The College as a global partner. July Events medicine services: anaesthesia s central role

Transcription

1 July 2017 Events medicine services: anaesthesia s central role The 6th National Audit Project (NAP6) A day in the life of an HSRC Fellow The College as a global partner

2 Bulletin Issue 104 July 2017 SEPTEMBER 6 8 SEPTEMBER 2017 Updates in Anaesthesia, Critical Care and Pain Management 490 EVENTS CALENDAR Further information about all of our events can be found on our website. events@rcoa.ac.uk 15 SEPTEMBER 2017 Paediatric Emergency Management for the Anaesthetic Team 240 ( 180 for RCoA registered trainees) SEPTEMBER 2017 Anaesthetists as Educators: Teaching and Training in the Workplace 425 ( 320 for RCoA registered trainees) 20 SEPTEMBER 2017 Advanced Airway Workshop 240 ( 180 for RCoA registered trainees) SEPTEMBER 2017 CPD Study Days 355 ( 270 for RCoA registered trainees) 27 SEPTEMBER 2017 Anaesthetists as Educators: An Introduction 220 ( 165 for RCoA registered trainees) 29 SEPTEMBER 2017 Leadership and Management: Personal Effectiveness 220 OCTOBER 2 OCTOBER 2017 Developing World Anaesthesia OCTOBER 2017 CPD Study Day 200 ( 150 for RCoA registered trainees) 3 OCTOBER 2017 Ultrasound Workshop 240 ( 180 for RCoA registered trainees) 12 OCTOBER 2017 Airway Workshop G&V Hotel, Edinburgh 240 ( 180 for RCoA registered trainees) 12 OCTOBER 2017 Joint RCoA/AAGBI Meeting Less Than Full-Time Matters OCTOBER 2017 Anaesthetists as Educators: Simulation Unplugged 220 ( 165 for RCoA registered trainees) OCTOBER 2017 UK Training in Emergency Airway Management (TEAM) Course 450 NOVEMBER 9 10 NOVEMBER 2017 UK Training in Emergency Airway Management (TEAM) Edinburgh Royal Infirmary NOVEMBER 2017 CPD Study Day Royal Hotel, Hull 200 ( 150 for RCoA registered trainees) 17 NOVEMBER 2017 GASAgain (Giving Anaesthesia Safely Again) NOVEMBER 2017 Leadership and Management: Working Well in Teams and Making an Impact NOVEMBER 2017 SALG Patient Safety Conference Manchester Conference Centre NOVEMBER 2017 CPD Study Day 200 ( 150 for RCoA registered trainees) 24 NOVEMBER 2017 Anaesthetists as Educators: ANTS (Anaesthetists Non-Technical Skills) 220 ( 165 for RCoA registered trainees) 28 NOVEMBER 2017 Joint RCoA/AAGBI Clinical Directors Meeting By invitation only DECEMBER 1 DECEMBER 2017 FPM 10th Annual Meeting: Core Topics in Pain Medicine 200 ( 140 for trainees and nurses) DECEMBER 2017 Updates in Anaesthesia, Critical Care and Pain Management Royal Welsh College of Music and Drama, Cardiff DECEMBER 2017 Joint RCoA/Tri-Services Anaesthetic Society Annual Scientific Meeting 200 ( 150 for RCoA registered trainees) 13 DECEMBER 2017 Joint RCoA/LSORA Regional Anaesthesia Workshop 240 ( 180 for RCoA registered trainees) A reduced rate of 340 ( 260 for RCoA registered trainees) is available for those attending both RCoA/LSORA events) 14 DECEMBER 2017 Joint RCoA/LSORA Regional Anaesthesia Symposium 200 ( 150 for RCoA registered trainees) A reduced rate of 340 ( 260 for RCoA registered trainees) is available for those attending both RCoA/LSORA events) JANUARY 9 12 JANUARY 2018 Primary FRCA Masterclass JANUARY 2018 Final FRCA Masterclass SEPTEMBER 2017 Introduction to Leadership and Management: The Essentials 4 OCTOBER 2017 A Career in Anaesthesia NOVEMBER 2017 RCoA Winter Symposium: Excellence ( 295 for RCoA registered trainees) Book your place at: 1

3 Bulletin Issue 104 July 2017 Bulletin Issue 104 July 2017 Contents Data science for docs So what is our position on Data Science? Is it just a rebranding of statistics, which, despite underpinning quantum mechanics, modern finance, and the humble weather forecast, has never managed to seem cool? Page 12 The President s View 4 News in brief 8 Guest Editorial 12 Experience of ACSA at Central Manchester Foundation Trust 14 Inaugural information day for CPD Assessors 15 Faculty of Pain Medicine (FPM) 16 Faculty of Intensive Care Medicine (FICM) 17 A brave new world? 18 Becoming more resilient 20 Small grants and awards: A how to guide 22 NELA Clinical Lead 26 NELA risk-prediction tool 28 Meet the HSRC Research Fellows 30 A day in the life of an HSRC Fellow 34 The 6th National Audit Project (NAP6) 36 SAS anaesthetists and the training programme 38 Professor Monty Mythen Welcome to the July Bulletin! From the editor I am writing this in mid-may, and an election has been called. Thus, we are in purdah the pre-election period in the UK during which the activities of civil servants are restricted. During the time between the announcement of an election and the actual election, the government is not allowed to make any announcements about controversial initiatives. If you are working in the areas of policy or strategy, purdah might seem to translate as holiday. But some say that it is a great opportunity to reflect on life thinking space time to talk to people and do some really high-quality work. I wonder why we don t have longer periods of purdah, interrupted by short bursts of normal parliamentary government. I really enjoyed reading all the articles in this Bulletin, but I took most from Shirley Remington s article on resilience. She reminds us that: Defining specific goals in life and having a focus on what one wishes to achieve are important in building wellbeing. Personal purdah? If you have some personal goals