The P-POSSUM scoring systems for predicting the mortality of neurosurgical patients undergoing craniotomy: Further validation of usefulness and application across healthcare systems.

BACKGROUND AND AIMS: Continuous audit of clinical practice is an essential part of making improvements in medicine and enhancing patient care. Validated tools are needed to gather evidence for comparisons. Recently, Physiological and Operative Severity Score for the enumeration of Mortality and morbidity (POSSUM) and Portsmouth-POSSUM (P-POSSUM) scores were evaluated in Indian patients undergoing elective craniotomy and it was concluded that P-POSSUM was highly accurate in predicting overall mortality. We wished to study whether this system could be used in a different country and health care system [United Kingdom, UK]. We have evaluated these scores in patients undergoing elective and emergency craniotomies in a tertiary centre in the UK. METHODS: Data was collected from all neurosurgical patients who underwent craniotomy overone year. Preoperative variables were collected prior to induction of anaesthesia, and operative variables were also collected. Chi-square test was used for expected and actual mortality differences. Survivor and non-survivor demographics were compared by one-way ANOVA for continuous and Chi-square for categorical variables. RESULTS: One hundred and forty-five patients were studied. Mean [SD] physiologic score of the patients was 18.83 [5.07], and mean [SD] operative score was 18.09 [3.75]. P-POSSUM was a better predictor for elective patients and for those undergoing immediate life-saving surgery. CONCLUSION: This study confirms and validates the findings of previous work that P-POSSUM is an accurate and reliable tool for estimating in-hospital mortality. It also confirms its usefulness in comparison of results across healthcare systems internationally. Larger scale evaluations may be needed to examine its usefulness in emergency procedures.

What should be included in a simulation course for anaesthetists? The Merseyside trainee perspective.

BACKGROUND AND OBJECTIVES: This study is the first attempt in the UK to establish the views of senior anaesthetic trainees in relation to acquiring the attributes of an 'ideal' anaesthetist, and how these could be met by a simulation course. METHODS: An electronic questionnaire consisting of open and closed questions was distributed to all 79 post-fellowship anaesthetic trainees in Merseyside, UK. Responses were anonymous and answers to open questions were independently coded into one of three themes: skills, knowledge and attributes/behaviour. RESULTS: The response rate was 81% (64 of 79). The most frequently mentioned attributes of the ideal anaesthetist were behavioural, rather than skills or knowledge elements. Respondents thought that a simulation course should concentrate on developing leadership, teamwork and communication skills. A total of 69% (40) felt that their current training had helped them to develop attributes of an ideal anaesthetist and half of this subset felt that simulation-based training had helped them acquire these qualities. Additional benefits of a simulation course are considered to be additional practice, exposure to rare events and a realistic environment. At least 25% of the respondents thought that simulation training should be a mandatory part of anaesthetic training. CONCLUSION: This study on the training needs of senior anaesthetic trainees, who have described the behavioural characteristics of an 'ideal anaesthetist'. Some of these attributes can be taught by simulation training. Our results should be used in the design of future simulation courses.

An evaluation of the Charlson co-morbidity score for predicting sepsis after elective major surgery.

BACKGROUND AND AIMS: Severe sepsis is a significant cause of morbidity and mortality following major surgery. The Charlson co-morbidity score (CCS) has been shown to be associated with severe sepsis following major surgery for cancer. This prospective observational study investigated the effect of patient factors (CCS, gender, age and malignancy) and intraoperative factors (duration of surgery and allogeneic blood transfusion) on the incidence of sepsis after elective major surgery, and the impact of patient co-morbidities on length of stay in critical care. MATERIALS AND METHODS: We prospectively identified a cohort of 101 patients undergoing elective major surgery in a university teaching hospital. The CCS was calculated before surgery, and the incidence of sepsis was documented following surgery. We investigated whether age, malignancy, intraoperative allogeneic blood transfusion, length of surgery or gender were associated with sepsis following surgery. RESULTS: Twenty-seven (27%) patients developed sepsis. Using multivariate logistic regression, the duration of surgery was associated with the development of sepsis after surgery (P = 0.054, odds ratio 1.2). The CCS was not associated with sepsis in this population of cancer and non-cancer patients undergoing elective major surgery, but was associated with longer length of stay in the intensive care unit (P = 0.016). CONCLUSIONS: Duration of surgery, but not patient co-morbidity as assessed by the CCS, may predict the postoperative incidence of sepsis. CCS could be used as a guide to predict consumption of critical care resources by elective surgical patients. A higher CCS was associated with a longer ICU stay. Resources, such as postoperative goal directed therapy, may be useful in reducing length of stay, hospital costs and risks of infective complications in this subgroup of patients with higher CCS.

