General Practice Surgeries Research Articles

Engaging young people with sexual health services in general practice surgeries - A qualitative study of health care professionals.

Evidence to date suggests that young people are becoming more sexually active and are forming relationships during the early stages of their lives, sometimes engaging in sexual risk-taking, which contributes to high rates of conception and sexually transmitted infections (STIs). Young people at risk of adverse sexual health outcomes are the least likely to engage with reproductive and sexual health promotion programmes and services (RSHPPs), especially in mainstream clinics such as general practice (GP) surgeries. The study aimed to explore the views and experiences of service providers. A qualitative approach to explore the views and experiences of designing and implementing RSHPPs for young people in GP surgeries was used. A total of seven participants were interviewed, including four general practitioners (GPs), two of whom were managers at the practice; one nurse; one healthcare and support worker; and one practice manager. The context of RSHPPs such as local health priorities and partnerships to address STIs and unplanned pregnancies among young people contribute to the implementation and engagement of young people with RSHPPs. Training of GPs, nurses, and support workers helps develop confidence and overcome personal factors by promoting effective engagement of young people with RSHPPs. Addressing local health priorities such as reducing teenage pregnancies and STIs requires organisations to provide RSHPPs in both non-clinical and clinical settings to ensure that RSHPPs are accessible to young people. There is room for improvement in access to RSH for young people in GP surgeries by addressing organisational and structural barriers to access.

Support Vector Machine Approach for Survival Prediction in Liver Transplant and Exploration of General Surgery Practice

Support Vector Machine Approach for Survival Prediction in Liver Transplant and Exploration of General Surgery Practice

Expanding general practice with interprofessional teams: a mixed-methods patient perspective study

BackgroundAcross healthcare systems, current health policies promote interprofessional teamwork. Compared to single-profession general practitioner care, interprofessional primary healthcare teams are expected to possess added capacity to care for an increasingly complex patient population. This study aims to explore patients’ experiences when their usual primary healthcare encounter with general practice shifts from single-profession general practitioner care to interprofessional team-based care.MethodsQualitative and quantitative data were collected through interviews and a survey among Norwegian patients. The interviews included ten patients (five women and five men) aged between 28 and 89, and four next of kin (all women). The qualitative analysis was carried out using thematic analysis and a continuity framework. The survey included 287 respondents, comprising 58 per cent female and 42 per cent male participants, aged 18 years and above. The respondents exhibited multiple diagnoses and often a lengthy history of illness. All participants experienced the transition to interprofessional teamwork at their general practitioner surgery as part of a primary healthcare team pilot.ResultsThe interviewees described team-based care as more fitting and better coordinated, including more time and more learning than with single-profession general practitioner care. Most survey respondents experienced improvements in understanding and mastering their health problems.Multi-morbid elderly interviewees and interviewees with mental illness shared experiences of improved information continuity. They found that important concerns they had raised with the nurse were known to the general practitioner and vice versa.None of the interviewees expressed dissatisfaction with the inclusion of a nurse in their general practitioner relationship. Several interviewees noted improved access to care. The nurse was seen as a strengthening link to the general practitioner. The survey respondents expressed strong agreement with being followed up by a nurse. The interviewees trusted that it was their general practitioner who controlled what happened to them in the general practitioner surgery.ConclusionFrom the patients’ perspective, interprofessional teamwork in general practice can strengthen management, informational, and relational continuity. However, a prerequisite seems to be a clear general practitioner presence in the team.

Perspectives on registration to primary care from inclusion health groups in England: a mixed-method study

