Líneas de trabajo futuras

Round One Round Two

Included Processes

Score (1-9) IQR All patients with severe sepsis or septic shock should have blood cultures taken and antibiotics

administered within 3 hours of admission (Dellinger et al., 2008). 9 0.5* - - Resuscitation or maintenance with intravenous fluid should be instigated where appropriate

(Powell-Tuck et al., 2008). 9 0.5* - -

Emergency surgical admissions should be to a ward which is appropriate for their clinical condition in terms of required specialty, level of care and presenting complaint (Martin et al., 2007a).

9 1.0* - -

Patients who are bleeding or at risk of bleeding should have a group and save sample taken. 9 1.0* - -

A clear treatment plan should be documented in the casenotes (Martin et al., 2007a). 9 1.0* - -

A clear handover should be made to the incoming surgical team, including patient name, location, diagnosis and investigations (Martin et al., 2007a, Royal College of Surgeons of England, 2007).

9 1.5* - -

By the time of the post-take ward round a preliminary diagnosis should have been made. 8 0.5* - -

The initial assessment of patients should include a doctor of sufficient experience and authority

to implement a management plan (Martin et al., 2007a). 8 1.0* - - Adequate intravenous access should be secured. 8 1.0* - -

Appropriate analgesia should be administered and titrated as necessary. 8 1.0* - -

Patients with haemodynamic instability should have a urethral catheter placed to monitor fluid

balance. 8 1.0* - -

Patients with persistent vomiting and signs of obstruction should have a nasogastric tube placed. 8 1.0* - -

Documentation of the first consultant review should be clearly indicated in the casenotes (Martin

et al., 2007a). 8 1.0* - -

Vital signs observations, including fluid balance, should be recorded in line with the physiological

monitoring plan and not less than twelve hourly (DeVita et al., 2010, 2007). 8 1.5* - - Basic bloods (U&E, FBC, CRP where appropriate) should have been performed. 8 1.5* - -

Casenotes for patients previously treated at the hospital should be obtained. 8 1.5* - -

Casenote entries should be legible, dated, timed and signed (Martin et al., 2007a). 8 2.0 8 0.5† Patient’s allergy status and routine medication should be transcribed onto the medication chart

unless contraindicated. 8 2.0 8 1.0†

Patients admitted as an emergency should be seen by a consultant at the earliest opportunity. Ideally this should be within 12 hours and should not be longer than 24 hours (Martin et al., 2007a).

8 2.0 8 1.5† A clear physiological monitoring plan should be made and documented for each patient (e.g. 4

hourly observations)(2007, Martin et al., 2007a, DeVita et al., 2010). 8 2.0 8 1.5† Patients with reduced oxygen saturation or PaO2 (usually less than 95%) should have

supplemental oxygen administered (Anderson, 2003). - - 8 0.5† Round One Round Two

Excluded Processes

Score (1-9) IQR A plan for oral intake should be documented in the casenotes. 7 1.0* - -

If a significant concurrent medical illness is apparent then the appropriate medical team should

be involved. 7 1.5* - -

Appropriate plain radiology should be complete. 7 1.5* - -

If NBM, important oral medications should be converted to an alternative route. 7 1.5* - -

All suitable patients should have appropriate thromboprophylaxis (2010). 7 2.0 7 1.5† Excessive transfers both within and outside the hospital should be avoided (Martin et al., 2007a). 7 2.5 7 1.5† Patient’s exercise tolerance and functional status should be clearly documented in the casenotes. - - 7 1.5†

IQR interquartile range; U&E urea and electrolytes; FBC full blood count; CRP C-reactive protein; PaO2 partial pressure of

oxygen

128 Some variation in opinion also occurred in processes accepted for the final list, again commonly between doctors and nurses. Doctors considered the teamwork processes of initial assessment by a suitable doctor (median 8 from doctors vs. 6 from nurses), consultant review within 24 hours (median 8 vs. 6) and clear handover (median 9 vs. 8) very important but nurses scored them less highly. Conversely nurses believed that clear, legible documentation would improve outcome but doctors were less sure (median 9 from nurses vs. 8 from doctors).