that need resourcing then consider the NIAA s Small Grants scheme. As Felicity Plaat explains, these grants fund Research, Education or Travel. The College as a global partner We are a truly international College Page 4 A brave new world Artificial intelligence is not just some science fiction story: it is already part of our lives Page 18 Meet the HSRC Research Fellows The HSRC s proudest achievement is the development of its team of research fellows The 6th National Audit Project (NAP6) The most comprehensive investigation of perioperative anaphylaxis ever undertaken Page 36 Training in paediatric intensive care medicine Paediatric intensive care is a diverse, tertiary-centre specialty Page 52 Isle of Man major trauma transfers 40 Perioperative Journal Watch 43 News from the perioperative medicine programme 44 Events medicine services: anaesthesia s central role 48 Random controlled trainees? 50 Training in paediatric intensive care medicine 52 Lifelong learning: what will be different? 54 As we were Letters to the Editor 58 Report of meetings of Council 60 Notices and adverts 63 If you attend sporting events on a regular basis, I strongly recommend the article by Joe Cosgrove (Newcastle) on events medicine. On more than one occasion, I have turned up to watch my local rugby club and been faced with a familiar official with a request that I have learned to dread: Can you be the crowd doc today Doc? We are going to have over 2,000 in today local derby! As Joe explains, this request should not be accepted lightly, and, under his leadership, pragmatic guidance has been developed by a working party (sponsored by the Hillsborough Family Support Group). Rhys Clayton (Manchester) reports his department s experience of the RCoA Anaesthesia Clinical Services Accreditation (ACSA) scheme. This scheme has been applauded by the Care Quality Commission, and is rapidly being taken up throughout the UK. Rhys reports that: The ACSA process has been very beneficial for the department. It has allowed us to improve the service we deliver, provide reassurance to management, patients and staff that we are delivering care of a high standard, and has also improved morale by highlighting the excellent work that is carried out throughout the department. Please don t miss the 25th Anniversary Photography Competition there is still time to enter. As part of the College s 25th Anniversary celebrations, and in partnership with the Royal Photographic Society, we are running our first-ever photographic competition for Fellows and Members. We welcome entries from everyone from beginners to advanced photographers. Page 30 College events 68 The theme for the competition is In Safe Hands. 2 3

4 Bulletin Issue 104 July 2017 Dr Liam Brennan, President The bricks and mortar may be in London, but I am proud to say that with members and fellows in 75 different countries, we are a truly international College. Thirty per cent of our members undertook their primary medical qualification outside of the UK, and 9% currently work outside the four UK nations. It is therefore vital that we engage with, and provide support for, our overseas members and fellows in delivering high-quality patient care. The President s View THE COLLEGE AS A GLOBAL PARTNER But it is just as important that, through the co-ordination of the College, we utilise the wealth of experience across our international network to meet the need for the provision of anaesthesia, critical care and pain medicine, in all corners of the globe. With the publication of our Global Partnerships Strategy, we are aiming to do just that. At the time of writing we have just published our manifesto for the UK General Election ( the outcome of which should be known by the time you read this edition of the Bulletin. The General Election campaign and the formation of a new government will almost certainly be defined by the challenges and choices of Brexit, underlining the international reverberations of decisions made in one locality. No organisation can operate in a bubble, shielded from the impact of change outside its walls. What organisations have to do, therefore, is seek to mould the terms on which they engage with the external environment and aim to shape their impact. When we published our Strategic Plan ( we recognised that forming Global Partnerships would be a pillar of the development of the organisation over the next five years, and I am pleased to say that we have now published our Global Partnerships Strategy ( ) ( 4 5

5 The Global Partnerships Strategy our international journey The Strategy details how the College will work in partnership with overseas organisations, health ministries and professional bodies to ensure the development of high-quality training for the anaesthetic workforce which meets the long-term needs of the local healthcare system. Steered by our Strategy, the primary focus of the College will be on the improvement of postgraduate anaesthetic education. We recognise that we have the tools to provide expertise in the development of curricula, assessment methodology, and training-the-trainer methodologies, all of which have international application. The Strategy also outlines our commitment to continue to utilise and develop e-learning capacity, and I am enthused by our ambitious plan to make