BackgroundAlthough everyone living in the UK is entitled to access free primary care within the National Health Service (NHS), evidence shows that people in need of health care are wrongly being refused access. This study aimed to explore the perspectives of individuals from inclusion health groups on primary care registration and accessibility. MethodsThis was a mixed-methods study. From Oct 5, 2022, to Feb 20, 2023, we surveyed 49 people (36 [73%] men; 12 [24%] women) and interviewed 25 other (14 [56%] men; 11 [44%] women) who were service users of the University College London Hospital Find & Treat mobile service. This service included people with lived experience of homelessness, asylum seeking, addiction, selling sex, and irregular immigration. We recruited these participants through hostels for people with ongoing addiction and complex needs, initial asylum accommodation centres, and day shelters. Our research team included two peer researchers. FindingsOf those surveyed, 25 (51%) perceived their access to primary health-care services as good, and 17 (35%) reported obstacles to going to the general practitioner (GP). Participants described multiple barriers to registering for GP surgeries, including a lack of understanding and poor communication with NHS services, a fear of discrimination, and a lack of digital access that prevents information seeking and access to services. Respondents also reported using emergency services instead of primary care because they were more immediately accessible without previous registration. Facilitators to GP registration included one-on-one support and outreach work that helps people navigate into services and know their rights, and the use of specialist GP services, which are perceived as more accepting, especially for people experiencing homelessness. InterpretationThe barriers to registration identified are related to both individual and group level characteristics and produce both similar and divergent needs between different inclusion health groups. The need for additional support during registration was clear, and our work highlights the requirement for interventions to improve access to primary care for underserved groups, as well as coordinated policy action. One-on-one support in particular, either outreach or provided in services where inclusion health groups spend time, appears to be a key facilitator to ensuring comprehensive and fast access to GP services. FundingNational Institute for Health and Care Research (NIHR).

‘It’s the stuff they can do better than us’: case studies of general practice surgeries’ experiences of optimising the skill-mix contribution of practice-based pharmacists in Wales

ObjectivePharmacists are increasingly joining the general practice skill-mix. Research is still in relative infancy, but barriers and facilitators to their integration are emerging, as well as indications that pharmacists’ skillset...

Community pharmacy services during the COVID-19 pandemic: Insights from providers and policy makers

BackgroundReadily accessible to the public, community pharmacies (CPs) were placed under increased pressure during the COVID-19 pandemic. In England, dispensing volume increased by 25% between February and March 2020. This followed a decade of stagnant government funding, which has been attributed to CP closures. If another pandemic emerged, the reduced number of CPs may face increased pressures. ObjectiveTo explore CP service provision in England throughout the COVID-19 pandemic from the perspectives of providers and policy makers, including what can be learned in preparation for any future pandemic. MethodsCP providers (n = 10) and policy makers (n = 6) were interviewed via telephone between June and September 2021. Interviews were transcribed and then analysed thematically using NVivo. ResultsPandemic specific pressures were identified, as well as long-term issues which preceded the pandemic. Increased workload was recognised by both providers and policy makers due to changes in prescribing habits and was exacerbated by staff shortages. CP staff safety was a major concern, with limited personal protective equipment provided despite being open to the public. General Practitioner (GP) surgeries received more protective equipment than CP and still referred patients to pharmacy e.g., for a blood pressure check. ConclusionsThe pandemic re-confirmed CPs role of providing accessible healthcare, particularly medicines provision, but also highlighted the demand for in-person clinical services. Improved communication channels between CP and GP surgeries are required, as is pandemic prescribing guidance to ensure appropriate prescribing to safeguard the medicines supply chain. To ensure the health of all providers is fairly protected, activities which require in-person contact or can be undertaken remotely by CP, GP surgeries and other providers should be reviewed. For pandemic preparation, legislative changes are required which empower pharmacy to fully contribute to patient care. A review of pharmacy funding and staffing is also needed to ensure services are sustainable.

Identifying malnutrition in emergency general surgery: systematic review.

Emergency general surgery practice is high risk. Surgery is a key part of treatment, with resultant catabolic stress and frequent need for nutritional support. The aim of this study was to examine the current methods of defining and determining malnutrition in emergency general surgery. This included examining the use of nutrition screening and assessment tools and other measures of malnutrition. MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, trial registries, and relevant journals published between January 2000 and January 2022 were searched for studies of adult patients with any emergency general surgery diagnosis, managed conservatively or operatively, with an assessment of nutritional status. Mixed populations were included if more than 50 per cent of patients were emergency general surgery patients or emergency general surgery results could be separately extracted. Studies in which patients had received nutritional support were excluded. The protocol was registered with PROSPERO, the international prospective register of systematic reviews (CRD42021285897). From 6700 studies screened, 324 full texts were retrieved and 31 were included in the analysis. A definition of malnutrition was provided in 23 studies (75 per cent), with nutritional status being determined by a variety of methods. A total of seven nutrition screening tools and a total of nine 'assessment' tools were reported. To define malnutrition, the most commonly used primary or secondary marker of nutritional status was BMI, followed by albumin level. Wide variation exists in approaches to identify malnutrition risk in emergency general surgery patients, using a range of tools and nutrition markers. Future studies should seek to standardize nutrition screening and assessment in the emergency general surgery setting as two discrete processes. This will permit better understanding of malnutrition risk in surgical patients.

