Pre-assessment Clinics Research Articles

BN SO13 - Re-Audit of Biliary Pancreatitis Management: Enhancing Compliance with Timely Laparoscopic Cholecystectomy

Abstract Background Biliary acute pancreatitis requires timely management to prevent complications. Guidelines recommend laparoscopic cholecystectomy within two weeks of admission. A previous audit in our surgery department showed only 32.6% compliance with this guideline. This re-audit aimed to evaluate improvements in compliance, identify barriers, and provide insights for enhancing patient care. By retrospectively analyzing patient data from January to November 2023, we assessed progress and highlighted areas needing further improvement to align with established guidelines and ensure better patient outcomes. Method A retrospective analysis was conducted on a cohort of 32 patients admitted to the general surgery department with a diagnosis of biliary acute pancreatitis between January 2023 and November 2023. Patient records were reviewed to gather data on the timing of laparoscopic cholecystectomy performed within two weeks of the index admission. The compliance rate from this period was compared to a previous audit to assess improvements. Key barriers to timely intervention, such as the availability of ultrasound slots, hot gallbladder lists, and pre-assessment clinics, were also identified and analyzed. Statistical methods were used to confirm the significance of observed changes. Results he re-audit revealed a significant improvement in compliance with guidelines for the management of biliary acute pancreatitis. The percentage of patients undergoing laparoscopic cholecystectomy within two weeks of admission increased from 32.6% in the initial audit to 64.5% in the re-audit. However, the analysis identified persistent barriers to timely intervention, including limited availability of ultrasound slots, insufficient "hot gallbladder" surgical lists, and fear of difficulty of acute laparoscopic cholecystectomy. These findings highlight both the progress made and the areas needing further attention to enhance compliance and patient care. Conclusion The re-audit demonstrated a notable improvement in adherence to guidelines for the management of biliary acute pancreatitis, with a significant increase in timely laparoscopic cholecystectomy. Despite this progress, persistent barriers such as limited ultrasound availability, insufficient "hot gallbladder" lists, and pre-assessment clinics need to be addressed. Continuous evaluation and targeted interventions are essential to further enhance compliance, reduce complications, and improve patient outcomes. Ongoing efforts to refine clinical practices will help achieve the highest standards of care for patients with biliary pancreatitis.

Established and emerging theatre pharmacy services: a scoping review

Abstract Introduction Guidelines recommend that pharmacists contribute to perioperative patient care.[1,2] Expansion of perioperative pharmacy services was considered in Tallaght University Hospital following the appointment of a Critical Care & Anaesthesia Chief II Pharmacist. Preliminary research indicated that activities at surgical pre-assessment clinics, in critical care and on inpatient wards are well-documented, while theatre pharmacy services appear comparatively under-developed. Pharmacists are well-placed to promote the safe and cost-effective use of medicines in this high-risk environment. An understanding of the evidence base could provide a foundation on which pharmacy departments seeking to expand their clinical services can build. Aim To determine the range, extent and nature of theatre pharmacy services internationally, and to describe any reported outcomes of these services. Methods This scoping review was conducted and reported as per the Joanna Briggs Institute methodology for scoping reviews and the PRISMA-ScR checklist. The review protocol was registered on Open Science Framework. A search was conducted across electronic (Ovid® MEDLINE, Embase, CINAHL and PsycInfo) and grey literature databases (Google Scholar, BASE, CADTH, and Google) without limitations on date of publication, study type or language (where English translation available). A manual search of the citation lists of all included publications supplemented the electronic search. One reviewer screened titles and abstracts and carried out data extraction, with a 10% sample screened by a second reviewer. Two reviewers evaluated full texts. Critical appraisal was performed using the Mixed Methods Appraisal Tool where appropriate. A narrative approach to evidence synthesis was employed. Extracted data about the type of pharmacy service(s) and associated outcomes were studied to inform development of key concepts through which results were presented. Results Ninety-two publications were included from 3924 results. Fifty-seven were primary research articles. Most publications were descriptive in nature. Over half of the included publications described services in the United States; the remainder were from Australia, several European countries, Egypt, Morocco, Japan, China and Taiwan. The majority of theatre pharmacy services involved medication management, i.e. procurement, spending, storage, formulary development and distribution of medicines. Clinical services incorporated provision of medicines information, protocol and guideline development, antimicrobial stewardship, education and training of healthcare professionals, engagement with health informatics and medication safety projects, practice-based research and intraoperative emergency support. Reported outcomes included financial savings, improved accountability of controlled substances, improved patient safety and staff satisfaction with the service. Many publications highlighted improved inter-departmental relationships between pharmacy and anaesthesiology. Of the 57 primary research articles, 48 lacked a clear research question and so did not satisfy the MMAT screening criteria. Of the nine assessed, adherence to quality criteria ranged from 40-100%. Conclusion Evidence for theatre pharmacy services is extensive and varied. Empirical research of high methodological quality is required to assess the outcomes of these services. Strengths of this review include the use of reporting guidelines and quality appraisal of the evidence. This review may have been limited by the exclusion of non-English language publications. This review collates practical guidance on the development of theatre pharmacy services and highlights facilitators of successful service establishment.