this resource available to individuals in low- and middle-income countries. Which countries will the College engage with? The publication of the Strategy is a big stride forward, but we have already made significant progress in building international relationships. Through outreach and engagement from across the College s network, we have established formal partnerships in Hong Kong and Iceland, as well as providing support for burgeoning initiatives in Zambia and Sierra Leone, with educational links with Namibia also at an early stage. This is just the start, and there will be continued development in the breadth and depth of the international links we seek to build over the lifespan of the Strategy. As I have said many times, and as I continue to communicate to the politicians and decision-makers I meet, the members and fellows of this College are team players. We do not learn in isolation, and we need to have the vision to pass on best practice and learn from other colleagues around the world. The Strategy will greatly enhance the profile of the College at a time when we are expanding our footprint through investment in a number of areas. But it is important to remember that the starting point for this new venture is the recognition of unjustifiable health inequalities which exist across the globe. The Lancet Commission s 2015 Report Global Surgery 2030: evidence and solutions for achieving health, welfare and economic development ( found that an estimated 67% of the world s population has unmet surgical need. We cannot help to meet that need unless we work in partnership. The scale of the challenge five billion people The Lancet Commission reported that five billion people worldwide do not have access to safe, affordable surgical and anaesthetic care. I believe that we have a moral duty to help ensure that the best standards of patient care are universally available, and that as a College we should contribute to meeting this huge gulf of unmet need. We want to share what we know already works, and assist in developing bespoke solutions for the problems identified by our international partners. But these partnerships should not be one-way traffic. Professor Ellen O Sullivan, Council Lead for Global Partnerships, makes the point well in the foreword to the Strategy: We believe that it is important that relationships are two-way while our expertise can be used for the benefit of others, we must not forget that there is much that we can learn from our peers in different settings, be these differences cultural, economic or geographical. Ultimately, our Strategy is focused on outcomes, and its success will be judged on the contribution we make to improving the standard of, and the access to, anaesthetic care around the world. I am very proud that we have launched this Strategy, and I look forward to updating you on developments in this new and exciting area of the College s activity in the future. As always, if you have any comments or questions on any of the issues discussed in this article or would like to express your views on any other matters, I would like to hear from you. Please contact me via presidentnews@rcoa.ac.uk. President Liam Brennan Bulletin of the Royal College of Anaesthetists Churchill House 35 Red Lion Square London WC1R 4SG bulletin@rcoa.ac.uk Vice-Presidents Jeremy Langton & Ravi /RoyalCollegeofAnaesthetists Registered Charity No Registered Charity in Scotland No SC VAT Registration No GB Vice-Presidents Elect Ravi Mahajan & Janice Fazackerley Editorial Board Monty Mythen Editor David Bogod Council Member Simon Fletcher Council Member Jaideep Pandit Council Member Krish Ramachandran Council Member Lila Dinner Lead Regional Adviser David Booth Lead College Tutor Kate Tatham Trainee Committee Emma Stiby SAS Member Carol Pellowe Lay Committee Gavin Dallas Communications Manager Mandie Kelly Website & Publications Officer Anamika Trivedi Website & Publications Officer An estimated 67% of the world s Articles for submission, together with any declaration of interest, should be sent to the Editor via to bulletin@rcoa.ac.uk. All contributions will receive an acknowledgement and the Editor reserves the right to edit articles for reasons of space or clarity. population has unmet surgical need. We cannot help to meet that need unless we work in partnership The views and opinions expressed in the Bulletin are solely those of the individual authors. Adverts imply no form of endorsement and neither do they represent the view of the Royal College of Anaesthetists Bulletin of the Royal College of Anaesthetists All Rights Reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any other means, electronic, mechanical, photocopying, recording, or otherwise, without prior permission, in writing, of the Royal College of Anaesthetists. ISSN (print): ISSN (online):

