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Article ; Online: Why are we not optimising healthcare?

Handley, Thomas / Denning, Max / Melcher, Marc L

BMJ leader

2023

Language	English
Publishing date	2023-01-26
Publishing country	England
Document type	Journal Article
ISSN	2398-631X
ISSN (online)	2398-631X
DOI	10.1136/leader-2022-000674
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Article: The Modified Crescenteric Anterior Intercostal Perforator Flap.

Denning, Max / Hayes, Philippa / Tsang, Fiona / Leff, Daniel / Thiruchelvam, Paul / Hadjiminas, Dimitri

Plastic and reconstructive surgery. Global open

2020 Volume 8, Issue 5, Page(s) e2785

Abstract: Lower pole breast cancers are challenging to manage because conventional wide local excision may produce a "bird's beak" deformity. In an era of oncoplastic surgery, techniques that balance oncological results with cosmetic outcomes such as local flaps ... ...

Abstract	Lower pole breast cancers are challenging to manage because conventional wide local excision may produce a "bird's beak" deformity. In an era of oncoplastic surgery, techniques that balance oncological results with cosmetic outcomes such as local flaps have extended the role of breast-conserving surgery. Local flaps are particularly useful for partial breast reconstruction due to the relative simplicity of the surgical procedure and reduced morbidity. Intercostal artery perforator flaps have a shorter duration of surgery than free flaps and do not require microsurgical anastomoses. Anterior intercostal artery perforator (AICAP) flaps provide excellent cosmesis, yet traditional crescenteric harvest yields limited volume for reconstruction. We describe a modification to an established reconstructive technique for lower pole breast defects. The technique is based on 3 extensions of tissue, providing a larger volume of tissue replacement compared with traditional AICAP flaps. The technique is particularly suitable for small- and medium-sized non-ptotic breasts, with lower pole tumors. The modified crescenteric AICAP technique can be used to increase the available tissue when performing lower pole reconstructions.
Language	English
Publishing date	2020-05-26
Publishing country	United States
Document type	Journal Article
ZDB-ID	2851682-5
ISSN	2169-7574 ; 2169-7574
ISSN (online)	2169-7574
ISSN	2169-7574
DOI	10.1097/GOX.0000000000002785
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Article: Assessing trauma care systems in low-income and middle-income countries: a systematic review and evidence synthesis mapping the Three Delays framework to injury health system assessments.

Whitaker, John / O'Donohoe, Nollaig / Denning, Max / Poenaru, Dan / Guadagno, Elena / Leather, Andrew J M / Davies, Justine I

BMJ global health

2021 Volume 6, Issue 5

Abstract: Background: The large burden of injuries falls disproportionately on low/middle-income countries (LMICs). Health system interventions improve outcomes in high-income countries. Assessing LMIC trauma systems supports their improvement. Evaluating systems ...

Abstract	Background: The large burden of injuries falls disproportionately on low/middle-income countries (LMICs). Health system interventions improve outcomes in high-income countries. Assessing LMIC trauma systems supports their improvement. Evaluating systems using a Three Delays framework, considering barriers to seeking (Delay 1), reaching (Delay 2) and receiving care (Delay 3), has aided maternal health gains. Rapid assessments allow timely appraisal within resource and logistically constrained settings. We systematically reviewed existing literature on the assessment of LMIC trauma systems, applying the Three Delays framework and rapid assessment principles. Methods: We conducted a systematic review and narrative synthesis of articles assessing LMIC trauma systems. We searched seven databases and grey literature for studies and reports published until October 2018. Inclusion criteria were an injury care focus and assessment of at least one defined system aspect. We mapped each study to the Three Delays framework and judged its suitability for rapid assessment. Results: Of 14 677 articles identified, 111 studies and 8 documents were included. Sub-Saharan Africa was the most commonly included region (44.1%). Delay 3, either alone or in combination, was most commonly assessed (79.3%) followed by Delay 2 (46.8%) and Delay 1 (10.8%). Facility assessment was the most common method of assessment (36.0%). Only 2.7% of studies assessed all Three Delays. We judged 62.6% of study methodologies potentially suitable for rapid assessment. Conclusions: Whole health system injury research is needed as facility capacity assessments dominate. Future studies should consider novel or combined methods to study Delays 1 and 2, alongside care processes and outcomes.
MeSH term(s)	Africa South of the Sahara ; Developing Countries ; Emergency Medical Services ; Humans ; Income ; Poverty
Language	English
Publishing date	2021-05-04
Publishing country	England
Document type	Journal Article ; Research Support, Non-U.S. Gov't ; Systematic Review
ISSN	2059-7908
ISSN	2059-7908
DOI	10.1136/bmjgh-2020-004324
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Article ; Online: Grass-roots junior doctor communication network in response to the COVID-19 pandemic: a service evaluation.

