A diagrammatic summary of updated NICE melanoma guidance: A simple way to mitigate human factors in MDTs and clinics.

National Institute for Health and Care Excellence (NICE) has published an updated guideline on melanoma assessment and management in July 2022, which has included recommendation on BRAF analysis of primary melanoma tissue samples, staging with sentinel lymph node biopsy, guidance on patient follow-up as well as surveillance imaging requirement based on patients' melanoma stages. However, very often, assimilating this considerable amount of information in an efficient and accurate way can be challenging, especially in the setting of a busy multidisciplinary team (MDT) meeting. Human factors are well recognised as a key principle to mitigate against mistakes and human errors and thereby aiming to optimise patient care. To date, there is very limited literature available on the subject of the role of human factors in the context of MDT meetings. In recent years, the numbers and complexity of patients in cancer MDT meetings have grown significantly. Long MDT meetings could lead to distraction, loss of attention span, miscommunication, missed information, and hence increasing the risk of clinical error. We present a diagrammatic summary of the most recent NICE guidance for melanoma follow-up that is currently being used locally in our department. This aims to offer clarity and ease of use to help health care professionals to check patients' treatment pathways. It can also be included in patients' medical record for annotation or reference in future follow-up clinics, which is a simple measure to mitigate the risks of human factors, as well as ensuring consistency in continuity of patient care.

Patient-reported outcomes for nipple reconstruction: Review of literature.

BACKGROUND: There is currently no validated patient-reported outcome measure (PROM) that is specific to nipple-areola complex (NAC) reconstruction. This paper evaluates all patient-reported outcomes for NAC reconstruction in the literature. METHODS: Systematic literature searches of The Cochrane Central Register of Controlled Trials, MEDLINE and World Health Organization International Clinical Trials Registry Platform were conducted to identify all primary studies with patient-reported outcomes for NAC reconstruction. The primary outcome measures were patient satisfaction rates for appearance and symmetry of NAC reconstruction. RESULTS: Fifty-nine papers were included in this review. Reported patient satisfaction was generally high, with the pooled average satisfaction rate for appearance being 81.9% and symmetry 80.3%. 89.5% of respondents would do it again and 94.8% would recommend it to others. There is no standardised or validated PROM specific to NAC reconstruction and this contributes to a lack of conclusive findings from studies in this area. CONCLUSION: There is a need for a validated PROM that is specific to NAC reconstruction, in order to serve as a standardised outcome assessment to guide further research and improve patient care.

Comment on: "A structured pathway for accelerated postoperative recovery reduces hospital stay and cost of care following microvascular breast reconstruction without increased complications".

We read with great interest a recent article by O'Neill et al. on the implementation of an accelerated postoperative recovery protocol following DIEP flap breast reconstruction. Our department has formally introduced a DIEP Enhanced Recovery After Surgery (ERAS) Pathway in May 2019. Although in a much smaller sample size, our results were similar to this article and we would agree with the authors' conclusion that implementation of such protocol could effectively reduce the length of inpatient stay (LoS) and cost of care, without compromising patient care nor increasing complication rates. Prior to the introduction of ERAS Pathway, 28 of our patients who had DIEP between November 2018 and May 2019 had an mean LoS of 7.1 days (median 6 days, range 5-21 days); whereas 27 patients who experienced the ERAS Pathway between May and December 2019 had an mean LoS of 4.8 days (median 5 days, range 3-7 days). The cost of inpatient stay in a normal ward at our hospital is approximately £232 per patient per day. By reducing an extra 2.3 days of inpatient stay, our Trust could save at least an average of £32,016 per annum with the estimated 60 DIEP performed annually at our department. We would like to emphasise the benefits and effectiveness of this multimodal, patient-centre and evidence-based ERAS. This, perhaps, should be the standard of care for all patients who undergo microvascular breast reconstruction in the future.

Orthoplastics, tariffs and the reality of providing complex fracture care.

INTRODUCTION: The United Kingdom (UK) Major Trauma Network has encouraged cohorting of significantly injured patients with specific injury patterns. Complex injuries to the limbs is a key area of this patient population. Funding and clinician resource allocation, have not been appropriately adjusted to take account of this approach. We assessed the orthoplastic trauma workload in our unit over a 12 month period, taking into account the resource burden of each admission in comparison to the funding received. MATERIALS AND METHODS: The details of admissions requiring orthoplastic care over the period from February 2017-February 2018 were extracted from hospital records. Data regarding patient demographics, admission length, procedures and complications was analysed. Additional data regarding time spent in theatre was obtained from computerised records, as well as detailed coding data regarding clinical events coded for and funding received for the admission. RESULTS: 24 patients were identified as meeting the criteria for inclusion in this study. Mean length of stay was 23 days (1-98 days) and theatre time 386 min (15-842 min). Average payment per admission was £14,497 (£593-£86,245). CONCLUSION: Tariff payments barely cover the cost of a hospital bed and theatre time. Materials costs, as well as the additional costs associated with providing a high quality specialist service mean that our orthoplastic service is currently being run at a significant loss. The benefits for patients in having a well-established orthoplastic unit are numerous and well documented. This study provides evidence to support negotiation for a tariff uplift to allow ongoing provision of a high quality orthoplastic service without detriment to hospital budgets.