STARSurgUKSTUDENT 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 BhanguGeneral Surgery Registrar, West Midlands

Trainee collaboration• Difficult to do alone!

• Frustration at small projects

• Natural network.

• Requirement.

• Interest and enthusiasm.

Team leading& working

Team leading& working

Enhance CVEnhance CVWrite papersWrite papers

Publications & Presentations

Publications & Presentations

Transferableskills

Transferableskills

Data Collection & analysis

Data Collection & analysis

Project Methodology

& design

Project Methodology

& design

Trainee

Quality ofResearch

Patients

Region

Benefits of Research

Collaborative

More clinical surgical trialsMore clinical surgical trials

MulticentreTrials

MulticentreTrials

Better recruitment

Better recruitment

Benefits• Medical school network.

• All centres represented.

• Auditable & useful questions.

• PubMed citable co-authorship.

• Local, on-going networks.

• Participation in audit.

Factors leading to success

• Enthusiastic network.

• Communications.

• Leaders.

• Supporters.

• Ideas:

- simple, broadly applicable, common.

First project• Simple.

• Broadly applicable to every hospital.

• To establish network.

• Test the network.

• Final outcome not reliant on result.

The future1. First project > committee > annual

report.

2. Align support > RCS, ASGBI, surgical societies

3. Pan-European.

4. Strengthen local links > Sepsis.

5. Global study 2014.

Surgical AuditDmitri Nepogodiev

FY2, Norfolk & Norwich University Hospital

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”.

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.

• Change procedures.

• Then re-audit!

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.ukhttp://

surgicalcareers.rcseng.ac.uk

STARSurgUK Protocol

Chetan KhatriImperial College London Medical School

NSAIDs

1Gotissen, BJS, 2012, 2Klein, 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.

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

• What are the other risk factors for poor outcome following bowel resection?

Inclusion criteria• Consecutive patients undergoing bowel

resection.

• Elective or emergency patients.

• Open, laparoscopic or lap assisted procedures.

• Age 18 years or over.

Exclusion criteria• Appendicecotomy for acute

appendicitis.

• Bowel repair without resection.

• Wedge resection.

• Trauma laparotomy.

• Gynaecological primary indication.

• Urological primary indication.

Patient identification• Daily review of:

• Elective theatre lists.

• Theatre logbooks.

• Handover sheets (emergency/ ward lists).

STARSurgUK Protocol

Michael KellyLiverpool Medical School

Data quality is key!• Become familiar with the Clavien-Dindo

classification.

• Complete the e-learning module!http://quizstar.4teachers.org/index.jsp

Pilot period• Should take place post-audit approval.

• All team members should be involved.

• Get familiar with how to access/ record necessary patient data .

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

Data sources• Patient Notes/ nursing notes.

• Computer-based electronic records.

• Anaesthetic/ recovery notes.

• Operation notes.

• Outpatient records.

The Clavien-Dindo Classification

James GlasbeyCardiff 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 reproducible.

Data sources• Patient Notes/ nursing notes.

• Computer-based electronic records.

• Anaesthetic/ recovery notes.

• Operation notes.

• Outpatient records.

Dindo et al., 2004, Annals of Surgery

Definitions

IAny deviation from the normal postoperative course without the need for pharmacological treatment [other than the “allowed therapeutic regimens”], surgical, endoscopic or radiological interventions.

IIRequiring pharmacological treatment with drugs other than the allowed therapeutic regimens. Includes transfusions and TPN.

IIIRequiring surgical, endoscopic or radiological intervention.  

IVLife-threatening complications requiring critical care management and CNS complications. 

VDeath of a patient

The Clavien-Dindo classification

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.

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.

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.

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

James GlasbeyAssociation of Surgeons in

Traininghttp://

www.asit.org

Any questions?