Search tips
Search criteria

Results 1-25 (774378)

Clipboard (0)

Related Articles

1.  Survey of General Paediatric Surgery Provision in England, Wales and Northern Ireland 
A survey was carried out to ascertain the current provision of general paediatric surgery (GPS) in all hospitals in England, Wales and Northern Ireland with 100% return rate. The provision of GPS is at a crossroads with a drift of these cases to the overstretched, tertiary referral hospitals.
The regional representatives on the council of the Association of Surgeons of Great Britain and Ireland (ASGBI) obtained data from their regions. Any gaps in the data were completed by the author telephoning the remaining hospitals to ascertain their current provision.
A total of 325 acute hospitals are potentially available to admit elective and/or emergency paediatric patients, of which 25 hospitals provide a tertiary paediatric surgical service. Of the remaining ‘non-tertiary’ hospitals, 138 provide elective GPS and 147 provide emergency GPS. The ages at which GPS is carried out varies considerably, but 76% of non-tertiary hospitals provide elective GPS to those over the age of 2 years. The ages of emergency cases are 24% over the age of 2 years and 51.5% over the age of 5 years. The age at which surgery is carried out is dependent on the anaesthetic provision. Subspecialisation within each hospital has taken place with a limited number of surgeons providing the elective surgery. ‘Huband-spoke’ provision of GPS to a district general hospital (DGH) from a tertiary centre is embryonic with only 11 surgeons currently in post. An estimate of the annual elective case load of GPS based on the average number of cases done on an operation list works out at 23,000 cases done outwith the tertiary centres.
Almost 10 years ago, a change in the training of young surgeons took place. An increase in training posts in Tertiary centres was made available following advice from the British Association of Paediatric Surgeons (BAPS) but these posts were often not taken up. Many DGH surgeons became uncertain whether they should continue GPS training. A subtle change in the wording of the general guidance by the Royal College of Anaesthetists altered the emphasis on the age at which it was appropriate to anaesthetise children. Change in clinical practice, reducing need, and a drift towards tertiary centres has reduced DGH operations by 30% over a decade. Young surgeons are now seldom exposed to this surgery, and are not being trained in it. The large volume of these low-risk operations in well children cannot be absorbed into the current tertiary centres due to pressure on beds. The future provision of this surgery is at risk unless action is taken now. This survey was carried out to inform the debate, and to make recommendations for the future. The principal recommendations are that: (i) GPS should continue to be provided as at present in those DGHs equipped to do so; (ii) GPS training should be carried out in the DGHs where a high volume of cases is carried out; (iii) management of these cases should use a network approach in each region; (iv) hospital trusts should actively advertise for an interest in GPS as a second subspecialty; and (v) the SAC in general surgery develop a strategy to make GPS relevant to trainee surgeons.
PMCID: PMC2430449  PMID: 18430332
Child; Surgical procedures; Elective; Hospitals; General
2.  Developing a placebo-controlled trial in surgery: Issues of design, acceptability and feasibility 
Trials  2011;12:50.
Surgical placebos are controversial. This in-depth study explored the design, acceptability, and feasibility issues relevant to designing a surgical placebo-controlled trial for the evaluation of the clinical and cost effectiveness of arthroscopic lavage for the management of people with osteoarthritis of the knee in the UK.
Two surgeon focus groups at a UK national meeting for orthopaedic surgeons and one regional surgeon focus group (41 surgeons); plenary discussion at a UK national meeting for orthopaedic anaesthetists (130 anaesthetists); three focus groups with anaesthetists (one national, two regional; 58 anaesthetists); two focus groups with members of the patient organisation Arthritis Care (7 participants); telephone interviews with people on consultant waiting lists from two UK regional centres (15 participants); interviews with Chairs of UK ethics committees (6 individuals); postal surveys of members of the British Association of Surgeons of the Knee (382 surgeons) and members of the British Society of Orthopaedic Anaesthetists (398 anaesthetists); two centre pilot (49 patients assessed).
There was widespread acceptance that evaluation of arthroscopic lavage had to be conducted with a placebo control if scientific rigour was not to be compromised. The choice of placebo surgical procedure (three small incisions) proved easier than the method of anaesthesia (general anaesthesia). General anaesthesia, while an excellent mimic, was more intrusive and raised concerns among some stakeholders and caused extensive discussion with local decision-makers when seeking formal approval for the pilot.
Patients were willing to participate in a pilot with a placebo arm; although some patients when allocated to surgery became apprehensive about the possibility of receiving placebo, and withdrew. Placebo surgery was undertaken successfully.
Our study illustrated the opposing and often strongly held opinions about surgical placebos, the ethical issues underpinning this controversy, and the challenges that exist even when ethics committee approval has been granted. It showed that a placebo-controlled trial could be conducted in principle, albeit with difficulty. It also highlighted that not only does a placebo-controlled trial in surgery have to be ethically and scientifically acceptable but that it also must be a feasible course of action. The place of placebo-controlled surgical trials more generally is likely to be limited and require specific circumstances to be met. Suggested criteria are presented.
Trial registration number
The trial was assigned ISRCTN02328576 through in June 2006. The first patient was randomised to the pilot in July 2007.
PMCID: PMC3052178  PMID: 21338481
3.  Surgical and anaesthetic capacity of hospitals in Malawi: key insights 
Health Policy and Planning  2014;30(8):985-994.
Background Surgery is increasingly recognized as an important driver for health systems strengthening, especially in developing countries. To facilitate quality improvement initiatives, baseline knowledge of capacity for surgical, anaesthetic, emergency and obstetric care is critical. In partnership with the Malawi Ministry of Health, we quantified government hospitals’ surgical capacity through workforce, infrastructure and health service delivery components.
Methods From November 2012 to January 2013, we surveyed district and mission hospital administrators and clinical staff onsite using a modified version of the Personnel, Infrastructure, Procedures, Equipment and Supplies (PIPES) tool from Surgeons OverSeas. We calculated percentage of facilities demonstrating adequacy of the assessed components, surgical case rates, operating theatre density and surgical workforce density.