Sivananthan, Arun / Machin, Matthew / Zijlstra, Geiske / Harris, Alexander / Radhakrishnan, Shiva T / Crook, Peter / Phillips, Georgina / Denning, Max Christopher / Patel, Nisha / Russell, Georgina / Darzi, Ara / Kinross, James / Brown, Ruth

BMJ open quality

2021 Volume 10, Issue 2

Abstract: Background: COVID-19 was declared a worldwide pandemic on 11 March 2020. Imperial College Healthcare NHS Trust provides 1412 inpatient beds staffed by 1200 junior doctors and faced a large burden of COVID-19 admissions.: Local problem: A survey of ... ...

Abstract	Background: COVID-19 was declared a worldwide pandemic on 11 March 2020. Imperial College Healthcare NHS Trust provides 1412 inpatient beds staffed by 1200 junior doctors and faced a large burden of COVID-19 admissions. Local problem: A survey of doctors revealed only 20% felt confident that they would know to whom they could raise concerns and that most were getting information from a combination of informal work discussions, trust emails, social media and medical literature. Methods: This quality improvement project was undertaken aligning with Standards for Quality Improvement Reporting Excellence 2.0 guidelines. Through an iterative process, a digital network (Imperial Covid cOmmunications Network; ICON) using existing smartphone technologies was developed. Concerns were collated from the junior body and conveyed to the leadership team (vertical-bottom-up using Google Form) and responses were conveyed from leadership to the junior body (vertical-top-down using WhatsApp and Zoom). Quantitative analysis on engagement with the network (members of the group and number of issues raised) and qualitative assessment (thematic analysis on issues) were undertaken. Results: Membership of the ICON WhatsApp group peaked at 780 on 17 May 2020. 197 concerns were recorded via the Google Form system between 20 March and 14 June 2020. There were five overarching themes: organisational and logistics; clinical strategy concerns; staff safety and well-being; clinical (COVID-19) and patient care; and facilities. 94.4% of members agreed ICON was helpful in receiving updates and 88.9% agreed ICON improved collaboration. Conclusions: This work demonstrates that a coordinated network using existing smartphone technologies and a novel communications structure can improve collaboration between senior leadership and junior doctors. Such a network could play an important role during times of pressure in a healthcare system.
MeSH term(s)	COVID-19/therapy ; Communication ; Humans ; Medical Staff, Hospital/standards ; Pandemics ; Quality Improvement ; SARS-CoV-2 ; United Kingdom
Language	English
Publishing date	2021-04-30
Publishing country	England
Document type	Journal Article
ISSN	2399-6641
ISSN (online)	2399-6641
DOI	10.1136/bmjoq-2020-001247
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Article ; Online: Assessing trauma care health systems in low- and middle-income countries, a protocol for a systematic literature review and narrative synthesis.

