Much of the variation seen in surgical outcomes can be explained by differences in the quality of management of post-operative complications and ward-based care. The surgical ward round (WR) is critical to determining post-operative care and serves as the primary point of interaction between clinician and patient. Despite this, it is an area not subject to training or assessment at present. This thesis demonstrates the high degree of variability which exists in the conduct of WRs. It establishes the link between suboptimal patient assessment and increased risk of preventable post-operative complications. These place patients not only at risk of short-term deterioration, but result in reduced long-term survival as well. In order to quantify WR quality, a novel assessment tool has been developed and validated within a simulated environment. Ward simulation is a nascent branch of simulation which has been only preliminarily explored to date. A simulation environment was developed to take advantage of the known benefits of simulation such as controllability, reproducibility, and recordability, whilst maintaining a high level of fidelity and realism. An evidence-based curriculum for surgical WR training was designed and implemented in a simulation-based course. By focusing on structured generic processes of patient assessment and management, this resulted in significant improvement of trainee performance in routine WRs. To ensure standardised and optimum management of specific conditions, checklists have proven themselves to be of great value in a number of surgical and medical disciplines. Surgical complications are common, yet their management often suboptimal. As part of this thesis, evidence-based protocols for the management of the six most common complications were designed and validated. The implementation of these in a simulation-based randomised, controlled trial has resulted in greatly increased adherence to evidence-based standards of care, as well as improved communication and clinician performance. This thesis explores the variance currently present in surgical ward rounds, and the potentially grave consequences of this for patient outcomes. To date, WRs have been one of the last areas of surgical care still dependent on the Halstedian principle of experiential learning alone. The tools have now been developed with which to assess, improve, and standardise critical structures and care processes in the assessment and management of the post-operative surgical patient. Future implementation of these and integration into surgical curricula will benefit clinician training, patient care, and surgical outcomes alike.
| Identifer | oai:union.ndltd.org:bl.uk/oai:ethos.bl.uk:656715 |
| Date | January 2014 |
| Creators | Pucher, Philip |
| Contributors | Darzi, Ara; Aggarwal, Rajesh |
| Publisher | Imperial College London |
| Source Sets | Ethos UK |
| Detected Language | English |
| Type | Electronic Thesis or Dissertation |
| Source | http://hdl.handle.net/10044/1/24994 |
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