Results Twenty-seven government hospitals were surveyed (90% of the district hospitals, all central hospitals). Of the surgical workforce surveyed (n = 370), 92.7% were non-surgeons and 77% were clinical officers (COs). Of the 109 anaesthesia providers, 95.4% were non-physician anaesthetists (anaesthesia COs or ACOs). Non-surgeons and ACOs were the only providers of surgical services and anaesthetic services in 85% and 88.9% of hospitals, respectively. No specialists served the district hospitals. All of the hospitals experienced periods without external electricity. Most did not always have a functioning generator (78.3% district, 25% central) or running water (82.6%, 50%). None of the district hospitals had an Intensive Care Unit (ICU). Cricothyroidotomy, bowel resection and cholecystectomy were not done in over two-thirds of hospitals. Every hospital provided general anaesthesia but some did not always have a functioning anaesthesia machine (52.2%, 50%). Surgical rate, operating theatre density and surgical workforce density per 100 000 population was 289.48–747.38 procedures, 0.98 and 5.41 and 3.68 surgical providers, respectively.
Conclusion COs form the backbone of Malawi’s surgical and anaesthetic workforce and should be supported with improvements in infrastructure as well as training and mentorship by specialist surgeons and anaesthetists.
PMCID: PMC4559113  PMID: 25261799
Anaesthesia; clinical officers; global health; global surgery; Malawi; surgical capacity; surgery; surgical care; surgical burden
4.  Tonsillectomy and Adenoidectomy in Children with Sleep-Related Breathing Disorders: Consensus Statement of a UK Multidisciplinary Working Party 
During 2008, ENT-UK received a number of professional enquiries from colleagues about the management of children with upper airway obstruction and uncomplicated obstructive sleep apnoea (OSA). These children with sleep-related breathing disorders (SRBDs) are usually referred to paediatricians and ENT surgeons.
In some district general hospitals, (DGHs) where paediatric intensive care (PICU) facilities to ventilate children were not available, paediatrician and anaesthetist colleagues were expressing concern about children with a clinical diagnosis of OSA having routine tonsillectomy, with or without adenoidectomy.
As BAPO President, I was asked by the ENT-UK President, Professor Richard Ramsden, to investigate the issues and rapidly develop a working consensus statement to support safe but local treatment of these children.
The Royal Colleges of Anaesthetists and Paediatrics and Child Health and the Association of Paediatric Anaesthetists nominated expert members from both secondary and tertiary care to contribute and develop a consensus statement based on the limited evidence base available.
Our terms of reference were to produce a statement that was brief, with a limited number of references, to inform decision-making at the present time.
With patient safety as the first priority, the working party wished to support practice that facilitated referral to a tertiary centre of those children who could be expected, on clinical assessment alone, potentially to require PICU facilities. In contrast, the majority of children who could be safely managed in a secondary care setting should be managed closer to home in a DGH.
BAPO, ENT-UK, APA, RCS-CSF and RCoA have endorsed the consensus statement; the RCPCH has no mechanism for endorsing consensus statements, but the RCPCH Clinical Effectiveness Committee reviewed the statement, concluding it was a ‘concise, accurate and helpful document’.
The consensus statement is an interim working tool, based on level-five evidence. It is intended as the starting point to catalyze further development towards a fully structured, evidence-based guideline; to this end, feedback and comment are welcomed. This and the constructive feedback from APA and RCPCH will be incorporated into a future guideline proposal.
PMCID: PMC2758429  PMID: 19622257
Consensus statement; Children; Sleep-related breathing disorders; Tonsillectomy; Adenoidectomy
5.  Diabetes services in the UK: third national survey confirms continuing deficiencies 
Aims: To determine the current level of diabetes services and to compare the results with previous national surveys.
Methods: A questionnaire was mailed to all paediatricians in the UK identified as providing care for children with diabetes aged under 16 years. Information was sought on staffing, personnel, clinic size, facilities, and patterns of care. Responses were compared with results of two previous national surveys.
Results: Replies were received from 244 consultant paediatricians caring for an estimated 17 192 children. A further 2234 children were identified as being cared for by other consultants who did not contribute to the survey. Of 244 consultants, 78% expressed a special interest in diabetes and 91% saw children in a designated diabetic clinic. In 93% of the clinics there was a specialist nurse (44% were not trained to care for children; 47% had nurse:patient ratio >1:100), 65% a paediatric dietitian, and in 25% some form of specialist psychology or counselling available. Glycated haemoglobin was measured routinely at clinics in 88%, retinopathy screening was performed in 87%, and microalbuminuria measured in 66%. Only 34% consultants used a computer database. There were significant differences between the services provided by paediatricians expressing a special interest in diabetes compared with "non-specialists", the latter describing less frequent clinic attendance of dietitians or psychologists, less usage of glycated haemoglobin measurements, and less screening for vascular complications. Non-specialist clinics met significantly fewer of the recommendations of good practice described by Diabetes UK.
Conclusions: The survey shows improvements in services provided for children with diabetes, but serious deficiencies remain. There is a shortage of diabetes specialist nurses trained to care for children and paediatric dietitians, and a major shortfall in the provision of psychology/counselling services. The services described confirm the need for more consultant paediatricians to receive specialist training and to develop expertise and experience in childhood diabetes.
PMCID: PMC1719265  PMID: 12495963
6.  Should surgeons take a break after an intraoperative death? Attitude survey and outcome evaluation 
BMJ : British Medical Journal  2004;328(7436):379.
Objectives To investigate attitudes of cardiac surgeons and anaesthetists towards working immediately after an intraoperative death and to establish whether an intraoperative death affects the outcome of subsequent surgery.
Design Questionnaire on attitudes to working after an intraoperative death and matched cohort study.
Setting UK adult cardiac surgery centres and regional cardiothoracic surgical centre.
Participants 371 consultant cardiac surgeons and anaesthetists in the United Kingdom were asked to complete a questionnaire, and seven surgeons from one centre who continued to operate after intraoperative death.
Main outcome measures Outcome for 233 patients operated on by a surgeon who had experienced an intraoperative death within the preceding 48 hours compared with outcome of 932 matched controls. Hospital mortality and length of stay as a surrogate for hospital morbidity.
Results The questionnaire response rate was 76%. Around a quarter of surgeons and anaesthetists thought they should stop work after an intraoperative death and most wanted guidelines on this subject. Overall, there was no increased mortality in patients operated on in the 48 hours after an intraoperative death. However, mortality was higher if the preceding intraoperative death was in an emergency or high risk case. Survivors operated on within 48 hours after an intraoperative death had longer stay in intensive care (odds ratio 1.64, 95% confidence interval 1.08 to 2.52, P = 0.02) and longer stay in hospital (relative change 1.15, 1.03 to 1.24, P = 0.02).
