AAGBI/Anaesthesia Research Grants

Background to Study:
Medical error may be the third leading cause of death in the US. Current changes in workplace training of doctors such as the European Working Time Directive have decreased training time and acquisition of procedure based skills which can lead to increased numbers of medical errors.

One method designed by our group to mitigate performance related risks to patients is proficiency based progression. It involves the detailed characterisation of a procedure into objective unambiguously defined steps and possible errors, known as metrics. Once defined, they allow the creation of an assessment tool that is subjected to a process of consensus by a group of experts (called the Delphi technique) to ensure it is accurate and represent the procedure being assessed. Once metrics are applied within a training programme, they have resulted in a 20-50% decrease in errors once the procedure is performed.

Nerve blocks are a procedure which involves locating a nerve within the body, often with an ultrasound, and injecting a drug known as a local anaesthetic close to it, in order to temporarily disrupt its function. Benefits include pain relief in the area of surgical operation, however it requires significant skill to perform. Previous work at our institution has defined proficiency based progression for nerve blocks of the arm and we hope to define the same for popliteal nerves which supply sensation to the foot.

Aims & Methodology:
This will be a single centre observational study.

In order to facilitate this process, videos of the procedure will be captured on patients. Approximately 10 recordings will be needed. The patients will be having the procedure as part of their normal care for foot and ankle surgery as outlined by their primary anaesthesiologist. Written informed consent will be obtained prior to any anaesthetic management being started.

1. Define the Metrics of Ultrasound Guided Popliteal Nerve Blocks
This will be defined by a panel of experts who will breakdown and define the procedure into its components and possible errors, that can be objectively measured, in a series of meetings. This will allow creation of an assessment tool.

2. Defined Metrics will be subject to the Delphi technique
An external panel of experts will meet and will vote on each defined metric to ensure it is accurate and represents a valid component of the procedure.

3. Testing of Assessment tool
Video recordings will be assessed using the assessment tool by two trained assessors. This is to ensure it measures what it is supposed to and does not produce differing results when applied by different assessors.

Outcomes:
We expect to create an objective assessment tool for ultrasound guided popliteal nerve blocks that we can then apply to a proficiency based training programme to train anaesthesiologists in this skill. The overall goal is to create objective assessment tools for the most common nerve blocks to create a regional anaesthesia (nerve block) training programme for anaesthetists.

Background:
Many patients in intensive care experience pain. Over two thirds of patients rate this as moderate to severe pain. They experience it for over half of the time they spend in intensive care. Often patients are taking strong pain medicine yet still feel pain. Pain can lead to slower recovery, staying in hospital for longer, more complications such as chest infections and having pain long term, even after leaving hospital. We know just assessing pain can improve pain treatment however less than half of patients in intensive care are assessed to see whether they are in pain. We also know that they are not being assessed using recommended techniques. We do not understand why this happens. It may be because it is difficult to assess pain when patients are very sick and unable to talk. It may be that the doctors and nurses focus on other aspects of care rather than pain. Guidelines for how to best assess pain in intensive care have been published in the United States. These include ways to assess pain even in patients unable to talk. However, these are not routinely used in the UK.

Aims:
This study aims to understand why pain is often not assessed in intensive care. It wants to find out what barriers exist to assessment and treatment of pain in intensive care. If we understand the barriers to assessing and treating pain, it could help us develop UK specific guidelines and education for doctors and nurses to improve pain management in intensive care.

Methods:
This study involves two parts. This first is a qualitative project interviewing doctors and nurses with different levels of experience, who work in hospitals where we know pain in intensive care is assessed very well or less well. Each interview will be conducted one to one with a researcher. These will explore views and beliefs about assessing pain and treating pain in intensive care. The interviews will be reviewed to highlight important issues surrounding pain assessment and management in intensive care. The second part of this study is to use the issues found to develop a survey that can be completed by intensive care doctors from across the UK to understand more about how they assess pain and manage pain in intensive care.

Expected outcomes and implications:
The interviews will be used to develop a survey tool. The results from the survey tool will be firstly shared with patient groups to see if this reflects their experiences of pain in intensive care. Additionally it will be discussed with both intensive care and pain national societies to help develop UK guidelines regarding pain assessment and management in intensive care. It is hoped this will improve the assessment and management of pain for all patients in intensive care.

Background:
The World Health Organization defines haemoglobin concentration <120 g/L as anaemia in non-pregnant women, whereas the definition in men is haemoglobin concentration <130 g/L. Therefore, women with haemoglobin levels of 120-130 g/L (which we define as borderline anaemia) will not be treated before surgery, potentially putting them at a disadvantage.
These women are more likely to receive a blood transfusion during or after surgery - the risk is almost doubled. From other studies, we know that blood transfusion carries a risk of more complications, such as death, kidney failure and longer hospital stay. The most common reason for anaemia is iron deficiency. This can be treated with an infusion of intravenous iron, which can now be safely given in 15 minutes as an outpatient, and increases haemoglobin in around two or three weeks, meaning it could be given before surgery without delaying it. However, its use for cardiac surgery in women with borderline anaemia has not been objectively studied before.

Aims:
To observe and quantify the effect of intravenous iron, when given to cardiac surgical women with borderline anaemia an iron deficiency, on haemoglobin level before surgery.