How practitioner-led colonoscopy surveillance management improves productivity while saving money

Background: The British Society for Gastroenterology (BSG) guidelines for post-polypectomy and post-cancer-resection surveillance were changed in October 2020, essentially excluding a large proportion of patients awaiting a surveillance colonoscopy as they now no longer fit the criteria for surveillance. Aims: To audit the colonoscopy surveillance waiting list at the Wye Valley Trust to ascertain patient appropriateness for colonoscopy under the new BSG guidelines. Methods: A practitioner-led colonoscopy surveillance clinic led by a clinical endoscopist was set up to audit the colonoscopy surveillance waiting list of over 1200 patients. The aim was to clinically assess each patient against the guidelines and determine discharge from, or continuation of, the surveillance pathway for each patient. The patients were then offered outpatient clinic appointments where fitness was assessed and appropriate investigations were finalised. Results: Patient numbers on the colonoscopy surveillance waiting list were reduced by nearly 50%, with waiting times down to 0 weeks, by facilitating practitioner-led pre-assessment and outpatient clinics, all while saving Weston General Hospital almost £300000 in the initial 9 months. Conclusions: The new colonoscopy surveillance guidelines presented an opportunity to audit and evaluate the colonoscopy guidelines in the Wye Valley Trust. The facilitation of a clinical endoscopist committed time to implement new pre-assessment processes and outpatient clinics, this process allowed the discharge of almost 50% of patients upon the colonoscopy surveillance waiting list, it created extra colonoscopy capacity for 2 week wait and urgent colonoscopies, while generating a positive financial implication for the trust.

The Incidence of Surgical Cancellations: Lessons Learned from the Resumption of Elective Orthopaedic Operating after the First Wave of COVID-19

Category:Ankle; OtherIntroduction/Purpose:In the aftermath of the first wave of COVID-19, there was a significant backlog of elective orthopaedic cases. To address this problem, efficient running of theatres with optimal theatre utilisation was paramount. However, as new processes were introduced to reduce transmission risk, 'last-minute' cancellations of patients were inevitable. We report our experience of resuming elective work, with particular focus on surgical cancellations, and lessons learned.Methods:This was a retrospective, single centre audit at a specialist elective orthopaedic hospital. We identified and examined all cancellations in foot and ankle cases between June and October 2020. Data was analysed and cancellations were categorised into groups by reason of cancellation.Results:There were 36 cancellations out of 193 patients listed (19%). Twenty-one cancellations (57%) were directly related to COVID-19 and its processes. These comprised six patients (17%) with COVID-19 swab related issues including: booking errors, transport problems, non-attendance, and invalid swabs. Three patients (8%) contracted COVID-19 preoperatively. Nine patients (25%) cancelled their procedure at short notice amidst fears of contracting COVID-19 perioperatively. Three (8%) cancellations were due to the patient being unfit on the day of surgery - these issues were not routinely identified at pre-assessment appointments as face-to-face pre-assessment clinics had been suspended. A further 15 cancellations (42%) were due to non- COVID-19 reasons including lack of beds, unwell patients, and patients cancelling for other personal reasons.Conclusion:Mitigation of cancellations is a key factor in maintaining theatre utilisation. Based on our experience we recommend thorough counselling of patients regarding the importance of self-isolation prior to surgery and of the pre-operative swab. Having a designated team to manage COVID-19 swabs is also critical. Reinstatement of face-to-face pre-operative assessments may help identify evolving issues and prevent last-minute cancellations. These lessons are pertinent to trusts, particularly as we emerge from subsequent waves of COVID-19.