Conclusion Mortality is not increased in operations performed in the immediate aftermath of an intraoperative death, but survivors have longer stays in intensive care and on the hospital ward.
PMCID: PMC341385  PMID: 14734519
7.  Job satisfaction and stress levels among anaesthesiologists of south India 
Indian Journal of Anaesthesia  2011;55(5):513-517.
Stress being high among practicing anaesthesiologists has effects on the quality of life. Methods to mitigate the stress have to be ensured to achieve job satisfaction.
A survey was conducted through a questionnaire to know the various aspects of job satisfaction and job stress. The results of the data obtained were analyzed.
An anaesthetists work area may vary from a small private hospital to a large tertiary centre.Depending on the number of anaesthetists in a particular hospital, the working hours and on call duties would be distributed. Overworked anaesthetists are prone to burnout due to sleep deprivation. This could lead to fatigue related error. Lesser the number of anaesthetists would mean less support from colleagues in the event of complications. Having a good rapport with surgical colleagues also helps to prevent stress.Anaesthesiologists should have adequate monitors to avoid error in judgement. Chronic stress has serious health hazards. Keeping updated with latest developments in our field helps to improve the quality of care provided. Anaesthetists should also receive the recognition and remuneration due to them.
To improve the quality of care provided to a patient,anaesthesiologists must cope with job stress. An anaesthetist must enjoy the work rather than be burdened by it.
PMCID: PMC3237154  PMID: 22174471
Anaesthesiologists; burnout; job satisfaction; quality of life; stress
8.  Attitudes to blood transfusion post arthroplasty surgery in the United Kingdom: A national survey 
International Orthopaedics  2007;32(3):325-329.
Five hundred orthopaedic surgeons and 336 anaesthetists were surveyed to assess current UK attitudes towards transfusion practice following arthroplasty surgery. Seventy-two percent of surgeons and 73% of anaesthetists responded to the survey. In an uncomplicated patient following total hip arthroplasty, 53.2% of surgeons and 63.1% of anaesthetists would transfuse at or below a haemoglobin (Hb) level of 8 g/dL. Surgeons tended to be more aggressive in their attitudes, with a mean transfusion threshold of 8.3 g/dL compared to 7.9 g/dL for anaesthetists (p < 0.01), and with 97% of surgeons transfusing two or more units compared to 78% of anaesthetists (p < 0.01). This threshold Hb increased if the patient was symptomatic (surgeons 9.3 g/dL, anaesthetists 8.8 g/dL, p < 0.05) or was known to have pre-existing ischaemic heart disease (surgeons 9.0 g/dL, anaesthetists 9.2 g/dL, p <  0.05). A wide variability in attitudes and practices is demonstrated, and the development and adoption of consensus guidelines needs to be encouraged if efforts to reduce the use of blood products are to succeed.
PMCID: PMC2323427  PMID: 17396259
9.  Provision of services for the diagnosis and treatment of heart disease. Fourth report of a Joint Cardiology Committee of the Royal College of Physicians of London and the Royal College of Surgeons of England. 
British Heart Journal  1992;67(1):106-116.
The principal conclusions of the fourth report of the Joint Cardiology Committee are: 1 Cardiovascular disease remains a major cause of death and morbidity in the population and of utilisation of medical services. 2 Reduction in the risk of cardiovascular disease is feasible, and better co-ordination is required of strategies most likely to be effective. 3 Pre-hospital care of cardiac emergencies, in particular the provision of facilities for defibrillation, should continue to be developed. 4 There remains a large shortfall in provision of cardiological services with almost one in five district hospitals in England and Wales having no physician with the appropriate training. Few of the larger districts have two cardiologists to meet the recommendation for populations of over 250,000. One hundred and fifty extra consultant posts (in both district and regional centres) together with adequate supporting staff and facilities are urgently needed to provide modest cover for existing requirements. 5 The provision of coronary bypass grafting has expanded since 1985, but few regions have fulfilled the unambitious objectives stated in the Third Joint Cardiology Report. 6 The development of coronary angioplasty has been slow and haphazard. All regional centres should have at least two cardiologists trained in coronary angioplasty and there should be a designated budget. Surgical cover is still required for most procedures and is best provided on site. 7 Advances in the management of arrhythmias, including the use of specialised pacemakers, implantable defibrillators, and percutaneous or surgical ablation of parts of the cardiac conducting system have resulted in great benefit to patients. Planned development of the emerging sub-specialty of arrhythmology is required. 8 Strategies must be developed to limit the increased exposure of cardiologists to ionising radiation which will result from the expansion and increasing complexity of interventional procedures. 9 Supra-regional funding for infant cardiac surgery and transplantation has been successful and should be continued. 10 Despite advances in non-invasive diagnosis of congenital heart disease the amount of cardiac catheterisation of children has risen due to the increase in number of interventional procedures. Vacant consultant posts in paediatric cardiology and the need for an increase in the number of such posts cannot be filled from existing senior registrar posts. All paediatric cardiac units should have a senior registrar and in the meantime it may be necessary to make proleptic appointments to consultant posts with arrangements for the appointees to complete their training. 11 Provision of care for the increasing number of adolescent and adult survivors of complex congenital heart disease is urgently required. The management of these patients is specialised, and the committee recommends that it should ultimately be undertaken by either adult or pediatric cardiologists with appropriate additional training working in supra-regionally funded centers alongside specially trained surgeons. 12 Cardiac rehabilitation should be available to all patients in the United Kingdom. 13 New recommendations for training in cardiology are for a total of at least five years in the specialty after general professional training, plus a year as senior registrar in general medicine. An additional year may be required for those wishing to work in interventional cardiology and adequate provision must be made for those with an academic interest. 14 It is essential that both basic and clinical research is carried out in cardiac centres but these activities are becoming increasingly limited by the lack of properly funded posts in the basic sciences and restriction in the number of honorary posts for clinical research workers. 15 A joint audit committee of the Royal College of Physicians and the British Cardiac Society has been established to coordinate audit in the specialty. All district and regional cardiac centres should cooperate with the work of the committee, in addition to their participation in local audit activities.