Whitaker, John / Denning, Max / O'Donohoe, Nollaig / Poenaru, Dan / Guadagno, Elena / Leather, Andy / Davies, Justine

Systematic reviews

2019 Volume 8, Issue 1, Page(s) 157

Abstract: Background: Trauma represents a major global health problem projected to increase in importance over the next decade. The majority of deaths occur in low- and middle-income countries (LMICs) where survival rates are lower than their high-income country ( ...

Abstract	Background: Trauma represents a major global health problem projected to increase in importance over the next decade. The majority of deaths occur in low- and middle-income countries (LMICs) where survival rates are lower than their high-income country (HIC) counterparts. Health system level changes in care for injured patients have been attributed to significant improvements in care quality and outcomes in HIC settings. There is a need for further research to assess trauma care health systems in LMICs to inform health system strengthening for the care of the injured. This study aims to conduct a narrative synthesis of a systematic search of the literature on the assessment of trauma care health systems in LMICs in order to inform the further development of trauma care health system assessment. Methods: The review will include primary quantitative, qualitative or mixed method studies and secondary literature reviews. No restriction will be placed on language or date. Reports and publications identified from the grey literature including from relevant national and international health organisations will be included. Articles will be screened by two independent reviewers with a third reviewer resolving any persisting disagreement. The search will reveal heterogenous studies not suitable for meta-analysis. A narrative synthesis of the identified papers will be conducted to identify key methodological ideas and paradigms used to assess trauma care health systems. The analysis will consider how the differing methodological approaches could be adopted to understand barriers and delays to seeking, reaching and receiving care within a "Three Delays" framework. An iterative approach will be adopted to categorise identified articles, with the results presented as both within and across study analysis. Discussion: The results of the review will be disseminated through publication in a peer-reviewed academic journal. The study forms part of a PhD project. The results will inform the development of a trauma care health system assessment applicable to LMICs. As this is a review of secondary data, no formal ethical approval is required. Systematic review registration: PROSPERO CRD42018112990.
MeSH term(s)	Delivery of Health Care/methods ; Developing Countries ; Humans ; Income ; Poverty ; Wounds and Injuries/therapy ; Systematic Reviews as Topic
Language	English
Publishing date	2019-07-02
Publishing country	England
Document type	Journal Article ; Research Support, Non-U.S. Gov't
ZDB-ID	2662257-9
ISSN	2046-4053 ; 2046-4053
ISSN (online)	2046-4053
ISSN	2046-4053
DOI	10.1186/s13643-019-1075-8
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Article ; Online: Why are patients not more involved in their own safety? A questionnaire-based survey in a multi-ethnic North London hospital population.

Yoong, Wai / Assassi, Zouina / Ahmedani, Iman / Abdinasir, Rahma / Denning, Max / Taylor, Harriet / Chandrakumar, Danya / Kwakye, Michael / Nauta, Maud

Postgraduate medical journal

2019 Volume 95, Issue 1123, Page(s) 266–270

Abstract: Purpose: Active patient participation in safety pathways has demonstrated benefits in reducing preventable errors, especially in relation to hand hygiene and surgical site marking. The authors sought to examine patient participation in a range of safety- ...