Introducing a reserve waiting list initiative for elective general surgery at a District General Hospital

Cancelled operations represent a significant burden on the National Health Service in terms of theatre efficiency, financial implications and lost training opportunities. Moreover, they carry considerable physical and psychological effects...

Absence of Association between Preoperative Estimated Glomerular Filtration Rates and Postoperative Outcomes following Elective Gastrointestinal Surgeries: A Prospective Cohort Study

Background Preoperative risk stratification and optimising care of patients undergoing elective surgery are important to reduce the risk of postoperative outcomes. Renal dysfunction is becoming increasingly prevalent, but its impact on patients undergoing elective gastrointestinal surgery is unknown although much evidence is available for cardiac surgery. This study aimed to investigate the impact of preoperative estimated glomerular filtration rate (eGFR) and postoperative outcomes in patients undergoing elective gastrointestinal surgeries. Methods This prospective study included consecutive adult patients undergoing elective gastrointestinal surgeries attending preassessment screening (PAS) clinics at the Queen Elizabeth Hospital Birmingham (QEHB) between July and August 2016. Primary outcome measure was 30-day overall complication rates and secondary outcomes were grade of complications, 30-day readmission rates, and postoperative care setting. Results This study included 370 patients, of which 11% (41/370) had eGFR of <60 ml/min/1.73 m2. Patients with eGFR < 60 ml/min/1.73 m2 were more likely to have ASA grade 3/4 (p < 0.001) and >2 comorbidities (p < 0.001). Overall complication rates were 15% (54/370), with no significant difference in overall (p=0.644) and major complication rates (p=0.831) between both groups. In adjusted models, only surgery grade was predictive of overall complications. Preoperative eGFR did not impact on overall complications (HR: 0.89, 95% CI: 0.45–1.54; p=0.2). Conclusions Preoperative eGFR does not appear to impact on postoperative complications in patients undergoing elective gastrointestinal surgeries, even when stratified by surgery grade. These findings will help preassessment clinics in risk stratification and optimisation of perioperative care of patients.

9Implementation of opportunistic screening at Pre-Assessment Clinics for upgrade/downgrade of cardiac devices

9Implementation of opportunistic screening at Pre-Assessment Clinics for upgrade/downgrade of cardiac devices

Preassessment clinic interview and patient anxiety.

Background:It is widely recognized that patients have increased anxiety before elective surgery, however, previous research investigating the effect of preassessment clinics (PACs) on anxiety levels has been limited specifically to patient information literature or multimedia use, rather than the consultation process itself. The aim was to investigate the effect attendance at PAC had on patients’ anxiety levels, associated with their subsequent surgery and anesthetic.Materials and Methods:This survey consisted of a cross-sectional, questionnaire-based, quantitative study investigating patients’ anxiety levels before and after attendance at the PAC. The questionnaire consisted of a series of statements concerning the surgery and anesthetic and rated using a Likert-type scale. All adult patients who attended an appointment at the PAC were eligible to participate in the study. Those unable to read and understand the questionnaire were excluded.Results:Overall 121 participants were included in the study. Participants felt less anxious about their subsequent surgery and anesthetic following consultation at the PAC (P < 0.001). This was true for both gender subgroups (P < 0.05) Concerns about intraoperative complications generated the most anxiety. Postoperatively, male participants were most anxious about pain and females about nausea and vomiting. Participants also reported high satisfaction rates for the service at the PAC.Conclusions:This study contributes to a greater understanding of preoperative anxiety and has important implications for PACs. This clinical survey has been able to demonstrate that consultation at the PAC has a statistically significant positive effect on alleviating patients’ anxieties in regards to their surgery and anesthetic.

Use of a patient completed iPad questionnaire to improve pre-operative assessment.