9.6. Discussion

This study has identified a core list of 21 processes that clinically experienced assessors believe will improve outcome for EGS admissions. This list will allow a quantitative assessment of the

effectiveness of care for EGS admissions and may provide the basis for future interventions. Six of the processes in the initial list came from available guidelines or an evidence base for their use in published literature. Of these six, five were accepted by the panel and included in the final list however thromboprophylaxis, with the weight of several randomised controlled trials, meta-

analyses and a NICE guideline, albeit predominantly in elective patients, was not accepted. The nurse participants were in favour of this process, possibly because of ward protocols advocating

thromboprophylaxis, but doctors were less convinced, perhaps considering that the potential risks of thromboprophylaxis outweigh the benefits in emergency patients.

The initial list of statements included nine recommendations from the recent NCEPOD report on emergency admissions (Martin et al., 2007a). Eight of these processes were accepted by the panel for the final list however “excessive transfers both within and outside the hospital should be avoided” was not. Though nurses, who have first-hand experience of the problems caused by transfers, considered that its implementation would improve outcomes, doctors did not and suggested that it may actually be beneficial when indicated by the patient’s disease or clinical condition. Responses by doctors resulted in this process being rejected.

129 Differences of opinion were apparent for a number of processes and this was not surprising given the differing backgrounds of the participants. It was not a shock to see that while surgeons are keen on physicians’ input for their patients, anaesthetists would much rather manage medical conditions themselves. Nurses scored protocol and documentation processes highly but doctors valued senior doctor involvement and teamwork and this reflects the inherently different cultures of these healthcare professions.

Previous work in this area has confined its process analysis to either the literature or expert opinion alone (Kreckler et al., 2009, Stevenson et al., 2007) and explored a much smaller set of processes than this study encompasses. The use of a comprehensive search strategy and a robust method of process selection have produced a useful and repeatable list of processes on which to base further research.

9.6.1. Limitations

As with any consensus process this Delphi is subject to a number of limitations. The primary

limitation is the lack of robust evidence for participants to base their judgements upon. Clearly this is the main reason consensus methods are required in the first place. Secondly the consensus

gathering itself is only as good as the panel assembled. There is a risk of deriving “collective

ignorance” rather than group knowledge (Jones and Hunter, 1995), however, by including a range of healthcare professionals in the process and ensuring appropriate experience of the panel, this risk has been minimised. This limitation may be illustrated by the exclusion of thromboprophylaxis, against the recommendation of NICE guidelines and current clinical practice, however the panel recommendation is in line with the equivocal literature review on this topic (Bergqvist et al., 1996).

There were varying opinions for a number of processes but the differing occupation of participants ensured a more balanced consensus. It is possible that nursing opinions were underrepresented as there were only three nurses on the panel, however it is not possible to fully balance the groups of

130 doctors versus nurses and those of anaesthetists versus nurses versus surgeons and therefore a pragmatic approach was taken. As discussed in Chapter 5 (Section 5.5.1) participants were limited to experienced clinical staff at a single institution and many were known to the research team in advance. This may have resulted in bias given the lack of opinion from other NHS hospitals and the fact that some staff may have felt obliged to participate based on their previous encounters with the research team. Published experts in the field of emergency surgery may have weighted responses differently and, should the study be repeated, a wider and more experienced group of participants could be used, especially in view of the development of significantly greater numbers of senior clinicians with a stated interest in emergency general surgery.

A final limitation is the lack of communication and discussion between participants that, while it avoids some personal and professional interests dominating others, does not allow reasoned argument or development of additional ideas.

9.7. Conclusion

This Delphi process used consensus methodology to develop an explicit list of standard processes for the initial treatment of emergency surgical admissions. The following chapter will use the process list developed in this study to make an assessment of the effectiveness of care for EGS admissions in multiple NHS institutions. This list can also be used to audit treatment of EGS admissions, as a checklist intervention to try to improve process reliability and as a training tool for the junior medical staff who usually perform the majority of these processes.

131

10. ADHERENCE TO FUNDAMENTAL CARE PROCESSES FOR THE