The geographic diversity of authorship in leading general surgery journals; A study of 24,332 authors

BackgroundResearch guides evidence-based general surgery practice, advocacy, policy and resource allocation, but is seemingly lacking representation from those countries with greatest disease burden and mortality. Accordingly, we conducted a geographic study of publications in the most impactful general surgery journals worldwide. MethodsThe six general surgery journals with the highest 2020 impact factors were selected. Only journals specific to general surgery were included. For all original articles over the past five years, the affiliated country and city were extracted for the first, second and last author. Number of publications were adjusted per capita, and compared to Human Development Index (HDI) using logistic regression. Results8274 original articles were published in the top six ranked general surgery journals over 2016–2020, with 24,332 affiliated authors. Authors were most commonly associated with the US (27.88%), Japan (9.09%) and China (8.46%), or per capita, The Netherlands, Sweden and Singapore. There is a linear association between publishing in a top six journal and HDI of country of affiliation. Just four publications were from medium or low HDI countries over the period. ConclusionAuthorship in leading general surgery journals is predominantly from wealthy, Western countries. Authorship is associated with affiliation with a high HDI country, with few authors from medium or low HDI countries. There is a lack of representation in literature from Africa, Russia, and parts of Southeast Asia, and thus a lack of locally relevant evidence to guide surgical practice in these areas of high disease burden and low life expectancy.

573 Proforma for Referrals to the Paediatric Surgery Ward from General Practice (GP) Surgeries and Urgent Care Centres for Foundation Year One (FY1) Doctors

Abstract Introduction The foundation year one (FY 1) doctors hold a bleep and receive referrals from primary care centres especially from the General Practice (GP) surgeries and Urgent Care centres. For many FY 1 doctors, this job may be their first experience in the NHS in taking referrals and it could be quite challenging to take a good referral from primary care centres in the NHS. This was the basis to conduct this quality improvement project (QIP) to help the FY 1 doctors in taking good primary care referral documentation. Aim To develop a primary care centre referral proforma as a guide for the FY 1 doctors in taking referrals and to assess the junior doctors and other ward staff satisfaction in using the proforma. Method This QIP was registered and approved by the Continuous Quality Improvement Team of Hull University Teaching Hospital NHS Trust. This was a prospective study with designed proforma for FY 1 doctors to be used following primary care centres referral to the Paediatric Surgery ward. Results There were 38 primary care referrals between 16th October 2022 and 20th December 2022 with 30 referrals from the GP surgeries and 8 referrals from the Urgent Care centres. The overall satisfaction was excellent with the use of the designed proforma by the FY 1 doctors and other ward and we had 100% completion in filling in the designed proforma. Conclusions A well designed referral proforma could improve the confidence and quality of referral documentation from primary care centres by FY 1 doctors.

102 An Audit of Phimosis Management at Primary Care Level

Abstract Aim To audit the appropriateness of phimosis management and adherence to paediatric surgical referral guidelines at the primary care level against the Royal College of Surgeons (RCS) recommendations. Method A search of paediatric patients with diagnoses of phimosis, paraphimosis and Balanitis Xerotica Obliterans from January 2016 to October 2021 was performed at one General Practice (GP) surgery with a population size of 14,315 patients. Data on the frequency of urological symptoms reported, the medical treatment initiated, the number of paediatric surgical referrals and waiting times, and outcomes were recorded. Results A total of 35 patients with ages ranging from 1-17 years old were included. The most common symptom reported was dysuria (n = 21, 60%). Twenty-five (71.4%) paediatric patients with phimosis were referred. The paediatric surgical referral waiting times ranged from 3–232 days (mean = 111.4). Fourteen of the referred patients (73.7%) who had been reviewed by the surgical team were diagnosed with physiological phimosis and discharged back to the GP. Thirty-two per cent of the referrals (n = 8) were done without trialling on topical steroids. In terms of potency, 53.5% of the steroids (n = 15) prescribed by the GP were weaker than is recommended by the RCS. Conclusions Variation in practice was seen in phimosis management, including the types of steroids initiated and decisions on surgical referrals. Only pathological phimosis generally requires a referral. Therefore, a clear management and referral pathway and additional training on phimosis management within primary care providers can help optimise the patient management and appropriateness of secondary care referrals.