Developments in healthcare technology could improve patient care and reduce healthcare costs. There is a need to facilitate communication and increase efficiency in surgical pre-assessment clinics. This study aimed to develop an iPad application to deliver an electronic patient questionnaire, and to evaluate its use in the pre-assessment environment. Software was developed, MyOp, for a standard iPad that mirrored the paper-based pre-assessment system, with features designed for ease of patient use and remote data transfer. A case-control study was conducted, comparing use of MyOp with paper-based practice, to evaluate feasibility and patient preference. Patients were offered the use of MyOp or paper-based system. Outcomes measured included time to complete iPad questionnaire, consultation duration, and a patient preference questionnaire. MyOp cost £3500 to develop. 104 individuals participated in the study, 53 MyOp and 51 controls. MyOp reduced the median consultation duration by 5.00min. A reduction was seen in all subgroups except those aged over 70 or urology patients. Patients preferred to complete the form independently, using a touchpad or computer but expressed concerns about data security. Use of an electronic patient questionnaire reduces consultation time delivering greater efficiency of pre-assessment nurse time. Preconceived ideas about the use of technology in older age groups are likely inaccurate and less of a barrier than previously thought. Electronic pre-assessments could be used routinely to reduce demands on healthcare facilities, improve patient care, and triage patients prior to clinic attendance.

PWE-437 The effectiveness of a collaborative educational programme between 2 centres for newly appointed screening specialist practitioners (ssps)?: Abstract PWE-437 Table 1

<h3>Introduction</h3> Within the Bowel cancer screening programme- Specialist Screening practitioner have a pivot role. Training new SSPs can take up 1 year and include gaining competencies in pre-assessment clinics for patients on the FOBT programme and compulsory attendance and attainment of the JMU course. The introduction of bowel scope has led to the significant increase in recruitment of SSP to cope with the programme. <h3>Method</h3> Two separate BCSP programmes in the Northwest and Cheshire, recruited 8 new SSP to deal with the demand of bowel scope. They collaborated to deliver a multidisciplinary weekly educational programme between 2 sites to help accelerate training of the new SSPs. After the course, the SSPs were asked to complete an anonymous feedback questionnaire on the effectiveness of the course rating 0–10 (10-best score). <h3>Results</h3> Tutorial lasted 1–2 h and covered: SSP role, colonoscopy and assessment, documentation, 3x sessions on complex cases, pathology and cancer datasets, AVI reporting, lesion recognition, EMR, Difficult pathways on open Exeter, management of new anticoagulants. Tutors include clinical director, lead colonscopists, Associate specialist, lead Specialist Screening Practitioner (Nurse) and a Programme Manager On average seven SSP between the 2 sites attended each tutorial. <h3>Conclusion</h3> Collaboration between two sites can lead to an effective delivery of educational programme for SSPs. <h3>Disclosure of interest</h3> None Declared.

G529(P) The paediatric short stay unit: the power of data in tackling a ‘wicked’ problem