PMCID: PMC1024713  PMID: 1739519
10.  Intravenous postoperative fluid prescriptions for children: A survey of practice 
BMC Surgery  2008;8:10.
Postoperative deaths and neurological injury have resulted from hyponatraemia associated with the use of hypotonic saline solutions following surgery. We aimed to determine the rates and types of intravenous fluids being prescribed postoperatively for children in the UK.
A questionnaire was sent to members of the British Association of Paediatric Surgeons (BAPS) and Association of Paediatric Anaesthetists of Great Britain and Ireland (APAGBI) based at UK paediatric centres. Respondents were asked to prescribe postoperative fluids for scenarios involving children of different ages. The study period was between May 2006 and November 2006.
The most frequently used solution was sodium chloride 0.45% with glucose 5% although one quarter of respondents still used sodium chloride 0.18% with glucose 4%. Isotonic fluids were used by 41% of anaesthetists and 9.8% of surgeons for the older child, but fewer for infants. Standard maintenance rates or greater were prescribed by over 80% of respondents.
Most doctors said they would prescribe hypotonic fluids at volumes equal to or greater than traditional maintenance rates at the time of the survey. A survey to describe practice since publication of National Patient Safety Agency (NPSA) recommendations is required.
PMCID: PMC2435100  PMID: 18541019
11.  What do trainees think about advanced trauma life support (ATLS)? 
Advanced trauma life support (ATLS) has become a desirable or even essential part of training for many surgeons and anaesthetists, but aspects of the ATLS course have attracted criticism. In the absence of published data on the views of trainees, this study sought their opinions in a structured questionnaire, which was completed by trainees in accident and emergency (A & E) (26), anaesthetic (82), general surgical (26), orthopaedic (42) and other (5) posts in different hospitals (response rate 66%). Of the trainees, 78% had done an ATLS course and, of these, 83% considered ATLS a 'major advantage' or 'essential' for practising their proposed specialty--100% for A & E, 94% for orthopaedics, 92% for general surgery, and 75% for anaesthetics. ATLS was considered a major curriculum vitae (CV) advantage by 94%, 85%, 50%, and 45%, respectively. Over 90% had positive attitudes towards ATLS, and 74% selected 'genuine improvement of management of trauma patients' as the most important reason for doing the course: 93% thought ATLS saved lives. Of the respondents, 83% thought that all existing consultants dealing with trauma patients should have done the course, and 41% thought it offered major advantages to doctors not involved in trauma. Funding problems for ATLS courses had been experienced by 14% trainees. This survey has shown that most trainees view ATLS positively. They believe that it provides genuine practical benefit for patients, and very few regard ATLS primarily as a career advantage or mandate.
PMCID: PMC2503502  PMID: 10932661
12.  Gaslini's tracheal team: preliminary experience after one year of paediatric airway reconstructive surgery 
congenital and acquired airway anomalies represent a relatively common albeit challenging problem in a national tertiary care hospital. In the past, most of these patients were sent to foreign Centres because of the lack of local experience in reconstructive surgery of the paediatric airway. In 2009, a dedicated team was established at our Institute. Gaslini's Tracheal Team includes different professionals, namely anaesthetists, intensive care specialists, neonatologists, pulmonologists, radiologists, and ENT, paediatric, and cardiovascular surgeons. The aim of this project was to provide these multidisciplinary patients, at any time, with intensive care, radiological investigations, diagnostic and operative endoscopy, reconstructive surgery, ECMO or cardiopulmonary bypass. Aim of this study is to present the results of the first year of airway reconstructive surgery activity of the Tracheal Team.
between September 2009 and December 2010, 97 patients were evaluated or treated by our Gaslini Tracheal Team. Most of them were evaluated by both rigid and flexible endoscopy. In this study we included 8 patients who underwent reconstructive surgery of the airways. Four of them were referred to our centre or previously treated surgically or endoscopically without success in other Centres.
Eight patients required 9 surgical procedures on the airway: 4 cricotracheal resections, 2 laryngotracheoplasties, 1 tracheal resection, 1 repair of laryngeal cleft and 1 foreign body removal with cardiopulmonary bypass through anterior tracheal opening. Moreover, in 1 case secondary aortopexy was performed. All patients achieved finally good results, but two of them required two surgeries and most required endoscopic manoeuvres after surgery. The most complex cases were the ones who had already been previously treated.
The treatment of paediatric airway anomalies requires a dedicated multidisciplinary approach and a single tertiary care Centre providing rapid access to endoscopic and surgical manoeuvres on upper and lower airways and the possibility to start immediately cardiopulmonary bypass or ECMO.
The preliminary experience of the Tracheal Team shows that good results can be obtained with this multidisciplinary approach in the treatment of complicated cases. The centralization of all the cases in one or few national Centres should be considered.
PMCID: PMC3223146  PMID: 22029825
13.  Surgical checklists: the human factor 
Surgical checklists has been shown to improve patient safety and teamwork in the operating theatre. However, despite the known benefits of the use of checklists in surgery, in some cases the practical implementation has been found to be less than universal. A questionnaire methodology was used to quantitatively evaluate the attitudes of theatre staff towards a modified version of the World Health Organisation (WHO) surgical checklist with relation to: beliefs about levels of compliance and support, impact on patient safety and teamwork, and barriers to the use of the checklist.
Using the theory of planned behaviour as a framework, 14 semi-structured interviews were conducted with theatre personnel regarding their attitudes towards, and levels of compliance with, a checklist. Based upon the interviews, a 27-item questionnaire was developed and distribute to all theatre personnel in an Irish hospital.
Responses were obtained from 107 theatre staff (42.6% response rate). Particularly for nurses, the overall attitudes towards the effect of the checklist on safety and teamworking were positive. However, there was a lack of rigour with which the checklist was being applied. Nurses were significantly more sensitive to the barriers to the use of the checklist than anaesthetists or surgeons. Moreover, anaesthetists were not as positively disposed to the surgical checklist as surgeons and nurse. This finding was attributed to the tendency for the checklist to be completed during a period of high workload for the anaesthetists, resulting in a lack of engagement with the process.
In order to improve the rigour with which the surgical checklist is applied, there is a need for: the involvement of all members of the theatre team in the checklist process, demonstrated support for the checklist from senior personnel, on-going education and training, and barriers to the implementation of the checklist to be addressed.
