 0.21 (95% CI, 0.07-0.35), respectively. Overall, the intervention group reported significantly more positive culture scores-including at baseline. CONCLUSIONS: Implementation of the SSC had rather limited impact on the safety culture within this hospital.
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ItemTeam performance in resuscitation teams: comparison and critique of two recently developed scoring tools.(Elsevier BV, 2012-12)BACKGROUND AND AIM: Following high profile errors resulting in patient harm and attracting negative publicity, the healthcare sector has begun to focus on training non-technical teamworking skills as one way of reducing the rate of adverse events. Within the area of resuscitation, two tools have been developed recently aiming to assess these skills - TEAM and OSCAR. The aims of the study reported here were: METHODS: The study consisted of two phases - reliability assessment; and content comparison, and correlation. Assessments were made by two resuscitation experts, who watched 24 pre-recorded resuscitation simulations, and independently rated team behaviours using both tools. The tools were critically appraised, and correlation between overall score surrogates was assessed. RESULTS: Both OSCAR and TEAM achieved high levels of inter-rater reliability (in the form of adequate intra-class coefficients) and minor significant differences between Wilcoxon tests. Comparison of the scores from both tools demonstrated a high degree of correlation (and hence concurrent validity). Finally, critique of each tool highlighted differences in length and complexity. CONCLUSION: Both OSCAR and TEAM can be used to assess resuscitation teams in a simulated environment, with the tools correlating well with one another. We envisage a role for both tools - with TEAM giving a quick, global assessment of the team, but OSCAR enabling more detailed breakdown of the assessment, facilitating feedback, and identifying areas of weakness for future training.
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ItemThe cancer multi-disciplinary team from the coordinators' perspective: results from a national survey in the UK.(Springer Science and Business Media LLC, 2012-12-13)BACKGROUND: The MDT-Coordinators' role is relatively new, and as such it is evolving. What is apparent is that the coordinator's work is pivotal to the effectiveness and efficiency of an MDT. This study aimed to assess the views and needs of MDT-coordinators. METHODS: Views of MDT-coordinators were evaluated through an online survey that covered their current practice and role, MDT chairing, opinions on how to improve MDT meetings, and coordinators' educational/training needs. RESULTS: 265 coordinators responded to the survey. More than one third of the respondents felt that the job plan does not reflect their actual duties. It was reported that medical members of the MDT always contribute to case discussions. 66.9% of the respondents reported that the MDTs are chaired by Surgeons. The majority reported having training on data management and IT skills but more than 50% reported that they felt further training is needed in areas of Oncology, Anatomy and physiology, audit and research, peer-review, and leadership skills. CONCLUSIONS: MDT-Coordinators' role is central to the care of cancer patients. The study reveals areas of training requirements that remain unmet. Improving the resources and training available to MDT-coordinators can give them an opportunity to develop the required additional skills and contribute to improved MDT performance and ultimately cancer care. Finally, this study looks forward to the impact of the recent launch of a new e-learning training programme for MDT coordinators and discusses implications for future research.