6 Bulletin Issue 104 July 2017 Bulletin Issue 104 July 2017 News in brief News and information from around the College Policy and Public Affairs: our call for a New Deal By the time you read this piece the General Election will be behind us. Significantly for the College, this election marked the first time we published a policy manifesto, which we used to call for a New Deal for the NHS ( The manifesto lists seven priorities for the next government to support the ambition for all parts of the health and social care system to be appropriately resourced, effectively integrated and sustainably delivered in the best interests of patients. The manifesto was shared with each of the political parties with elected representation in Parliament, reflecting the College s political neutral position. Engaging with policy makers in Government, the NHS and wider political structures is a vital component in realising the vision of the College to support our fellows and members to play a central role in the delivery of highquality healthcare. I look forward to keeping you updated as we take strides forward in the development of this new area for the College. Anaesthesia Clinical Services Accreditation (ACSA) update The RCoA s accreditation scheme ACSA, continues to advance with an increased interest from healthcare organisations working towards subspecialty accreditation. The ACSA standards include five Domains : 1 The Care Pathway 2 Equipment, Facilities and Staffing 3 Patient Experience 4 Clinical Governance 5 Subspecialties. Domains 1 4 cover all aspects of general anaesthetic care provided in every hospital in the UK. Domain 5 focuses on the provision of additional levels of specialised care delivered by a separate subspecialty unit in a general or acute care hospital. The anaesthesia subspecialties currently included in Domain 5 are: 1 Adult Cardiothoracic Services 2 Neuroanaesthesia and Neurocritical Care 3 Ophthalmic Anaesthesia 4 Vascular Anaesthesia. Healthcare organisations can choose to undergo accreditation for Domains 1 to 4 only, or also to include any of the Domain 5 sub-specialties. Fifteen departments have received an accreditation, with four achieving Domains 1 to 5 accreditation, including vascular anaesthesia, ophthalmic anaesthesia and neuroanaesthesia. If you are interested to find out more about the ACSA process please visit or contact acsa@rcoa.ac.uk. ACSA Anaesthesia Clinical Services Accreditation ACCREDITATION 25th Anniversary celebrations continue The College s 25th Anniversary celebrations continue, with events being held across the UK. One goal of our celebration has been the opportunity to engage with school students about our specialty through the Inspiring the Future programme and the Debrett s Mentoring Scheme. Members of the College attended the Science 4 U Conference at the University of Westminster in April (below), to encourage students in years 9 11 to consider anaesthesia as a career. More events are planned for coming months, including Meet the Expert events in Birmingham and Newcastle, the screening of Green for Danger at the Barbican Centre with an introduction by Dr Tom Clutton-Brock, and a talk on the History of Anaesthesia by Dr David Wilkinson at the Old Operating Theatre in London Bridge. Our 25th Anniversary photography competition is also well underway and we encourage you to participate. The theme for the competition is In Safe Hands. There are cash prizes to be won, and the successful entries will be exhibited at the College and be used more widely to promote our specialty. More information about upcoming events and the photography competition can be found on the 25th Anniversary website: NIAA National Institute of Academic Anaesthesia H S R C Health Services Research Centre Research and Quality Improvement SNAP-2: EpiCCS (2nd Sprint National Anaesthesia Project: Epidemiology of Provision of Critical Care Services) ( ran from Tuesday 21 to Monday 27 March 2017, with a week of patient followup. SNAP-2, overseen by the Health Services Research Centre (HSRC), is examining the epidemiology of critical care provision after surgery, and whether planned postoperative critical care admission is effective as an intervention to reduce postoperative morbidity. There has been amazing support and engagement for SNAP-2 from Team Anaesthesia UK. A total of 254 sites participated in the study, with more than 2,700 local collaborators. More than 22,700 patient records and 10,300 clinician perception records have been logged. We are incredibly grateful to all local teams for their efforts. Sites are now able to export their own data for secondary analyses and quality improvement projects. on twitter for updates. PQIP has now launched its own YouTube channel ( please subscribe and look out for more videos. The first episode of the PQIP Podcast is also up on itunes ( You can watch and listen to everything in Resources at Other research articles in this issue of the Bulletin include Meet the HSRC Fellows where you can get an idea of the incredible hard work they put into our projects, and an article introducing NELA s new Clinical Lead and its online risk calculator. SNAP happy at Bolton anaesthetic 8 9