Context This improvement project took place within the paediatric short-stay unit (PSSU) of a busy inner-city tertiary referral hospital. The aims were firstly to streamline care pathways of patients using the unit, and secondly, to improve patient’s and staff’s experiences. Problem The PSSU, which opened 9 years ago, was designed as an unit for acute paediatric short-stay admissions and a facility to accommodate ambulatory work. It comprises of eight inpatient beds, one clinic room and a waiting/playroom. Since opening, unit activity has grown rapidly, with numerous teams using the facility for a variety of reasons. Rapid-access, surgical pre-assessment and prolonged jaundice clinics were incorporated, and more inpatients were discharged early, to complete ambulatory antibiotic courses facilitated by the unit. There were no robust systems in place to record the unit’s type and amount of activity. The ‘short stay’ identity was progressively lost with the inpatient beds often occupied by long-term chronic patients. Staff morale was low and it was suspected that patient experience was suboptimal due to the significant time spent waiting for clinic rooms to be available. Notes were often missing due to the multiple poorly defined referral routes into the unit. Assessment of problem and analysis of its causes The problem was brought to the ‘Quality Improvement Sprint’, an innovative forum in which healthcare professionals teamed up with artists, musicians and designers to use creative thinking to tackle problems within the trust. It became apparent that without information regarding activity and patient journeys through the unit, it would be impossible to identify interventions which would improve function. Intervention A seven-day data gathering exercise was designed to map the journey of every patient who passed through PSSU. Each child and family completed a patient experience proforma and staff kept daily activity diaries. Activity in the Emergency Department (PED), other inpatients wards and day surgery unit was also collected. Strategy for change The data clearly showed that the high level of activity on PSSU was unsustainable within its confines. Conversely, activity on the adjacent surgical day unit was much lower, indicating suboptimal use of space and highlighting an opportunity to redesign and improve functionality. Many short-stay patients were admitted to the other wards, whilst longer-stay patients were admitted onto PSSU. Particular breeches in the PED were felt to have been avoidable if short-stay beds had been available. Although patient experience was positive, feedback from the staff emphasised the frustration of working in such a chaotic environment. The information was fed back to the Paediatric Executive Board. Effects of changes The PSSU is reclaiming it’s short-stay status. Nurse-led discharge has been introduced and admission pathways from the PED redesigned to improve patient flow. A ‘virtual PSSU’ trial is underway on the ward, with ring-fencing of a number of beds to be reserved for short stay patients and to be staffed by PSSU. Relevant workload has been diverted to outpatients and a merger of PSSU and surgical day unit is being considered. Modelling of very short-stay patients suitable for a co-located observation bay, is informing plans for the PED rebuild. Lessons learnt Initially the ‘PSSU problem’ seemed too complicated to solve. Working with designers in the QI Sprint allowed us to devise a novel approach to improving the quality of care provided within the PSSU. The data gathering exercise was very powerful and quantified the issues objectively. This enabled us to devise a clear message when disseminating findings and campaigning for change. Mapping individual patient journeys brought a human face to the unit. Message for others Data is powerful and can help define an ‘undefinable’ problem.

Parents' lived experience in the anaesthetic room

Background: It is a common practice today in the UK that the majority of children are accompanied to the operating theatre by one or two parents. The Association of Anaesthetists of Great Britain and Ireland (AAGBI) recommends that this is offered to the parents as a recommended standard of care ( AAGBI, 2010 ). Aim: To describe the lived experiences of parents whose children had been scheduled for induction of general anaesthesia. Methods: This study (n=13) adopted a single-method approach involving purposeful sampling to select the participants aged 18–75 years, recruited from the pre-assessment clinics. The use of in-depth interviews was used to generate data about the participant's personal experiences. It is based on a descriptive approach within a phenomenological framework. Results: The analysis of the interviews and narrations of the participants led to the extraction of five major themes consisting of emotional impact, views of the impact of their presence, professional issues, information need and coping strategies. Conclusion: The experience of parents witnessing their children in the anaesthetic room being placed under anaesthesia can be considered to be stressful for the parents. Intervention strategies are needed to reduce the stress for the parents during this period. Health professionals need to have a better understanding of the individual coping strategies to support each parent and the impacts on parents' wellbeing.

Implementation of an integrated preoperative care pathway and regional electronic clinical portal for preoperative assessment.

BackgroundEffective surgical pre-assessment will depend upon the collection of relevant medical information, good data management and communication between the members of the preoperative multi-disciplinary team. NHS Greater Glasgow and Clyde has implemented an electronic preoperative integrated care pathway (eForm) allowing all hospitals to access a comprehensive patient medical history via a clinical portal on the health-board intranet.MethodsWe conducted six face-to-face semi-structured interviews and participated in one focus group and two workshops with key stakeholders involved in the Planned Care Improvement (PCIP) and Electronic Patient Record programmes. We used qualitative methods and Normalisation Process Theory in order to identify the key factors which led to the successful deployment of the preoperative eForm in the health-board.ResultsIn January 2013, more than 90,000 patient preoperative assessments had been completed via the electronic portal. Two complementary strategic efforts were instrumental in the successful deployment of the preoperative eForm. At the local health-board level: the PCIP led to the rationalisation of surgical pre-assessment clinics and the standardisation of preoperative processes. At the national level: the eHealth programme selected portal technology as an iterative strategic technology solution towards a virtual electronic patient record. Our study has highlighted clear synergies between these two standardisation efforts.ConclusionThe adoption of the eForm into routine preoperative work practices can be attributed to: (i) a policy context – including performance targets – promoting the rationalisation of surgical pre-assessment pathways, (ii) financial and organisational resources to support service redesign and the use of information technology for operationalising the standardisation of preoperative processes, (iii) a sustained engagement with stakeholders throughout the iterative phases of the preoperative clinics redesign, guidelines standardisation and the eForm development, (iv) the use of a pragmatic and domain-agnostic technology solution and finally: (v) a consensual and contextualised implementation.Electronic supplementary materialThe online version of this article (doi:10.1186/1472-6947-14-93) contains supplementary material, which is available to authorized users.