Experimental design:
All patients scheduled for cardiac surgery will have blood tests, including haemoglobin concentration, taken immediately after the decision to proceed to surgery. Women with haemoglobin concentration 120-130 g/L will be approached to have more blood tests taken to determine the reason for the lower haemoglobin concentration. If iron deficiency is the underlying cause, the patient will have the study explained to them and offered the opportunity to take part. If they agree, they will be given a single dose of intravenous iron in the clinic. The haemoglobin level and tests for iron status will then be repeated when they are admitted to hospital immediately before surgery. During their stay in the hospital data will be collected to assess the safety and efficacy of the intravenous iron. Three UK centres will take part in this trial: Papworth (Cambridge); Liverpool (Heart and Chest Hospital); and Cardiff (University Hospital of Wales). We have calculated that, to see whether the increase in haemoglobin we expect to see is truly present, we will need to study 63 patients who receive intravenous iron.

As we age, gradual loss of cognitive function, manifesting as a worsening of memory and concentration, is common. A considerable proportion of patients over 60 having major surgery under general or regional anaesthesia display an apparently accelerated post-operative cognitive decline, which may be permanent, but because of limitations with the research to date, we do not know whether this decline would have happened anyway without the operation or how to predict those who are at risk. Characterisation of cognition requires a time-consuming test battery (approximately 90 minutes) delivered by psychologists; accordingly studies generally include low patient numbers (less than 200 participants) tested on only a few occasions. We have insufficient knowledge about the cognitive trajectory of patients in the time leading up to surgery and few studies that monitor elderly people who are not exposed to an operation.

Cognitive Monitoring in Planned Arthroplasty Surgery Study (COMPASS) is a collaborative project between anaesthesia and GP trainee led research networks, patients, psychology & dementia experts, and industry. Cogtrack © is a self-administered battery of online digital tests for memory and reaction speed, validated to characterise cognition. It takes about 20 minutes to perform the test; results are presented in 9 different domains which all relate to different aspects of cognitive function. Adopting a "light touch" approach, we plan to deploy Cogtrack remotely (supported by our primary & secondary care networks) in patients over 60 years of age undergoing planned hip and knee joint replacements. Scores will be compared to a control group (either spouses or age matched patients identified from GP practice lists) who have not undergone any surgery. Repeated on several occasions over a long time window, this has the potential to address limitations of previous studies.

Following training, testing will be undertaken 5 times: approximately one month before surgery (baseline), once more before surgery, then at two days, 1 month and six weeks after surgery. Those in the control group will be tested over a similar time window at intervals to mirror these.

An initial feasibility study will test our plan of investigation and available resources. In particular we will assess the fidelity of Cogtrack when used this way (does it register a post-operative deflection, and if so, in which domains ? ), whether remote serial electronic monitoring is accessible and tolerable for our intended target population, and gather information about the prevalence of potentially confounding factors (dementia, delirium, distraction by pain or sedative medication) and other factors which we may have to adjust for in our analysis (age, gender, socioeconomic status, physical health status). We will also gauge the success of our recruitment & follow up process, "acceptability" of the tests to our patient group, whether patients remain sufficiently engaged to perform assessments at all the planned time points. Using pilot data gathered and lessons learnt from this study, our ambition is to exploit the large reach of our research network to deploy a multicentre study at scale.

Background:
Self-reported drug allergies are common in surgical patients, with reports estimating up to one third of patients report an allergy. Allergy labels are of particular concern for anaesthetists, who expose patients to a wide range of drugs during the period around surgery. Often, drug allergy labels are based not on reactions indicating true allergies, but on side effects, other non-allergic symptoms or as an informal 'patient alert' system for needle phobia or anxiety. One good example of this is penicillin allergy, which is reported by 10% of the population, but only 1 in 20 of those that report a penicillin allergy actually suffers from a 'true' allergy. Allergy labels may significantly influence drug prescribing, leading to unnecessary avoidance of safe drugs in favour of less effective and more toxic alternatives.

Aims:
We aim to define the true prevalence (rate) of drug allergy labelling in the UK surgical population, and to determine the proportion of these labels which are likely to reflect true allergy. We will study the impact of such labels on prescribing by Anaesthetists, and for a sub-set of allergy labels, will study the impact on selected outcomes. We will also conduct an attitude and knowledge-based survey of anaesthetists, to explore understanding of drug allergies, the effect of allergy labels on prescribing habits, and ideas to help reduce the burden of inaccurate labelling in the future.

Method:
The study will be delivered by RAFT (www.raftrainees.com), a trainee network with a track record for delivering and supporting nationwide research and audit projects. We will give eligible patients a questionnaire on the day of surgery, whilst the patient is in a preoperative waiting area. A subset of patients with allergy labels to penicillin, ibuprofen like drugs (also known as "NSAIDs") or opioids will undergo limited same-day follow-up, to assess the impact of these labels on selected outcomes; this will not involve any further interaction with the patient. The study will run over 3 consecutive days across all participating sites. During this study period, anaesthetists of all grades will be invited to complete a brief electronic survey that covers different ground from the 6th National Audit Project. There is no link between individual cases and the anaesthetic questionnaires. We hope to offer participation in the study to 18,000 patients from over 200 UK NHS sites, and around 2000 anaesthetists.