Abstract	Purpose: Active patient participation in safety pathways has demonstrated benefits in reducing preventable errors, especially in relation to hand hygiene and surgical site marking. The authors sought to examine patient participation in a range of safety-related behaviours as well as factors that influence this, such as gender, education, age and language. Design: A 20-point questionnaire was employed in a London teaching hospital to explore safety-related behaviours, particularly assessing patient's willingness to challenge healthcare professionals and engagement in taking an active role in their own care while in hospital. Data was also collected on participant demographic details including gender, age, ethnicity, English language proficiency and education status. Results: 85% of the 175 patients surveyed would consider bringing a list of their medications to hospital, but only 60% would bring a list of previous surgeries. Only 45% would actively engage in the WHO Safer Surgery Checklist and over three quarters (80%) would not challenge doctors and nurses regarding hand hygiene, believing that they would cause offence. Female patients who had tertiary education, were fluent in English and less than 60 years of age were statistically more likely to feel responsible for their own safety and take an active role in safety-related behaviour while in hospital (p<0.05). Conclusions: Many patients are not engaged in safety-related behaviour and do not challenge healthcare professionals on safety issues. Older male patients who were not tertiary educated or fluent in English need to be empowered to take an active role in such behaviour. Further research is required to investigate how to achieve this.
MeSH term(s)	Adult ; Checklist ; Ethnic Groups/statistics & numerical data ; Female ; Hand Hygiene/standards ; Health Care Surveys ; Health Knowledge, Attitudes, Practice ; Hospitals, Teaching ; Humans ; London/epidemiology ; Male ; Middle Aged ; Needs Assessment ; Patient Acceptance of Health Care/statistics & numerical data ; Patient Participation/statistics & numerical data ; Patient Safety/standards ; Pilot Projects
Language	English
Publishing date	2019-05-25
Publishing country	England
Document type	Journal Article
ZDB-ID	80325-x
ISSN	1469-0756 ; 0032-5473
ISSN (online)	1469-0756
ISSN	0032-5473
DOI	10.1136/postgradmedj-2018-136221
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Article ; Online: Changing the Paradigm of Surgical Research During a Pandemic.

Markar, Sheraz R / Martin, Guy / Penna, Marta / Yalamanchili, Seema / Beatty, Jasmine Winter / Clarke, Jonathan / Erridge, Simon / Sounderajah, Viknesh / Denning, Max / Scott, Alasdair / Purkayastha, Sanjay / Kinross, James

Annals of surgery

2020 Volume 272, Issue 2, Page(s) e170–e171

MeSH term(s)	COVID-19 ; Coronavirus Infections/epidemiology ; Female ; General Surgery ; Humans ; Male ; Pandemics/statistics & numerical data ; Pneumonia, Viral/epidemiology ; Research Design/statistics & numerical data ; United Kingdom
Keywords	covid19
Language	English
Publishing date	2020-07-16
Publishing country	United States
Document type	Journal Article
ZDB-ID	340-2
ISSN	1528-1140 ; 0003-4932
ISSN (online)	1528-1140
ISSN	0003-4932
DOI	10.1097/SLA.0000000000004000
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Article ; Online: Insights from a global snapshot of the change in elective colorectal practice due to the COVID-19 pandemic.

Mason, Sam E / Scott, Alasdair J / Markar, Sheraz R / Clarke, Jonathan M / Martin, Guy / Winter Beatty, Jasmine / Sounderajah, Viknesh / Yalamanchili, Seema / Denning, Max / Arulampalam, Thanjakumar / Kinross, James M

PloS one

2020 Volume 15, Issue 10, Page(s) e0240397

Abstract: Background: There is a need to understand the impact of COVID-19 on colorectal cancer care globally and determine drivers of variation.: Objective: To evaluate COVID-19 impact on colorectal cancer services globally and identify predictors for ... ...