7 RCoA s Membership Engagement Panel: share your views to shape our strategy As part of our Strategic Plan, the College has committed to improving its engagement with and support for our fellows and members. As part of this commitment, we have recently created our first-ever Membership Engagement Panel. More than 1,750 members across all career stages have joined the panel and are actively sharing their views on how we can improve what we do and how we do it. The first survey was sent to panel members in April, seeking feedback on what support our fellows and members would like in order to further advance their skills and professional development in anaesthesia. Thank you to panel members who completed the survey your responses will help to shape the College s future strategy on training, education and leadership development. Our second survey will focus on what support our fellows and members require to develop their knowledge and skills in quality improvement methods and practices. Results will be shared in the autumn of If you re interested in joining the Membership Engagement Panel and are keen to take part in future member surveys, sign up here: We would love to hear your ideas about how we can improve our engagement with College members. Please send your thoughts to engage@rcoa.ac.uk FRCA Examinations Update 339 candidates sat the May OSCE/SOE, which ran from 15 to 19 May 2017, with an overall Primary pass rate of 64%. The pass rates for the last three Primary OSCE/SOEs were 51%, 64% and 64% in January 2017, November 2016 and May 2016 respectively. The Final SOE examinations also took place over 19 to 22 June 2017, and further details of this exam will be published in the next edition of the Bulletin. Applications will open in July for vacancies to the FRCA Board of Examiners and will remain open until October. All new examiners are initially recruited for the Primary. In years two or three of their examinership, approximately 60% of the examiner cohort will move to the Final Board to ensure an even spread of experience across both exam boards. Without exception, retiring examiners say they found their time as an examiner to be one of the most rewarding roles they have undertaken. The College usually receives significantly more applications than there are vacancies in the Examiner Board, and only applications that meet all essential criteria as set out in the Person Specification ( at the time of submission of the form will have their application forwarded to the selection panel for consideration. Applicants should note that visiting FRCA exams within five years is an essential requirement. A successful applicant can expect to complete at least ten years as an FRCA examiner. Further details of how to apply to become an FRCA Examiner are available on page 63. Advisory Appointments Committees (AACs) Assessors Training Day Patient information update The College s Patient Information Group has completed a review and update of the free patient and carer information provided on our website ( As well as updated content and enhanced navigation, a number of new resources have also been created. These include new and comprehensive FAQs, a glossary of medical terms for patients and a section on Questions to ask at the preoperative assessment ( Over the past year we have also re-branded and updated all our risk leaflets. Please take a look at the website and encourage your preoperative assessment team to share our resources with their patients. News in brief News and information from around the College If you are an AAC assessor for the RCoA or are interested in becoming one, there is an assessor training day on 10 July Further information is available from: If you have any ideas or suggestions for the College s patient information resources, please contact: patientinformation@rcoa.ac.uk 11

8 Despite this public denial, we are We believe that Data Science actually scenarios (such as audit, surveys, nonetheless a data-literate profession. summarises a much better approach. and small clinical research projects) We read and interpret scientific Very simply it means documenting that are a feature of clinical work. papers, we run audit projects, your work as code. Why code? Not This requires care where patient and we write business cases for just because it automates the process, information is being used, but these improvement projects. These are all but much more importantly because are surmountable problems not intrinsically quantitative undertakings. it requires you to be precise about impossible barriers. However, our adopted posture gets in the way of our doing these things as well as possible, and engaging with statistics and data. So what is our position on Data Science? Is it just a rebranding of statistics, which, despite underpinning quantum mechanics, modern finance, and the humble weather forecast, has never managed to seem cool? what you have done. English can be ambiguous, but a working computer program cannot. We believe that with modern, free, open-source tools this approach is achievable with a very small amount of training. It is with this premise that we created the Data Science for Docs course. We teach the concept of a data pipeline, so that reproducibility Syllabus summary: preliminaries + motivational demo R for newbies Excel hell data pipelines data wrangling just enough statistics data visualisation. Conclusion Guest Editorial DATA SCIENCE FOR DOCS Dr Steve Harris, Consultant in Anaesthesia and Critical Care, University College London Hospital; Health Foundation Improvement Science Fellow Dr Ahmed Al-Hindawi, Magill Research Fellow, Chelsea and Westminster Hospital Dr Finn Catling, Clinical Research Fellow, UCLH, NHS England Clinical Entrepreneur Dr Edward Palmer, Anaesthetic Registrar, Harefield Hospital Dr Danny Wong, Anaesthetic Registrar, South East School of Anaesthesia and NIAA HSRC SNAP-2 