PMCID: PMC3669630  PMID: 23672665
Surgical checklist; Surgery; Patient safety
14.  Current practice in primary total hip replacement: results from the National Hip Replacement Outcome Project. 
As part of the National Study of Primary Hip Replacement Outcome, 402 consultant orthopaedic surgeons from three regions were contacted by postal questionnaire which covered all aspects of total hip replacement (THR). There was a 70% response rate of which 71 did not perform hip surgery, a further 33 refused to take part, leaving 181 valid responses. Preoperative assessment clinics were used by 89% of surgeons, but anaesthetists and rehabilitation services were rarely involved at this stage. Of respondents, 99% used routine thromboprophylaxis, with 79% using a combination of mechanical and chemical methods. Of surgeons, 84% routinely used stockings, whereas 95.5% used chemical prophylaxis, 63% employed low molecular weight heparins. Theatre facilities were shared with other surgical specialties by 6% of surgeons and 18% regularly used body exhaust suits for THR. Antibiotic loaded cement was used by 69% of surgeons, the majority (65%) used a single brand of normal viscosity cement with 9% using reduced viscosity formulations. Modern cementing techniques were commonly used at least in part, 87% used a cement gun and 94% a cement restrictor for femoral cementing. On the acetabulum, 47% pressurised the cement. In all, 36 different femoral stems and 35 acetabular cups were in routine use, but the majority of surgeons (55%) used Charnley type prostheses. Of the surgeons, 57% performed only cemented THR, while 3% exclusively used uncemented THR. Of consultants, 21% followed up their patients to 5 years, the majority discharge patients within the first year. Of concern is a large proportion of surgeons using low molecular weight heparins despite a lack of evidence with regard to reducing fatal pulmonary embolism, and also the small number of surgeons using prostheses of unproven value. Third generation cementing techniques have yet to be fully adopted. The introduction of a national hip register could help to resolve some of these issues.
PMCID: PMC2503116  PMID: 9849338
15.  A survey of surgical team members’ perceptions of near misses and attitudes towards Time Out protocols 
BMC Surgery  2013;13:46.
Medical errors are inherently of concern in modern health care. Although surgical errors as incorrect surgery (e.g., wrong patient, wrong site, or wrong procedure) are infrequent, they are devastating events to experience. To gain insight about incidents that could lead to incorrect surgery, we surveyed how surgical team members perceive near misses and their attitudes towards the use of Time Out protocols in the operating room. We hypothesised that perceptions of near-miss experiences and attitudes towards Time Out protocols vary widely among surgical team members.
This cross-sectional study (N = 427) included surgeons, anaesthetists, nurse anaesthetists, and operating room nurses. The questionnaire consisted of 14 items, 11 of which had dichotomous responses (0 = no; 1 = yes) and 3 of which had responses on an ordinal scale (never = 0; sometimes = 1; often = 2; always = 3). Items reflected team members’ experience of near misses or mistakes; their strategies for verifying the correct patient, site, and procedure; questions about whether they believed that these mistakes could be avoided using the Time Out protocol; and how they would accept the implementation of the protocol in the operating room.
In the operating room, 38% of respondents had experienced uncertainty of patient identity, 81% had experienced uncertainty of the surgical site or side, and 60% had prepared for the wrong procedure. Sixty-three per cent agreed that verifying the correct patient, site, and procedure should be a team responsibility. Thus, only nurse anaesthetists routinely performed identity checks prior to surgery (P ≤ 0.001). Of the surgical team members, 91% supported implementation of a Time Out protocol in their operating rooms.
The majority of our surgical personnel experienced near misses with regard to correct patient identity, surgical site, or procedure. Routines for ensuring the correct patient, site, and surgical procedure must involve all surgical team members. We find that the near-miss experiences are a wake-up call for systematic risk reducing efforts and the use of checklists in surgery.
PMCID: PMC3851944  PMID: 24106792
Surgery; Operating room; Near misses; Medical errors; Checklist
16.  A call centre and extended checklist for pre-screening elective surgical patients – a pilot study 
BMC Anesthesiology  2015;15:77.
Novel approaches to preoperative assessment and management before elective surgery are warranted to ensure that a sustainable high quality service is provided. The benefits of a call centre incorporating an extended preoperative electronic checklist and phone follow-up as an alternative to a clinic attendance were examined.
This was a pilot study of a new method of patient assessment in patients scheduled for elective non-cardiac surgery and who attended a conventional preoperative clinic. A call centre assessment, using a Computer-assisted Health Assessment by Telephone (CHAT), paper review by an anaesthetist, and a follow-up phone call if the anaesthetist wished more information, preceded the conventional preoperative clinic. Summaries from the call centre and clinic assessments were independently produced.
The times spent by call centre staff were recorded. The ‘procedural anaesthetist’ (who provided anaesthesia for each patient’s actual surgery/procedure) documented an opinion on whether the call centre assessment alone would have been sufficient to bypass the preoperative clinic if the patient were hypothetically undergoing laparoscopic cholecystectomy. This opinion was also sought from a panel of four senior anaesthetists, based on patient summaries from both the call centre and preoperative clinic, but expanded to three hypothetical operations of different complexity – cataract removal, laparoscopic cholecystectomy, and total hip replacement.
Call centre assessment followed by clinic attendance was studied in 193 patients. The mean time for CHAT was 19.8 (SD 7.5) minutes and, after review of CHAT summaries, anaesthetists telephoned 45.6 % of cases for follow-up information. The mean time spent by anaesthetists on summary review and phone calls was 3.8 (SD 3.9) minutes. Procedural anaesthetists considered 89 % of the patients under their care suitable to have bypassed the preoperative clinic if they were to have undergone cholecystectomy. The panel of senior anaesthetists judged 95-97 % of patients suitable to have bypassed preoperative clinic for cataract surgery, 81-85 % for cholecystectomy and 79-82 % for hip replacement.
A call centre to pre-screen elective surgical patients might substantially reduce patient numbers attending preoperative anaesthetic assessment clinics. Further studies to assess the quality of such an approach are indicated.
Trial registration
ANZCTR ACTRN12614000199617.