Abstract	Background: There is a need to understand the impact of COVID-19 on colorectal cancer care globally and determine drivers of variation. Objective: To evaluate COVID-19 impact on colorectal cancer services globally and identify predictors for behaviour change. Design: An online survey of colorectal cancer service change globally in May and June 2020. Participants: Attending or consultant surgeons involved in the care of patients with colorectal cancer. Main outcome measures: Changes in the delivery of diagnostics (diagnostic endoscopy), imaging for staging, therapeutics and surgical technique in the management of colorectal cancer. Predictors of change included increased hospital bed stress, critical care bed stress, mortality and world region. Results: 191 responses were included from surgeons in 159 centers across 46 countries, demonstrating widespread service reduction with global variation. Diagnostic endoscopy was reduced in 93% of responses, even with low hospital stress and mortality; whilst rising critical care bed stress triggered complete cessation (p = 0.02). Availability of CT and MRI fell by 40-41%, with MRI significantly reduced with high hospital stress. Neoadjuvant therapy use in rectal cancer changed in 48% of responses, where centers which had ceased surgery increased its use (62 vs 30%, p = 0.04) as did those with extended delays to surgery (p<0.001). High hospital and critical care bed stresses were associated with surgeons forming more stomas (p<0.04), using more experienced operators (p<0.003) and decreased laparoscopy use (critical care bed stress only, p<0.001). Patients were also more actively prioritized for resection, with increased importance of co-morbidities and ICU need. Conclusions: The COVID-19 pandemic was associated with severe restrictions in the availability of colorectal cancer services on a global scale, with significant variation in behaviours which cannot be fully accounted for by hospital burden or mortality.
MeSH term(s)	Betacoronavirus/physiology ; COVID-19 ; Colorectal Neoplasms/diagnosis ; Colorectal Neoplasms/therapy ; Coronavirus Infections/epidemiology ; Elective Surgical Procedures/statistics & numerical data ; Female ; Gastroenterology/organization & administration ; Gastroenterology/statistics & numerical data ; Health Care Rationing ; Health Services Needs and Demand ; Humans ; Male ; Pandemics ; Patient Safety ; Pneumonia, Viral/epidemiology ; SARS-CoV-2
Keywords	covid19
Language	English
Publishing date	2020-10-08
Publishing country	United States
Document type	Journal Article
ZDB-ID	2267670-3
ISSN	1932-6203 ; 1932-6203
ISSN (online)	1932-6203
ISSN	1932-6203
DOI	10.1371/journal.pone.0240397
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Article ; Online: Burnout and Associated Factors Among Health Care Workers in Singapore During the COVID-19 Pandemic.

Tan, Benjamin Y Q / Kanneganti, Abhiram / Lim, Lucas J H / Tan, Melanie / Chua, Ying Xian / Tan, Lifeng / Sia, Ching Hui / Denning, Max / Goh, Ee Teng / Purkayastha, Sanjay / Kinross, James / Sim, Kang / Chan, Yiong Huak / Ooi, Shirley B S

Journal of the American Medical Directors Association

2020 Volume 21, Issue 12, Page(s) 1751–1758.e5

Abstract: Objectives: The strain on health care systems due to the COVID-19 pandemic has led to increased psychological distress among health care workers (HCWs). As this global crisis continues with little signs of abatement, we examine burnout and associated ... ...

Abstract	Objectives: The strain on health care systems due to the COVID-19 pandemic has led to increased psychological distress among health care workers (HCWs). As this global crisis continues with little signs of abatement, we examine burnout and associated factors among HCWs. Design: Cross-sectional survey study. Setting and participants: Doctors, nurses, allied health professionals, administrative, and support staff in 4 public hospitals and 1 primary care service in Singapore 3 months after COVID-19 was declared a global pandemic. Methods: Study questionnaire captured demographic and workplace environment information and comprised 3 validated instruments, namely the Oldenburg Burnout Inventory (OLBI), Safety Attitudes Questionnaire (SAQ), and Hospital Anxiety and Depression Scale (HADS). Multivariate mixed model regression analyses were used to evaluate independent associations of mean OLBI-Disengagement and -Exhaustion scores. Further subgroup analysis was performed among redeployed HCWs. Results: Among 11,286 invited HCWs, 3075 valid responses were received, giving an overall response rate of 27.2%. Mean OLBI scores were 2.38 and 2.50 for Disengagement and Exhaustion, respectively. Burnout thresholds in Disengagement and Exhaustion were met by 79.7% and 75.3% of respondents, respectively. On multivariate regression analysis, Chinese or Malay ethnicity, HADS anxiety or depression scores ≥8, shifts lasting ≥8 hours, and being redeployed were significantly associated with higher OLBI mean scores, whereas high SAQ scores were significantly associated with lower scores. Among redeployed HCWs, those redeployed to high-risk areas in a different facility (offsite) had lower burnout scores than those redeployed within their own work facility (onsite). A higher proportion of HCWs redeployed offsite assessed their training to be good or better compared with those redeployed onsite. Conclusions and implications: Every level of the health care workforce is susceptible to high levels of burnout during this pandemic. Modifiable workplace factors include adequate training, avoiding prolonged shifts ≥8 hours, and promoting safe working environments. Mitigating strategies should target every level of the health care workforce, including frontline and nonfrontline staff. Addressing and ameliorating burnout among HCWs should be a key priority for the sustainment of efforts to care for patients in the face of a prolonged pandemic.
MeSH term(s)	Adult ; Anxiety/epidemiology ; Burnout, Professional/epidemiology ; COVID-19 ; Cross-Sectional Studies ; Depression/epidemiology ; Female ; Health Personnel/psychology ; Humans ; Male ; Middle Aged ; Pandemics ; SARS-CoV-2 ; Singapore/epidemiology ; Surveys and Questionnaires
Language	English
Publishing date	2020-10-05
Publishing country	United States
Document type	Journal Article
ZDB-ID	2171030-2
ISSN	1538-9375 ; 1525-8610
ISSN (online)	1538-9375
ISSN	1525-8610
DOI	10.1016/j.jamda.2020.09.035
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Article ; Online: What Has Been the Impact of Covid-19 on Safety Culture? A Case Study from a Large Metropolitan Healthcare Trust.