Prise en charge du tabagisme périopératoire : enquête de pratiques en région Lorraine

IntroductionEvidence shows that smoking leads to more perioperative complications. Smoking cessation before surgery reduces this postoperative morbidity. The French Society of Anaesthesia and Intensive Care published recommendations on this subject in 2005. We wanted to assess knowledge and practice amongst anaesthetists in Lorraine as regards the management of smoking in the perioperative period. MethodsWe conducted an internet-based survey of 365 anaesthetists in the Lorraine region during November and December 2011. At the same time, we also surveyed patients attending pre-assessment clinic at the CHU hospital, Nancy. ResultsHalf the practitioners surveyed were aware of the 2005 guidelines. Most pre-assessment clinics do not display posters warning of the perioperative hazards of smoking. The need for smoking cessation advice as a bare minimum is acknowledged by 47.9% of experienced practitioners; 76.3% of anaesthetists claim to offer advice occasionally, frequently or systematically. On the other hand, only 17% of the patients surveyed report receiving such advice. ConclusionDespite published guidelines on the benefits of smoking cessation prior to surgery, Lorraine anaesthetists fail to systematically advise their patients in this regard. We believe there is a need to improve the management of these patients, either through the development of smoking cessation protocols locally or through patient referral to a specialised clinic.

PTU-257 “Trials and tribulations of setting up an anaesthetist led day-case endoscopy list”

IntroductionEndoscopy in UK is performed under conscious sedation in daycase (DC) endoscopy units. Patients intolerant of the procedure subsequently undergo the procedure under a general anaesthetic in operating theatres. However...

Analysis of adherence to published guidelines for vestibular schwannoma screening: Correlating published guidelines to diagnostic yield

Analysis of adherence to published guidelines for vestibular schwannoma screening: Correlating published guidelines to diagnostic yield

OC-091 Modernising the endoscopy workforce: the development of an endoscopy assistant role

Introduction In order to meet the demands of the 2-week rule and to satisfy the 31 and 62-day cancer targets of the NHS Cancer Plan (2004), endoscopy units need to provide an effective, high quality and, above all, timely service. The rate limiting step in endoscopy service provision had been identified by the Healthcare Commission in 2005 as a shortage of suitably trained endoscopy nurses. It estimated 20% capacity lost nationally but local experience was nearer 30% (135/400 h per week of Qualified Nurse (QN) time lost through a combination of causes in Aug 2005). This led to list cancellations, often at short notice, to the detriment of patient care and waiting times while limiting staff opportunities for further career development such as specialist roles (IBD), nurse-led clinics (polyp surveillance) and improvement initiatives such as nurse-led consent and pre-assessment clinics. Within endoscopy, there are traditionally two levels of nurse support; QN and Health Care Assistants (HCAs). The latter while having developed their roles considerably to level 3 NVQ were unable to act up within the room and adopt some of the more advanced practices of the QN such as assisting with therapeutic procedures while the former could act down. We identified a need for service improvement and experienced HCAs in whom we saw potential for career development in support of the service. Methods 5 trainees (4WTE) were selected by interview (min requirement: NVQ 3 and 2 years endoscopy experience). We developed an in-house training programme and syllabus, agreed a Scope of Practice and a Clinical Governance framework with the support of our Trust Practice Development Team and funding from Aimhigher. We commissioned a module with Teesside University to address professional issues. A competency-based job description was mapped against the NHS Knowledge and Skills Framework (DOH 2005). In-house training and assessment was completed over 10 months and supported by a programme of tutorials, workshops and mentorship under supervision of nurse trainers. The university module took place over academic year 2008–2009. Results All five successfully completed in-service training, competency-based assessments and a Teesside University Certificate: Foundations in Endoscopic Practice (60 credits at level 1). In 6 months, they have assisted a QN in 60 complex procedures such as ERCP and also 55 acute upper GI bleeders at times when a second QN was unavailable. Our QNs now have the opportunity to develop their roles such as preassessment and nurse led clinics as envisaged. Conclusion This programme broadened the range of roles within the unit, with greater opportunity for career development at all levels and greater flexibility of working practices that has benefited the service and patient care.