PMCID: PMC4438626  PMID: 25985775
Anaesthesia; Preoperative assessment; Computer-assisted; CATI; Cost-benefit
17.  Anaesthetist-provided pre-hospital advanced airway management in children: a descriptive study 
Pre-hospital advanced airway management has been named one of the top-five research priorities in physician-provided pre-hospital critical care. Few studies have been made on paediatric pre-hospital advanced airway management.
The aim of this study was to investigate pre-hospital endotracheal intubation success rate in children, first-pass success rates and complications related to pre-hospital advanced airway management in patients younger than 16 years of age treated by pre-hospital critical care teams in the Central Denmark Region (1.3 million inhabitants).
A prospective descriptive study based on data collected from eight anaesthetist-staffed pre-hospital critical care teams between February 1st 2011 and November 1st 2012.
Primary endpoints were 1) pre-hospital endotracheal intubation success rate in children 2) pre-hospital endotracheal intubation first-pass success rate in children and 3) complications related to prehospital advanced airway management in children.
The pre-hospital critical care anaesthetists attempted endotracheal intubation in 25 children, 13 of which were less than 2 years old.
In one patient, a neonate (600 g birth weight), endotracheal intubation failed. The patient was managed by uneventful bag-mask ventilation. All other 24 children had their tracheas successfully intubated by the pre-hospital critical care anaesthetists resulting in a pre-hospital endotracheal intubation success rate of 96 %.
Overall first pass success-rate was 75 %. In the group of patients younger than 2 years old, first pass success-rate was 54 %.
The total rate of airway management related complications such as vomiting, aspiration, accidental intubation of the oesophagus or right main stem bronchus, hypoxia (oxygen saturation < 90 %) or bradycardia (according to age) was 20 % in children younger than 16 years of age and 38 % in children younger than 2 years of age. No deaths, cardiac arrests or severe bradycardia (heart rate <60) occurred in relation to pre-hospital advanced airway management.
Compared with the total population of patients receiving pre-hospital advanced airway management in our system, the overall success rate following pre-hospital endotracheal intubations in children is acceptable but the first-pass success rate is low. The complication rates in the paediatric population are higher than in our pre-hospital advanced airway management patient population as a whole. This illustrates that young children may represent a substantial pre-hospital airway management challenge even for experienced pre-hospital critical care anaesthetists. This may influence future training and quality insurance initiatives in paediatric pre-hospital advanced airway management.
PMCID: PMC4549899  PMID: 26307040
18.  Who cares for the patient with head injury now? 
Emergency Medicine Journal : EMJ  2001;18(5):352-357.
Objective—A recent report on head injury management from the Royal College of Surgeons of England suggests that surgeons are unsuited to the inpatient care of head injuries (ICHI) and should hand over responsibility entirely to neurosurgeons and accident and emergency (A&E) specialists. This prompted a survey of A&E consultants to establish their opinions on the current and future practice of head injury care.
Methods—Questionnaires were sent to consultant members of the British Association for Accident and Emergency medicine. Of a possible 256 A&E departments from Great Britain and Ireland with over 20 000 annual new attenders 206 (80%) replied.
Results—General surgeons contribute to ICHI for adults in 107 of 206 hospitals (52%) compared with orthopaedic surgeons in 73 of 206 (35%) and A&E consultants in 71 of 206 (34%). There was frequent criticism that surgeons are uninterested in head injury care. Fifty nine units (30%) commented on the lack of neurosurgery beds and difficulties experienced in getting patients accepted. Few hospitals seem to have well integrated rehabilitation or follow up services targeted at head injury. One in six patients with head injury admitted to a general hospital or observation ward remain after 48 hours and one in 20 stay beyond one week. Of the 132 A&E units without responsibility for ICHI 54 (41%) either wish to take on this responsibility or are willing to do so if the necessary resources are first put in place. The perceived net revenue cost required to allow 67 A&E units to take on ICHI is about 12.5 million pounds per year. This does not include the cost of further care after 48 hours, follow up or rehabilitation.
Conclusion—Only one third of A&E units at present have even part of the ICHI role recommended in the RCS report; another third are prepared to accept a new role if training and resources are provided and support is forthcoming from other specialists to take over the care after 48 hours; the remaining third are unwilling to accept responsibility for ICHI.
PMCID: PMC1725681  PMID: 11559605
19.  Development of anesthesiology and medical service in KSA 1956-2011 
In this historical report, a new light is shed on details of the development of anesthesiology and medical service in Kingdom Saudi Arabia 1956-2011. What Dr. Al-khawashki has done between the period of 1956-1980 was commendable. He has found himself and few anesthetists from Egypt and Pakistan in the front of huge task. The shortage of anesthetists worldwide and the increasing surgical specialties in Saudi Arabia, imposed a huge dilemma on the service. In order to face this problem, there was only one way to cover the continuous expanding surgical services by establishing technical institutes to produce anesthesia technicians able to work under supervision of consultants. This was known as the technician's era. It continued for a long period, but the changes were introduced from 1980 onwards by me. This was the era of the development of an up-to-date anesthesia service from 1980-2011. the first, developing the-state-of- the-art anesthesia services in the university hospitals. Second, the Saudi Anaesthetic Association was established under the auspices of the King Saud University. Third, this period culminated by starting the residency training programmes in the country and the Arab world. Moreover the Saudi specialty of anaesthesia and intensive care graduated over 60 specialists and has 98 residents up till now in the programme. Finally three subspecialties fellowships in critical care, cardiac, and pediatric anesthesia were established. The total number of Saudi anaesthetists jumped from one or two anaesthetists in the seventies to almost 300 in 2011. The numbers of consultants or senior registrar are over 160 and the rest are residents in the training program nationally and internationally.
PMCID: PMC4173470  PMID: 25885616
Alexandria University; GalalAref; I. Al-Khawashki; Mohammed Abdulla Seraj; development of anesthesia practice; saudi arabia
20.  Trauma care — a participant observer study of trauma centers at Delhi, Lucknow and Mumbai 
The Indian Journal of Surgery  2009;71(3):133-141.
Trained doctors and para-medical personnel in accident and emergency services are scant in India. Teaching and training in trauma and emergency medical system (EMS) as a specialty accredited by the Medical Council of India is yet to be started as a postgraduate medical education program. The MI and CMO (casualty medical officer) rooms at military and civilian hospitals in India that practice triage, first-aid, medico-legal formalities, reference and organize transport to respective departments leads to undue delays and lack multidisciplinary approach. Comprehensive trauma and emergency infrastructure were created only at a few cities and none in the rural areas of India in last few years.