350 Identifying Malnutrition in Emergency General Surgery (EGS): A Systematic Review

Abstract Aim Emergency general surgery (EGS) practice is high risk. Surgery is a key part of treatment, with resultant catabolic stress and frequent need for nutritional support. Aims of this study were to examine the current methods of defining and determining malnutrition in EGS. This included examining the use of nutrition screening and assessment tools, and other measures of malnutrition. Method Medline, Embase, CINAHL, trial registries and relevant journals published between January 2000 and January 2022 were searched for studies of adult patients with any EGS diagnosis, managed operatively or conservatively with an assessment of nutritional status. Mixed populations were included if more than 50% of patients were EGS or EGS results could be separately extracted. Studies whereby patients had received nutritional support were excluded. Results From 6,700 studies screened, 324 full texts were retrieved, and 31 were included in the analysis. A definition of malnutrition was provided in 75% (n = 23) of studies, with nutritional status being determined by a variety of methods. Seven nutrition screening tools and nine ‘assessment’ tools were reported. To define malnutrition, the most commonly used primary or secondary marker of nutritional status was body mass index followed by albumin level. Conclusions Wide variation exists in approaches to identify malnutrition risk in EGS patients, using a range of tools and nutrition markers. Future studies should seek to standardise nutrition screening and assessment in the EGS setting as two discrete processes. This will permit better understanding of malnutrition risk in surgical patients.

Mapping a shared care model in complex gastrointestinal surgery: A qualitative study of queues and stakeholders within a Canadian general surgery practice.

Shared Care Models (SCMs), in which a team of clinicians share in patient care and resource utilization, represent an opportunity for surgeon-level system change. We aimed to identify the queues and stakeholders within a complex gastrointestinal surgical care pathway to demonstrate the implications of a SCM on system efficiency. A multidisciplinary group of surgeons and care navigators working in SCMs were asked to develop a patient encounter map through consensus to illustrate relevant queues and stakeholders within a SCM. Fifteen surgeon-related queues were identified, each representing a point of potential delay to care in the patient's journey that could be addressed by shared care. A final patient encounter map was created, and advantages and challenges of SCMs were also described from multidisciplinary group discussions. The numerous queues identified in this map ultimately reflected opportunities for more efficient care navigation under a SCM through increased surgeon availability and shared resource utilization.

Prehabilitation in elective surgical interventions- what must the general and abdominal surgeon know.

For years, many efforts have been invested to prepare patients, in particular, those with reduced physical and psychic status, much better to provide and finally achieve better outocme if there is time available to provide several beneficial measures. Therefore, the objective was to illustrate the concept and various single elements of a complex prehabilitation concept based on (i)selective references from the medical literature and (ii) own clinical experiences from clinical practice in general and abdominal surgery. Prehabiliation can be considered the solution of the efforts to improve preoperative status for patients in a disadvantageous status for almost all types of surgery and all other operative and/or interventional procedures. It is the targeted process to improve individual functionality and organ function before a planned (elective) surgical intervention; P. comprises basically nutritional, physical and psychological measures; P. focusses especially onto the elderly, frail and malnourished patients before a planned surgical intervention; the overall aim is to significantly improve final outcome characterized by shorter length of stay, lower complication rate and mortality as well as cost efficiency; P. is especially important in cancer surgery, in which the beneficial effects can be particularly implemented; P. programs and/or "Standard Operating Protocols" (SOP) may help to establish and materialize itssingle aspects and enhanced recovery after surgery (ERAS). There is still further potential to reliably establish and to utilize the options of prehabilitation measures as listed above. Prehabiliation is an indispensable aspect in today's preparation for elective surgery, which needs to become obligatory part of the preparation measures to planned surgical interventions, which can further contribute to a better final outcome and ERAS as well as, in addtion, needs to be further developed and accomplished.