Fellow The general public would assume that medical professionals are numerically literate. University educated, technically trained in biological sciences and more, and with the unique legal privilege of prescribing medicines where incorrect dosing leads to disaster, there would seem to be no excuse for us not to be. However, most medics would deny any affinity for maths, and also exude a distaste for statistics. This is a truism even amongst anaesthetists, whose professional training includes physics and pharmacokinetics. At worst, statistics is cited as lies, damn lies and... But rename it to Data Science, chat about machine learning and drop in an artificial neural network, and you are part of the cool, new tech team. In fact, most of the work of a practising statistician is in preparing data. This is no different to working in a wet lab where the killer experiment can t be done until you have validated your reagents and calibrated your machines. The preparatory procedures must be documented and reproducible for the final table, figure or statistical test to have meaning. The same approach should apply to clinical research, audit and quality improvement. Such projects typically start with a paper form. Data is then laboriously transcribed into a spreadsheet. You might construct formulae, and copy-paste blocks of data to create summaries. New data means repeating the entire process by hand, and when you return to the project, inevitably months later, you struggle to remember your workflow. More formal analysis requires finding a friendly statistician and a license for SPSS (or another proprietary, menu- becomes an immediate advantage. A single document, or script, encodes the steps necessary to take data from an online web form into R (a free software environment for statistical computing and graphics) and then out into a report, a simple analysis, or a beautiful data visualisation. When new data is entered, a single keystroke is needed to rerun the entire analysis and update the output. When you come back to your work after a break, the steps required to produce your report are clearly documented. And when you want to share your work, it s as simple as sending a copy of your code to a collaborator. The tools necessary to do this work are freely available. Data can be collected on an online form (Google Forms or similar), stored automatically in a spreadsheet, cleaned and analysed in R, and the graphs plotted interactively using online platforms such as Plotly. We have borrowed heavily from the established and respected Software Carpentry and Data Carpentry courses, which teach a similar approach for scientists from undergraduate to post-docs. The course has been supported by the Software Sustainability Institute, who pioneered the Software Carpentry and Data Carpentry courses mentioned above, and by our own National Institute of Academic Anaesthesia. We have run the course at a hack weekend, where clinicians, biostatisticians, and software engineers worked together using the critical care data from the MIMIC database (Massachusetts Institute of Technology, Boston, USA), and NIHR Critical Care Health Informatics Collaborative (CC-HIC). We have even now run the course in Sri Lanka at the National Intensive Care Skills Training Centre! The materials for the course are freely available, partly because we think this is the right thing to do, and partly to provide a reference for people before and after the course. In the coming year, we will extend the course to a two-day format with a bring your own data option on the second day. With a very high facultyto-student ratio, we believe there is a very good chance that delegates will leave not just with a new set of skills, but with a completed analysis. driven statistical software package). However, we focus our course on 12 13

9 Anaesthesia Clinical Services Accreditation (ACSA) Experience of ACSA at Central Manchester Foundation Trust Revalidation for anaesthetists Inaugural information day for CPD Assessors Dr Rhys Clayton, Consultant Anaesthetist, Central Manchester Foundation Trust Chris Kennedy, RCoA CPD and Revalidation Co-ordinator In March 2017, after more than two years working towards it, Central Manchester Foundation Trust (CMFT) gained accreditation with the Royal College of Anaesthetists Anaesthesia Clinical Services Accreditation (ACSA) scheme. CMFT is one of the biggest trusts in the country, with the anaesthetic department covering four hospitals: Manchester Royal Infirmary, the Royal Eye Hospital, St. Mary s Hospital (the biggest delivery unit in the country), and Trafford General Hospital. We are the first hospital in the country to achieve ACSA Domain 5 accreditation in vascular and ophthalmic anaesthesia. ACSA is a voluntary scheme run by the RCoA, which offers service improvement through peer review. Departments benchmark their practice against standards laid down by the College, and subsequently have an external review to assess their compliance. We commenced the process in early We began by dividing the standards up amongst the consultant body, and then performing a gap analysis. This involved assessing where our practice was compared with each standard, and then looking for ways of closing any gap. We then spent several months working on areas where we felt that