To study the infrastructure, human resource allocation, working, future plans and vision of the established trauma centers at the 3 capital cities of India — Delhi (2 centres), Lucknow and Mumbai.
Setting and design
Participant observer structured open ended qualitative research by 7 days direct observation of the facilities and working of above trauma centers.
Material and methods
Information on, 1. Infrastructure; space and building, operating, ventilator, and diagnostic and blood bank facilities, finance and costs and pre-hospital care infrastructure, 2. Human resource; consultant and resident doctors, para-medical staff and specialists and 3. Work style; first responder, type of patients undertaken, burn management, surgical management and referral system, follow up patient management, social support, bereavement and postmortem services were recorded on a pre-structured open ended instrument interviewing the officials, staff and by direct observation. Data were compressed, peer-analyzed as for qualitative research and presented in explicit tables.
Union and state governments of Delhi, Maharashtra and Uttar Pradesh have spent heavily to create trauma and emergency infrastructure in their capital cities. Mostly general and orthopedics surgeons with their resident staff were managing the facilities. Comprehensively trained accident and emergency (AandE) personnel were not available at any of the centers. Expert management of cardiac peri-arrest arrhythmias, peripheral and microvascular repair were occasionally available. Maxillo-facial, dental and prosthodontic facilities, evenomation grading and treatment of poisoning — anti venom were not integrated. Ventilators, anesthetist, neuro and plastic surgeons were available on call for emergency care at all the 4 centers. Emergency diagnostic radiology (X-ray, CT scan, and ultrasound) and pathology were available at all the 4 centers. On the spot blood bank and component blood therapy was available only at the Delhi centers. Pre-hospital care, though envisioned by the officials, was lacking. Comprehensively trained senior A and E personnel as first responders were unavailable. Double barrier nursing for burn victims was not witnessed. Laparoscopic and fibreoptic endoscopic emergency procedures were also available only at Delhi. Delay in treatment on account of incomplete medico-legal formalities was not seen. Social and legal assistance, bereavement service and cold room for dead body were universally absent. Free treatment at Delhi and partial financial support at Lucknow were available for poor and destitute.
Though a late start, evolution of trauma services was observed and huge infrastructure for trauma have come up at Delhi and Lucknow. Postgraduate accreditation in Trauma and EMS and creation of National Injury Control Program must be mandated to improve trauma care in India. Integration of medical, non traumatic surgical and pediatric emergency along with pre-hospital care is recommended.
PMCID: PMC3452474  PMID: 23133136
Trauma Care; India; Trauma Centers; Participant observer
21.  Male orthopaedic surgeons and anaesthetists: equally good at estimating fluid volumes (and changing light bulbs) but equally poor at estimating procedure duration 
Singapore Medical Journal  2015;56(5):264-267.
How many orthopods does it take to change a light bulb? One – to refer to the medics for ‘Darkness ?Cause’. Additionally, anaesthetists and surgeons often disagree on the estimated blood loss during surgery and the estimated procedure duration. We designed this study to compare the ability of orthopaedic surgeons and anaesthetists in: (a) estimating fluid volumes; (b) estimating procedure durations; and (c) changing light bulbs.
Participants had to either be a specialist in anaesthesia or orthopaedic surgery, or a trainee in that specialty for at least two years. Three different fluid specimens were used for volume estimation (44 mL, 88 mL and 144 mL). Two videos of different lengths (140 seconds and 170 seconds), showing the suturing of a banana skin, were used for procedure duration estimation. To determine the ability at changing light bulbs, the participants had to match eight different light sockets to their respective bulbs.
30 male anaesthetists and trainees and 31 male orthopaedic surgeons and trainees participated in this study. Orthopaedic surgeons underestimated the three fluid volumes by 3.9% and anaesthetists overestimated by 5.1% (p = 0.925). Anaesthetists and orthopaedic surgeons overestimated the duration of the two procedures by 21.2% and 43.1%, respectively (p = 0.006). Anaesthetists had a faster mean time in changing light bulbs (70.1 seconds vs. 74.1 seconds, p = 0.319).
In an experimental environment, male orthopaedic surgeons are as good as male anaesthetists in estimating fluid volumes (in commonly seen surgical specimens) and in changing light bulbs. Both groups are poor at estimating procedure durations.
PMCID: PMC4447927  PMID: 26034318
anaesthetists; fluid estimation; light bulbs; orthopaedic surgeons; procedure duration
22.  Improved clinical practice but continuing service deficiencies following a regional audit of childhood diabetes mellitus 
Archives of Disease in Childhood  2000;82(4):302-304.
AIM—To assess the changes in services for children with diabetes in the south west of England between two regionwide audits performed in 1994 and 1998.
METHODS—Questionnaires were sent to consultant paediatricians, specialist diabetes nurses, dietitians, and Local Diabetes Service Advisory Groups. Information was gathered on consultant and nursing caseload, clinic structure, dietetic and psychological services, glycated haemoglobin use, and screening services.
RESULTS—In 1994 there were 21 consultant paediatricians caring for children with diabetes, only seven of whom fulfilled the British Paediatric Association definition of a specialist. By 1998 there were 14, 12 of whom fulfilled this definition. In 1994 a significant number of children were being seen in general paediatric clinics; by 1998 all centres stated that children were being seen in designated diabetes clinics. Between the two audits, despite a decrease in the average caseload of specialist diabetes nurses, nursing services in many centres remained deficient, as did dietetic and psychology services. Glycated haemoglobin use increased from 16 of 21 consultants to all consultants. In 1998 there was still patchy paediatric representation on Local Diabetes Service Advisory Groups.
CONCLUSIONS—The 1994 audit was followed by a change in clinical practice, in contrast to continuing deficiencies in resources, despite the availability of national recommendations and the widespread distribution of the audit report to those in a position of influence.

PMCID: PMC1718294  PMID: 10735836
23.  Error, stress, and teamwork in medicine and aviation: cross sectional surveys 
BMJ : British Medical Journal  2000;320(7237):745-749.
To survey operating theatre and intensive care unit staff about attitudes concerning error, stress, and teamwork and to compare these attitudes with those of airline cockpit crew.