Management of patients taking herbal medicines in the perioperative period: a survey of practice and policies within Anaesthetic Departments in the United Kingdom

Patients commonly take a combination of prescription drugs and herbal medicines. Often these alternative products have known pharmacological effects which may interact with drugs given perioperatively, resulting in adverse events. They can also cause physiological fluctuations which may influence the choice of anaesthetic technique used. This has been acknowledged by a number of national bodies that recommend eliciting a history of herbal medicine use preoperatively. This survey attempted to ascertain whether this guidance had been observed and turned into local policy. We also attempted to determine what advice patients were being given. Three hundred and twenty-one questionnaires were sent to all United Kingdom hospitals with an Anaesthetic Department in September 2006. Reminders were then sent to those recipients who did not respond. Replies were received from 233 (72.6%) anaesthetic departments. Seventeen (7.3%) departments have a perioperative herbal medicine policy in place and a further six had plans to develop one. The majority (98.3%) of departments did not have a specific section for documenting herbal medicine use on their an aesthetic records. Of the departments that held pre-assessment clinics, 34 (15.7%) asked patients routinely about herbal medicine use, and the advice given regarding the use of herbal medicines was varied, and generally, not in accordance with existing guidelines. Anaesthetic departments in the United Kingdom are not currently following national advice regarding herbal medicine use. There is no coherence in the advice being offered to patients in the perioperative period, which may reflect the lack of information available. National guidelines may help clinicians understand the issues and adopt best practice.

Daycase laparoscopic gynaecological procedures--current trends in anaesthetic management.

Laparoscopy for gynaecological procedures is minimally invasive and is mostly performed as a daycase. The advancement of laparoscopy and minimal access surgery has greatly influenced the evolution of anaesthetic techniques. Preoperative assessment can be simplified by the use of questionnaires in pre-assessment clinics. Intraoperative intravenous fluid administration improves patient well being while airway management can be by the age-old, tried and trusted orotracheal tube or by the newer laryngeal mask airways. The use of propofol as an induction agent, a short acting non-depolarizing muscle relaxant e.g. mivacurium, an inhalational anaesthetic agent with a fast wake up time e.g. sevoflurane or desflurane, and short acting opioids e.g. fentanyl guarantees quick recovery of patients. The trend towards a multimodal approach to postoperative pain and prevention of postoperative nausea and vomiting (PONV) improves postoperative profile of day case gynaecological patients. Expertise in providing a pneumoperitoneum with carbon dioxide is desirable even as other options for lifting the abdominal wall are being investigated.

Should patients set the agenda for informed, consent? A prospective survey of desire for information and discussion prior to routine cataract surgery

To ascertain the level of information relating to specific risks desired by patients prior to cataract surgery. Dedicated cataract surgery pre-assessment clinics of 2 hospitals in South West Wales, UK. Consecutive patients (106) were recruited prospectively. Of these, 6 were formally excluded due to deafness or disorientation. Eligible patients (100) were asked a set of preliminary questions to determine their understanding of the nature of cataract, risk perception, and level of information felt necessary prior to giving consent. Those who desired further information were guided through a standardized questionnaire, which included an audio-visual presentation giving information relating to each potential surgical complication, allowing patients to rate them for relevance to their giving of informed consent. Of the entire group of 100, 32 did not wish to know "anything at all" about risks and would prefer to leave decision making to their ophthalmologist; 22 were interested only in knowing their overall chance of visual improvement; and 46 welcomed a general discussion of possible complications, of whom 25 went on to enquire about specific complications. Of these 25, 18 wished to be informed of posterior capsular (PC) tearing, 17 of endophthalmitis, 16 each of dropped lens, retinal detachment and corneal clouding, and 15 of bleeding, sympathetic ophthalmia, and PC opacification. Patients differ in their desire for information prior to cataract surgery, with one significant minority favoring little or no discussion of risk and another wishing detailed consideration of specific risks. A system of consent where patients have a choice as to the level of discussion undertaken may better suit patients' wishes than a doctor-specified agenda.