Denning, Max / Goh, Ee Teng / Scott, Alasdair / Martin, Guy / Markar, Sheraz / Flott, Kelsey / Mason, Sam / Przybylowicz, Jan / Almonte, Melanie / Clarke, Jonathan / Winter Beatty, Jasmine / Chidambaram, Swathikan / Yalamanchili, Seema / Tan, Benjamin Yong-Qiang / Kanneganti, Abhiram / Sounderajah, Viknesh / Wells, Mary / Purkayastha, Sanjay / Kinross, James

International journal of environmental research and public health

2020 Volume 17, Issue 19

Abstract: Covid-19 has placed an unprecedented demand on healthcare systems worldwide. A positive safety culture is associated with improved patient safety and, in turn, with patient outcomes. To date, no study has evaluated the impact of Covid-19 on safety ... ...

Abstract	Covid-19 has placed an unprecedented demand on healthcare systems worldwide. A positive safety culture is associated with improved patient safety and, in turn, with patient outcomes. To date, no study has evaluated the impact of Covid-19 on safety culture. The Safety Attitudes Questionnaire (SAQ) was used to investigate safety culture at a large UK healthcare trust during Covid-19. Findings were compared with baseline data from 2017. Incident reporting from the year preceding the pandemic was also examined. SAQ scores of doctors and "other clinical staff", were relatively higher than the nursing group. During Covid-19, on univariate regression analysis, female gender, age 40-49 years, non-White ethnicity, and nursing job role were all associated with lower SAQ scores. Training and support for redeployment were associated with higher SAQ scores. On multivariate analysis, non-disclosed gender (-0.13), non-disclosed ethnicity (-0.11), nursing role (-0.15), and support (0.29) persisted to a level of significance. A significant decrease (
MeSH term(s)	Adult ; Attitude of Health Personnel ; Betacoronavirus ; COVID-19 ; Coronavirus Infections/epidemiology ; Female ; Humans ; Male ; Middle Aged ; Organizational Culture ; Pandemics ; Pneumonia, Viral/epidemiology ; SARS-CoV-2 ; Safety Management ; United Kingdom
Keywords	covid19
Language	English
Publishing date	2020-09-25
Publishing country	Switzerland
Document type	Journal Article
ZDB-ID	2175195-X
ISSN	1660-4601 ; 1661-7827
ISSN (online)	1660-4601
ISSN	1661-7827
DOI	10.3390/ijerph17197034
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