Cross sectional surveys.
Urban teaching and non-teaching hospitals in the United States, Israel, Germany, Switzerland, and Italy. Major airlines around the world.
1033 doctors, nurses, fellows, and residents working in operating theatres and intensive care units and over 30 000 cockpit crew members (captains, first officers, and second officers).
Main outcome measures:
Perceptions of error, stress, and teamwork.
Pilots were least likely to deny the effects of fatigue on performance (26% v 70% of consultant surgeons and 47% of consultant anaesthetists). Most pilots (97%) and intensive care staff (94%) rejected steep hierarchies (in which senior team members are not open to input from junior members), but only 55% of consultant surgeons rejected such hierarchies. High levels of teamwork with consultant surgeons were reported by 73% of surgical residents, 64% of consultant surgeons, 39% of anaesthesia consultants, 28% of surgical nurses, 25% of anaesthetic nurses, and 10% of anaesthetic residents. Only a third of staff reported that errors are handled appropriately at their hospital. A third of intensive care staff did not acknowledge that they make errors. Over half of intensive care staff reported that they find it difficult to discuss mistakes.
Medical staff reported that error is important but difficult to discuss and not handled well in their hospital. Barriers to discussing error are more important since medical staff seem to deny the effect of stress and fatigue on performance. Further problems include differing perceptions of teamwork among team members and reluctance of senior theatre staff to accept input from junior members.
PMCID: PMC27316  PMID: 10720356
24.  Mortality of doctors in different specialties: findings from a cohort of 20000 NHS hospital consultants. 
OBJECTIVES: To examine patterns of cause specific mortality in NHS hospital consultants according to their specialty and to assess these in the context of potential occupational exposures. METHODS: A historical cohort assembled from Department of Health records with follow up through the NHS Central Register involving 18,358 male and 2168 female NHS hospital consultants employed in England and Wales between 1962 and 1979. Main outcome measures examined were cause specific mortality during 1962-92 in all consultants combined, and separately for 17 specialty groups, with age, sex, and calendar year adjusted standardised mortality ratios (SMRs) for comparison with national rates, and rate ratios (RRs) for comparison with rates in all consultants combined. RESULTS: The 2798 deaths at ages 25 to 74 reported during the 30 year study period were less than half the number expected on the basis of national rates (SMR 48, 95% confidence interval (95% CI) 46 to 49). Low mortality was evident for cardiovascular disease, lung cancer, other diseases related to smoking, and particularly for diabetes (SMR 14, 95% CI 6 to 29). Death rates from accidental poisoning were significantly raised among male consultants (SMR 227, 95% CI 135 to 359), the excess being most apparent in obstetricians and gynaecologists (SMR 934); almost all deaths from accidental poisoning involved prescription drugs. A significantly raised death rate from injury and poisoning among female consultants was due largely to a twofold excess of suicide (SMR 215, 95% CI 93 to 423), the rate for this cause being significantly raised in anaesthetists (SMR 405). Compared with all consultants, significantly raised mortality was found in psychiatrists for all causes combined (RR 1.12), ischaemic heart disease (RR 1.18), and injury and poisoning (RR 1.46); in anaesthetists for cirrhosis (RR 2.22); and in radiologists and radiotherapists for respiratory disease (RR 1.68). There were significant excesses of colon cancer in psychiatrists (RR 1.67, compared with all consultants) and ear, nose, and throat surgeons (RR 2.25); melanoma in anaesthetists (RR 3.33); bladder cancer in general surgeons (RR 2.40); and laryngeal cancer in ophthalmologists (RR 7.63). CONCLUSIONS: Lower rates of smoking will have contributed substantially to the low overall death rates found in consultants, but other beneficial health related behaviours, and better access to health care, may have also played a part. The increased risks of accidental poisoning in male consultants, and of suicide in female consultants are of concern, and better preventive measures are needed. The few significant excesses of specific cancers found in certain specialties have no obvious explanation other than chance. A significant excess mortality from cirrhosis in anaesthetists might reflect an occupational hazard and may warrant further investigation.
PMCID: PMC1128798  PMID: 9245944
25.  Vestibular Schwannoma Management: Current Practice Amongst UK Otolaryngologists – Time for a National Prospective Audit 
It is generally agreed that the successful management of a vestibular schwannoma (VS) usually involves close collaboration between a neuro-otologist and neurosurgeon. In addition, it is accepted that the experience of the team managing such tumours is one of the key determinants of outcome after surgical intervention. The aim of this study was to identify current practice in the management of such tumours amongst otolaryngologists in the UK and to observe whether such collaborative working practices exist.
A cross sectional postal questionnaire survey of consultant members of the British Association of Otorhinolaryngologists – Head and Neck Surgeons (n = 542).
A total of 336 replies were received (62%). Of respondents, 299 consultants referred their patients to another surgeon for further management; 242 referred to another ENT surgeon (80.9%), 29 to a neurosurgeon (9.7%) and 28 to a combined team (9.4%). Twenty-eight of the responding otolaryngologists (8.6%) managed the tumours themselves, of whom 22 worked with a neurosurgeon. Of these 28 neuro-otologists, nearly two-thirds (64%) had been undertaking VS surgery for more than 10 years. The total number of patients with a VS referred to these 28 consultants during 2001 was 775, with a mean caseload of 29.8, median 23 and a range of 4 to 102 per surgeon. Seven of the 28 otolaryngologists chose their surgical approach entirely based on the size of the tumour. Eight consultants preferred the sub-occipital (SO) approach, 10 the trans-labyrinthine (TL) approach, three chose between SO and TL approaches. The majority of surgeons had a prospective, computer-based data collection and were willing to give further information about their outcomes and complications.
Amongst the otolaryngologists surveyed in the UK, we have identified 28 neuro-otologists who undertake VS surgery. The majority work with neurosurgical colleagues, confirming collaborative practice. The wide range in caseload raises the issue of training and maintaining standards and in the first instance we recommend a prospective national audit of VS management and outcomes with our neurosurgical colleagues. This would also be of value in manpower planning particularly if a minimum caseload could be identified below which results were seen to be less good.
PMCID: PMC1964657  PMID: 17002858
Vestibular schwannoma; Acoustic neuroma; Audit; Management; Collaboration

Results 1-25 (774378)