SP9.10 Identifying Malnutrition in Emergency General Surgery (EGS): A Systematic Review

Abstract Aims Emergency general surgery (EGS) practice is high risk. Surgery is a key part of treatment, with resultant catabolic stress and frequent need for nutritional support. Aims of this study were to examine the current methods of defining and determining malnutrition in EGS. This included examining the use of nutrition screening and assessment tools, and other measures of malnutrition. Methods Medline, Embase, CINAHL, trial registries and relevant journals published between January 2000 and January 2022 were searched for studies of adult patients with any EGS diagnosis, managed operatively or conservatively with an assessment of nutritional status. Mixed populations were included if more than 50% of patients were EGS or EGS results could be separately extracted. Studies whereby patients had received nutritional support were excluded. Results From 6,700 studies screened, 324 full texts were retrieved, and 31 were included in the analysis. A definition of malnutrition was provided in 75% (n = 23) of studies, with nutritional status being determined by a variety of methods. Seven nutrition screening tools and nine ‘assessment’ tools were reported. To define malnutrition, the most commonly used primary or secondary marker of nutritional status was body mass index followed by albumin level. Conclusions Wide variation exists in approaches to identify malnutrition risk in EGS patients, using a range of tools and nutrition markers. Future studies should seek to standardise nutrition screening and assessment in the EGS setting as two discrete processes. This will permit better understanding of malnutrition risk in surgical patients.

Access to first contact physiotherapy appointments in primary care: A scoping review

AbstractBackgroundFirst Contact Physiotherapy (FCP) is part of the drive to increase General Practice (GP) capacity by providing access to expert musculoskeletal (MSK) Physiotherapists in GP surgeries. For the FCP model to provide effective MSK care at the start of the patient's journey, it is essential that patients are directed to FCP appointments in a timely manner. It is therefore important to know how patients are accessing FCP appointments.ObjectiveTo provide an overview of the literature regarding patient access to FCP appointments.DesignScoping review.MethodsWe reviewed studies published from January 2016 to May 2023 that focused on FCP and made a mention of patient access to FCP appointments. A search was performed using six databases as well as grey literature sources. Study selection and data extraction were independently conducted by two reviewers. Extracted data were tabulated and analysed according to our research questions.ResultsFrom 186 records identified, 24 studies and other materials were included in the review. A variety of terms were used to describe access routes to FCP appointments, the most common being ‘signposting’. These studies suggest the importance of the role of GP reception/administrative staff in enabling efficient patient access to FCP appointments.ConclusionThere is a clear gap in the literature concerning how patients access FCP appointments. Since the importance of appropriate access is acknowledged as an essential feature of the expansion of FCP in Primary Care, future research is needed to refine and implement optimal FCP access models by identifying the key components needed to ensure timely and appropriate access to FCP.

Establishment of a successful robotic pediatric general surgery practice.

Robotic-assisted surgery (RAS) has a variety of theoretical advantages, including tremor filtration, optimal visualization, and improvement of surgeon ergonomics. Though it has achieved wide application in pediatric urology, the majority of pediatric general surgeons do not employ RAS. This study reports our institution's experience with RAS on a pediatric general surgery team. Following IRB approval, a retrospective review of all pediatric patients at our academic children's hospital who underwent RAS between 2017 and 2022 for pediatric general surgical conditions was performed. Patient demographics, operation performed, operating time, complications, and recovery were evaluated. A total of 159 children underwent RAS, increasing from 10 patients in 2017 to 59 patients in 2022. The median age and weight were 15.3years and 76.4kg, and 121 (76.1%) were female. The application of RAS was successful in all cases. There were no intraoperative complications and no conversions to an open approach. Eleven patients (6.9%) had unplanned presentations to the emergency department within 30days. Five of these patients (3.1%) required admission to the hospital. This study demonstrates that the application of RAS in an academic pediatric general surgery practice is feasible and safe. The application of RAS to pediatric general surgery should continue to increase as operative teams increase their experience and comfort.Level of evidence Level IV.

Direct oral anticoagulant (DOAC) monitoring within primary care: a quality improvement project

BackgroundPoor monitoring of anticoagulants is a significant area of patient safety. It can lead to the dichotomous risk of haemorrhage/clotting without appropriate counselling and monitoring. While healthcare professionals may be...

