Data Source
Process topic Interviews Literature Guidelines NCEPOD reports
Textbooks
Initial assessment X X X
Making a diagnosis X X X
Routine blood tests X X
Radiology investigations X X X
Formulating a management plan X X X
Documentation X X
Senior doctor review X X
Admission to suitable wards X X
Patient transfers X
Vital signs monitoring X X X X
Intravenous access X
Intravenous fluid resuscitation X X X X
Analgesia X X X
Antibiotic therapy X X X X
Thromboprophylaxis X X X X
Routine pre-admission medications X
Urinary catheterisation X X
Nasogastric drainage X X
Preoperative fasting X X X
Handover X X X X
NCEPOD, National Confidential Enquiry into Patient Outcomes and Deaths
A number of guidelines from speciality associations (Dellinger et al., 2008, DeVita et al., 2010, Powell-Tuck et al., 2008, Royal College of Surgeons of England, 2007) and the National Institute for Health and Clinical Excellence (NICE) (National Institute for Health and Clinical Excellence, 2007, National Institute for Health and Clinical Excellence, 2010) were identified and incorporated, covering a number of topics (Table 9.1).These were augmented by NCEPOD report
124 Critically Ill Surgical Patient (CCrISP) training course (Anderson, 2003, Olsen et al., 2007) as well as discussion between the researchers. The list was also piloted with approximately 10 surgical
registrars who were not participants in the study. The majority of NCEPOD recommendations related to the initial assessment of a patient, whereas guidelines mainly dealt with treatment processes. These data sources produced a list of 26 items for the first round of questionnaires (Appendix D).
9.4.3. Setting
The study was conducted between May and June 2010 at the same large, city centre university teaching hospital as our earlier interview study. All participants were approached in person, within the hospital and completed the questionnaires anonymously and without reference to any of the other contributors.
9.4.4. Participants
Delphi methodology requires the participation of “experts” to give opinion in areas in which
evidence is lacking or conflicting. It is also recommended that a variety of sources are used to ensure a breadth of views (Fink et al., 1984). As discussed in Chapter 5, experts in emergency general surgery are few and far between, especially at the time that this study was conducted. Use of “experts“ based on volume and quality of peer reviewed publications has its own inherent problems and is likely to result in dramatic underrepresentation of nurses in particular. To ensure a breadth of opinions and in order to maintain continuity with the preceding interview study, the same group of contributors were asked to participate in this study (Table 5.1). The participating staff had a mean of 5.9 years’ experience in their existing role, which was considered sufficient to be experienced in the process of care of EGS patients and the potential effect of failures in this care. Theatre nurses were excluded as they have no direct contact with the initial stages of treatment for the majority of emergency surgical admissions and therefore were not considered to have the required expertise to assess processes accurately. After the exclusion of theatre nurses, fifteen interviewees remained
125 including six surgeons, six anaesthetists and three ward nurses and all agreed to act as participants in this Delphi process.
9.4.5. Procedure
Participants were each given a copy of the first round questionnaire to complete (Appendix D), without reference to each other or other healthcare professionals. This questionnaire asked participants to rate each process on a nine point Likert scale, where 1 was insignificant and 9 was crucial, as to their importance in improving mortality and morbidity for emergency surgical
admissions. Participants were also asked to contribute extra processes that had not been considered for the initial questionnaire, to be included in subsequent rounds.
Personalised questionnaires for round two were produced that detailed the median and range of scores for each process that did not reach consensus in round one, as well as the individual participants’ original response (Appendix E). This feedback allowed participants to adjust their response to each remaining process and therefore improve consensus, without the inherent bias of a focus group. Two additional processes that were suggested by participants in round one were added to the questionnaires for round two.
9.4.6. Data Analysis
Questionnaire results were entered into an Excel spreadsheet (v2010, Microsoft Corp., Redmond, USA) and summary statistics calculated. A cut-off value for inclusion in the final list of processes was set as a median score of 8 on the nine point (1-9) Likert scale used. Consensus was considered to be achieved once the interquartile range fell below 1.5 for each process.
9.5. Results
All participants completed the entire Delphi process and response rate, both in terms of whole questionnaires and individual items was 100%. Following the first round of questionnaires 20 of the
126 26 items achieved a consensus opinion, with an interquartile range of 1.5 or less. Of these 20, 16 had a median score of eight or more out of nine, and were therefore included in the final list, and four did not and were discarded (Table 9.2).
The remaining six processes, along with the two suggested by participants during round one were submitted to a second round of questionnaires. Following this round, all items gained a consensus opinion and, of the eight processes, five were included in the final list of included processes and three were discarded (Table 9.2). One of the two processes suggested by participants in round 1 was accepted by the panel and one was rejected. In total, therefore, 21 out of the 28 processes surveyed were accepted by this Delphi.
There were notable differences in the scores allocated by different groups of healthcare
professionals, particularly for the processes that were rejected. For example, having a documented plan for oral intake was considered important by nurses (median 8), however doctors did not think it would contribute to better outcomes (median 7). The overall median for this process was 7 and therefore it was rejected. Another example of this was excessive patient transfers, which was given a median score of 9 by nurses in round one but only scored a median of 7 from doctors. This process was subsequently rejected following round two. Similarly, use of thromboprophylaxis was favoured by nurses (median 9) but not doctors (median 7). There were also discrepancies between types of doctors for some processes, for example involvement of a medical team for patients with concurrent illness was considered very important by surgeons (median 8.5) but not by anaesthetists (median 6.5).
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