the department s current practice fell short of the standards set. Trafford General Hospital had recently joined Central Manchester Foundation Trust, so we found that this was an excellent opportunity to ensure that guidelines and practices were homogenised across the two sites. By summer 2016, we felt that we were close to meeting all of the standards set by ACSA, so we contacted the College to arrange our external review for November Despite some anxiety preceding it, the external review felt like a real opportunity to showcase the excellent practice that is carried out in our trust. The feedback we received from the review team was very positive, with only a handful of standards needing some further work before accreditation could be confirmed. This confirmation came through in March The ACSA process has been very beneficial for the department. It has allowed us to improve the service we deliver, provide reassurance to management, patients and staff that we are delivering care of a high standard, and has also improved morale by highlighting the excellent work that is carried out throughout the department. For a number of years the College has offered a service for the CPD approval of courses and events. The approval process is based on criteria published by the Academy of Medical Royal Colleges. It is overseen by the CPD Board and underpinned by an annual quality assurance report. When an application is received, the College Revalidation and CPD Team completes an initial administrative review to check that the required documentation has been submitted, and to address any gaps making contact with the event provider s nominated contact as necessary. The event information is then sent to one of a group of CPD Assessors with the appropriate specialist knowledge which is relevant to the event content, to carry out the formal review. For providers, the benefits of approval include their events being featured on the College website and in the CPD Online Diary, and the benefit for the CPD Assessors is that their reviews can be included as a personal activity in their revalidation portfolio. With the volume of event applications continuing to increase, we invite all Fellows of the College to learn more about the role of the CPD Assessor by coming to an information day, arranged for Tuesday 26 September. Enquiries are particularly welcome from our SAS doctors. Taking place at the College, the information day will run from 11.00am until 3.00pm, and will include sessions on how to add meaningful reflection and how to develop an event, as well as workshops looking at previous CPD event applications and on the College Technology Strategy Programme. The day will also provide valuable networking opportunities. Places are limited, so for any further information, or to book your space, please contact Chris Kennedy, Revalidation and CPD Co-ordinator at ckennedy@rcoa.ac.uk

10 Faculty of Pain Medicine (FPM) Training and Assessment Committee update Faculty of Intensive Care Medicine (FICM) Training, assessment and quality Dr Jon McGhie, Chair, FPM Training and Assessment Committee Dr Tom Gallacher, Chair, FICM Training, Assessment and Quality Committee The Faculty of Pain Medicine Training and Assessment Committee (TAC) hosted an update day for Local Pain Medicine Educational Supervisors (LPMESs) at the College in March. The Dean, Dr Barry Miller, spoke on the future direction of the Faculty, and updates on the FFPMRCA exam and workforce issues were interspersed with talks aimed specifically at supporting the LPMESs in their role. Given the positive feedback received and the varied discussion points raised, we plan to host a similar event next year, to keep lines of communication open between the TAC and consultants delivering pain training. Current active FPM TAC projects include: creating a map of pain-training opportunities across the UK to help advanced pain trainees (APTs) identify sub-specialty training opportunities 1 supporting the development of a pain medicine research network to work in collaboration with existing anaesthetic research groups establishing a paediatric pain working group within TAC to review and develop training and assessment issues relevant to this field reviewing pain-training assessments in anticipation of the General Medical Council s recommendations on generic professional capabilities developing resources for trainees at the intermediate level of pain training. We recognise that this is an important stage of training in which to promote career options in pain medicine. To support this, we will have a display at the Group of Anaesthetists in Training (GAT) meeting later this month. More information will be uploaded to the FPM website as these projects progress during Another major workstream for TAC is workforce planning. The original pain census is now five years old, and we suspect that pension and tax changes in the last few years have altered retirement planning for many consultants. There is much concern and uncertainty surrounding withdrawal from the EU, and this has the potential to further undermine existing workforce calculations. 2 Regional variation in staffing of pain centres was a concern raised in the original census, and this is unlikely to have improved with ongoing financial restraint. 