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ItemGeneral practice training and virtual communities of practice - a review of the literature.(Springer Science and Business Media LLC, 2012-08-21)BACKGROUND: Good General Practice is essential for an effective health system. Good General Practice training is essential to sustain the workforce, however training for General Practice can be hampered by a number of pressures, including professional, structural and social isolation. General Practice trainees may be under more pressure than fully registered General Practitioners, and yet isolation can lead doctors to reduce hours and move away from rural practice. Virtual communities of practice (VCoPs) in business have been shown to be effective in improving knowledge sharing, thus reducing professional and structural isolation. This literature review will critically examine the current evidence relevant to virtual communities of practice in General Practice training, identify evidence-based principles that might guide their construction and suggest further avenues for research. METHODS: Major online databases Scopus, Psychlit and Pubmed were searched for the terms "Community of Practice" (CoP) AND (Online OR Virtual OR Electronic) AND (health OR healthcare OR medicine OR "Allied Health"). Only peer-reviewed journal articles in English were selected. A total of 76 articles were identified, with 23 meeting the inclusion criteria. There were no studies on CoP or VCoP in General Practice training. The review was structured using a framework of six themes for establishing communities of practice, derived from a key study from the business literature. This framework has been used to analyse the literature to determine whether similar themes are present in the health literature and to identify evidence in support of virtual communities of practice for General Practice training. RESULTS: The framework developed by Probst is mirrored in the health literature, albeit with some variations. In particular the roles of facilitator or moderator and leader whilst overlapping, are different. VCoPs are usually collaborations between stakeholders rather than single company VCoPs. Specific goals are important, but in specialised health fields sometimes less important than in business. Boundary spanning can involve the interactions of different professional groups, as well as using external experts seen in business VCoPs. There was less use of measurement in health VCoPs. Environments must be supportive as well as risk free. Additional findings were that ease of use of technology is paramount and it is desirable for VCoPs to blend online and face-to-face involvement. CONCLUSIONS: The business themes of leadership, sponsorship, objectives and goals, boundary spanning, risk-free environment and measurements become, in the health literature, facilitation, champion and support, objectives and goals, a broad church, supportive environment, measurement benchmarking and feedback, and technology and community.General Practice training is under pressure from isolation and virtual communities of practice may be a way of overcoming isolation. The health literature supports, with some variation, the business CoP framework developed by Probst. Further research is needed to clarify whether this framework is an effective method of health VCoP development and if these VCoPs overcome isolation and thus improve rural retention of General Practice registrars.
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ItemThe role of vascular endothelial growth factor in metastatic prostate cancer to the skeleton.(Hindawi Limited, 2013)Despite the clinical implication and high incidence of bone and spinal metastases, the molecular mechanisms behind prostate cancer metastasis to bone and spine are not well understood. In this review the molecular mechanisms that may contribute to the highly metastatic phenotype of prostate cancer are discussed. Proangiogenic factors such as vascular endothelial growth factor (VEGF) have been shown to not only aid in the metastatic capabilities of prostate cancer but also encourage the colonization and growth of prostate tumour cells in the skeleton. The importance of VEGF in the complex process of prostate cancer dissemination to the skeleton is discussed, including its role in the development of the bone premetastatic niche, metastatic tumour cell recognition of bone, and bone remodeling. The expression of VEGF has also been shown to be upregulated in prostate cancer and is associated with clinical stage, Gleason score, tumour stage, progression, metastasis, and survival. Due to the multifaceted effect VEGF has on tumour angiogenesis, tumour cell proliferation, and bone destruction, therapies targeting the VEGF pathways have shown promising clinical application and are being investigated in clinical trials.