Assessing the implementation of guidelines for the management of the potentially injured cervical spine in unconscious trauma patients in England.

BACKGROUND: There are many complications involved in the immobilization of unconscious patients with potential cervical spine injuries. In February 2005, the Intensive Care Society (ICS), United Kingdom, produced consensus guidelines to evaluate spinal injuries in unconscious victims of blunt multiple injuries to address this important clinical problem. METHODS: A postal questionnaire was sent to lead consultants of intensive care units in England enquiring about the management of the cervical spine in unconscious trauma patients. Data were collated, and the responses to open questions were grouped into themes. Responses were compared with published ICS guidelines. RESULTS: The response rate was 46% (91 of 199). Forty-four of 89 units had formal policies. Twenty-two of 44 of these units had adopted national guidelines. Common methods of immobilization were "collar & head blocks" (59 of 83) and collar only (18 of 83). Thirty of the 70 were immobilized in a semirigid collar. Common X-ray combinations were combined lateral/anteroposterior/Odontoid views (18 of 64) and lateral and anteroposterior views (21 of 64). Fifty of 71 would perform computed tomography scans if images were unsatisfactory. Senior radiologist involvement in reporting was mentioned by 65 of 78. Immobilization was discontinued in the presence of normal X-ray studies and computed tomography scans by 44 of 83. CONCLUSION: A unit policy ensures that current recommendations are followed. Despite the ICS guidelines being published 4 years ago, over half of the individual intensive care units have no policy in place. A lack of adequate guidance for junior doctors can lead to steps in the process of clearance being omitted and potential injuries being missed. We recommend that the national organization do more to facilitate a wider dissemination of these guidelines.

Retention and transferability of team resource management skills in anaesthetic emergencies: the long-term impact of a high-fidelity simulation-based course.

BACKGROUND AND OBJECTIVE: In 2005, we developed and implemented the Emergency Anaesthetic Simulated Experience course at the Cheshire and Merseyside Simulation Centre.Emergency Anaesthetic Simulated Experience aims to teach clinical and team resource management skills to junior trainees in anaesthesia. Here we present 'proof-of-concept' in terms of long-term retention and transferability of acquired skills into subsequent clinical practice. METHODS: An electronic questionnaire sent to 73 trainees, 9-20 months after the course, invited open-ended responses, addressing four areas; namely, real-life encounters with the same scenario as on the course, approach to real-life anaesthetic emergencies in general, approach to real-life routine anaesthesia and need to attend similar courses in the future, with their underlying reasons. RESULTS: Qualitative analysis of the descriptive responses showed that the lessons learnt in the context of simulated emergencies were applied by candidates themselves to real-life emergencies in general and to routine practice. CONCLUSION: Team resource management skills learnt in a single educational intervention, based on simulated anaesthetic emergencies, are retained over the long term, translated into clinical practice and are transferable across the breadth of clinical activities.

Evaluation of POSSUM and P-POSSUM scoring systems for predicting the mortality in elective neurosurgical patients.

A simple way of evaluating surgical outcomes is to compare mortality and morbidity. Such comparisons may be misleading without a proper case mix. The POSSUM scoring system was developed to overcome this problem. The score can be used to derive predictive mortality and morbidity for surgical procedures. POSSUM and a modified version P-POSSUM have been evaluated in various groups of surgical patients for the accuracy of predicting mortality. These scoring systems have not been evaluated in neurosurgical patients. Thus, we tried to evaluate the usefulness of POSSUM and P-POSSUM scoring systems in neurosurgical patients in predicting in-hospital mortality. POSSUM physiological and operative variables were collected from all neurosurgical patients undergoing elective craniotomy, from April 2005 to Feb 2006. In-hospital mortality was obtained from the hospital mortality register. The physiological score, operative score, POSSUM predicted mortality rate and P-POSSUM predicted mortality rate were calculated using a calculator. The observed number of deaths was compared against the predicted deaths. A total of 285 patients with a mean age of 38 +/- 15 years were studied. Overall observed mortality was nine patients (3.16%). The mortality predicted by the P-POSSUM model was also nine patients (3.16%). Mortality predicted by POSSUM was poor with predicted deaths in 31 patients (11%). The difference between observed and predicted deaths at different risk levels was not significant with P-POSSUM (p = 0.424) and was significantly different with POSSUM score (p < 0.001). P-POSSUM scoring system was highly accurate in predicting the overall mortality in neurosurgical patients. In contrast, POSSUM score was not useful for prediction of mortality.