Caregivers of people with learning disabilities and their experiences of communicating with healthcare professionals

Background Communication challenges are a recognised factor in the inequalities that people with learning disabilities experience in their access to, and use of, healthcare services. People with learning disabilities are often assisted in their interactions with healthcare professionals by a caregiver, whether paid or unpaid.Aim To understand the experiences of caregivers who support people with learning disabilities in their encounters with healthcare professionals in settings such as general practice surgeries, emergency departments, hospital outpatient departments and hospital wards.Method Paid and unpaid caregivers from different care environments were recruited using convenience and purposive sampling. Semi-structured interviews with 33 caregivers were conducted remotely, transcribed and thematically analysed.Findings Six themes emerged from the data and this article focuses on one of them: caregivers’ status, skills and knowledge. Participants explained that healthcare professionals often did not listen to them, did not recognise their skills and discounted their insights. Participants also felt that their caregiver role was misunderstood and that they were often labelled as ‘anxious’ or ‘pushy’.Conclusion Many people with learning disabilities need their caregiver to participate in clinical consultations, but healthcare professionals do not engage with caregivers in a way that enables them to contribute fully.

The role of clinical and sonographic assessments in pre-operative evaluation of patients with splenic injuries in a resource-limited economy.

Splenic trauma has been recognized as the most common cause of preventable deaths amongst trauma patients. Due to paucity of modern diagnostic imaging facilities in our setting, determination of the error rates and role of the simple, available diagnostic approaches are worthwhile and relevant to the practice of general surgery. The aim was to determine the role and diagnostic accuracy of clinical and sonographic assessments of splenic injuries. This was a prospective study of the value of pre-operative clinical and sonographic assessments of patients with splenic injuries in our setting. A total of 111 patients with abdominal trauma were evaluated. Of these, splenic injuries were confirmed in 75 patients intra-operatively, mainly from blunt trauma. Of the 97 cases diagnosed by clinical method, 66(68.0%) were confirmed by intraoperative findings. Similarly, of 86 sonographic diagnoses of splenic injuries, 61 (70.9%) truly had splenic trauma. Sensitivity for sonographic and clinical assessments was 84.7% and 78.9% respectively. False positive and negative rates for clinical (27.3% versus 44.1%) and ultrasonographic (29.1% versus 40.0%) assessments were high. Majority of splenic injuries were due to blunt abdominal trauma. The two diagnostic methods showed high sensitivity, but performed poorly for other validity tests.

A Case for Horizontal Distribution of Activities between General Surgery and Surgical Super Specialties

Under the current practice in organizing surgical services, proportionate representation of disciplines is provided in the curricular planning and in corresponding clinical functions. This is based on the level of competence expected by the end of training period. The disciplines as a “whole” are placed in general surgery or super specialty. The system of vertical arrangement has some serious concerns. Paradoxically, patients with diseases of simple and routine nature of discipline categorized as super specialty are neglected. Super specialist is unable to attend on account of preoccupation with serious challenging problems. The general surgeon hesitates because of privileging issues, fear of allegations of negligence and litigation. The system of vertical division is based on premise that some disciplines deal with complex procedures and others with only simple and routine nature. This premise is incorrect. Each discipline is a mix of simple and complex cases requiring specialized treatment. Alternate modified organization of surgical service is proposed. Activities of all disciplines are scrutinized according to the level of expected competence by the end of training. Categorization is shifted from the “discipline' to “activities.” Criteria applied for classification of activities are as follows: on completion, the trainee is capable to assume full responsibility-category 1; has gained sufficient experience-category 2; and is conversant with broad understanding of management-category 3. Activities of category 1 from all disciplines are assigned to general surgery and those of category 3 from all disciplines are assigned to respective super specialty. Those in the middle, comprising difficult cases but not requiring specialized training or heavy inputs in equipment, are in category 2. They are assigned to general surgery as additional/optional items, or super specialty, guided by local factors. The scope and practice of general surgery are broadened with a shift from “residual” to “comprehensive” discipline. Advantages, concerns, collateral issues of horizontal distribution of activities, its positive impact on research and education are discussed. It is concluded that the proposed organization of surgical services is a rational, logical, and practical strategy for good-quality surgical care in the society. The super specialists need to be convinced that “taking load off” is good for the specialty.