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ItemLaparoscopic bisegmentectomy 6 and 7 using a Glissonian approach and a half-Pringle maneuver(SPRINGER, 2013-05)BACKGROUND: Despite accumulated experience and advancing techniques for laparoscopic hepatectomy, surgeons still face challenging resections that require specific and innovative intraoperative maneuvers. The right posterior sectionectomy presents special concerns about its location, the extensive transection area, and the difficult access to the pedicle. The intrahepatic Glissonian approach allows safe en masse control of the portal structures without prolonged dissection. Its association with the half-Pringle maneuver results in less bleeding during parenchymal transection. METHODS: A 34-year-old woman was referred for treatment of an 8-cm hepatocellular adenoma located at segments 6 and 7. She was placed in a semi-supine position, and six ports were located in a distribution that resembled a Makuuchi incision. The right liver was mobilized, and preparation for an anatomic Glissonian approach was performed. A vascular clamp was placed to ensure that full control of the right posterior pedicle was possible. Then a vascular stapler replaced it, with division of the right posterior Glissonian pedicle. A vascular clamp was inserted from the inferior right-flank 5-mm trocar for performance of a half-Pringle maneuver of the right pedicle to minimize blood loss during parenchymal transection. The liver parenchyma was transected with a harmonic scalpel and a vascular stapler. The right hepatic vein was divided intraparenchymally with a vascular stapler. The specimen was extracted through a Pfannenstiel incision. RESULTS: The total surgical time was 210 min, and the estimated blood loss was 200 ml. No blood transfusion was required. The recovery was uneventful, and hospital discharge occurred on postoperative day 5. Pathology confirmed the diagnosis of an hepatocellular adenoma. CONCLUSIONS: Technical issues initially hindered the development of laparoscopic liver resections [7-10]. Surgeons were concerned about hemostasis, bleeding control, safe and effective parenchymal transection, adequate visualization, and the feasibility of working on deeper regions of the liver. During the past decade, many limitations were overcome, but lesions located on the posterosuperior liver are still considered tough to beat. Large series and extensive reviews show that resections located on the posterior segments still are infrequent. Limited access to the portal triad, difficult pedicle control, and a large transection area and its anatomic location, attached to the diaphragm and retroperitoneum and hidden from the surgeon's view, makes such resections defying. The authors' team has performed 97 laparoscopic hepatectomies, including resection of 6 lesions in the right posterior sector. In their series, half-pedicle clamping was used for 12 patients, and they adopt such a maneuver as an inflow control when operating on peripheric lesions with difficult vascular control (e.g., enucleations or posterosuperiorly located segmentectomies). This technique is safe and useful because it reduces liver ischemic aggression, a very important issue with diseased livers (e.g., steatosis, steatohepatitis, prolonged chemotherapy, cirrhosis). In their series, the authors applied the Glissonian intrahepatic approach in 7 cases (2 left hepatectomies and 5 right hepatectomies). They understand that laparoscopy applies perfectly to oddly (posterosuperior) located tumors and that right posterior sectionectomy can be accomplished safely. In fact, they share the opinion of other specialized hepatobiliary centers, believing that this may be the preferred approach.
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ItemNo Preview AvailableThe osteoblastic and osteoclastic interactions in spinal metastases secondary to prostate cancer.(SAGE Publications, 2013)Prostate cancer (PC) is one of the most common cancers arising in men and has a high propensity for bone metastasis, particularly to the spine. At this stage, it often causes severe morbidity due to pathological fracture and/or metastatic epidural spinal cord compression which, if untreated, inevitably leads to intractable pain, neurological deficit, and paralysis. Unfortunately, the underlying molecular mechanisms driving growth of secondary PC in the bony vertebral column remain largely unknown. Further investigation is warranted in order to identify therapeutic targets in the future. This review summarizes the current understanding of PC bone metastasis in the spine, highlighting interactions between key tumor and bone-derived factors which influence tumor progression, especially the functional roles of osteoblasts and osteoclasts in the bone microenvironment through their interactions with metastatic PC cells and the critical pathway RANK/RANKL/OPG in bone destruction.
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ItemNo Preview AvailableClinical review: The role of the intensivist and the rapid response team in nosocomial end-of-life care(BMC, 2013)In-hospital end-of-life care outside the ICU is a new and increasing aspect of practice for intensive care physicians in countries where rapid response teams have been introduced. As more of these patients die from withdrawal or withholding of artificial life support, determining whether a patient is dying or not has become as important to intensivists as the management of organ support therapy itself. Intensivists have now moved to making such decisions in hospital wards outside the boundaries of their usual closely monitored environment. This strategic change may cause concern to some intensivists; however, as custodians of the highest technology area in the hospital, intensivists are by necessity involved in such processes. Now, more than ever before, intensive care clinicians must consider the usefulness of key concepts surrounding nosocomial death and dying and the importance and value of making a formal diagnosis of dying in the wards. In this article, we assess the conceptual background, reference points, challenges and implications of these emerging aspects of intensive care medicine.