3 It is against this backdrop that we are undertaking a new census of the chronic-pain workforce in 2017, and we plan to present the results later in the year. References 1 How do you get recruited into pain medicine? FPM, London ( 2 Future of UK health care at risk as more than four in ten European doctors considering leaving UK following Brexit vote. BMA, London ( 3 Sicker patients the main reason for A&E winter pressures. The King s Fund Quarterly Monitoring Report, March 2017 ( The Faculty of Intensive Care Medicine has submitted its curriculum review to the GMC, with a view to removing the requirement for expanded case summaries and to replacing audits with quality improvement projects. Guidance will be available on the website once the changes are approved. Introduction of the revised curriculum is planned for August Following their Standards for Curricula and Assessment Review (SCAR), the GMC will introduce new style curricula to all specialties by 2020, and these will be outcomes based and are intended to reduce the burden of assessment on trainees and trainers. All curricula will incorporate Generic Professional Competencies (GPC). The GPC framework will prioritise core professional capabilities essential to safe clinical practice, and these will be assessed at every stage of training. A major curriculum rewrite cannot be done yet,as we need to wait for the GMC guidelines coming out of SCAR to be confirmed. As stated above, one of the aims of SCAR is to reduce the assessment burden, and it is likely that the FICM curriculum when rewritten will have fewer competencies which require formal assessment in order for the trainee to be deemed competent. In response to concerns fed back to the Faculty by trainees, we will be issuing guidance on how to minimise the assessment burden of our current curriculum. This will make it clear that a single clinical encounter can, where appropriate, be used to demonstrate multiple competencies, thus allowing multiple-competency sign-offs. An example would be that admitting a patient to the critical care unit could be used to demonstrate a host of knowledge, skills and attitudes competencies. We will place trainee-competency guidance for our revised current curriculum on our website. This guidance document (reference tool) will demonstrate ways in which hard-toachieve competencies can be addressed, and is intended to be an easily accessible resource for trainees and trainers

11 Patient perspective A BRAVE NEW WORLD? Mr Rob Thompson, Chair, RCoA Lay Committee I suppose my views about artificial intelligence (AI) mimicking cognitive functions such as learning and problem solving are shaped by Hollywood blockbusters and books such as Mary Shelley s Frankenstein. These dystopian tales often pit man against some monster that has grown out of control. A da Vinci Surgical System at Addenbrooke s Treatment Centre during the 2015 Cambridge Science Festival ( ly/2qauarh) Yet AI is not just some science fiction story: it is already part of our lives in our cars, telling us when the next service is due; in our Google searches and Amazon suggestions; in our Siri requests. It is getting increasingly sophisticated at doing what humans do but more quickly and efficiently, and cheaper too. AI is also making inroads into the NHS. In London an app is being piloted with users of the nonemergency 111 service. At the Royal Free Hospital, the Trust is developing an app aimed at patients with signs of acute kidney injury. The hospital claims the project, which uses information from 1.6 million patients a year, could free up more than half a million hours annually spent on paperwork. Big claims are being made for the diagnostic potential of AI. A supercomputer was credited with diagnosing, in minutes, the precise condition affecting a leukaemia patient which had baffled doctors for months, by cross-referencing her information with 20 million oncology records. Robots have been used in medicine for 30 years, from simple laboratory tasks to the complex surgical procedures carried out by the da Vinci robots. But what do patients think about such developments, and are they willing to accept them? A recent YouGov survey of 11,000 people across 12 countries has indicated an appetite to engage with AI and robots if doing so means better access to healthcare. Speed and accuracy of diagnosis and treatment are critical factors in this willingness. Further, trust in the technology is vital for wider use and adoption, and this may be where the human touch is still needed. One pattern that emerged was that emerging economies are more willing to embrace new technologies than established economies such as the UK and Germany. Yet consumers across all regions are willing to accept treatments, tests and services administered by AI or robot, such as heart monitoring, customised advice for fitness and health, and blood tests. In the operating theatre, however, preferences change. For minor surgery some developing countries are most willing to undergo surgery performed by robots, but in the UK only 36% were willing, and that dropped to 27% for major operations. When people were asked about the perceived advantages of these sorts of treatment, their answers were centred on: easier and quicker access faster and more accurate diagnosis better treatment recommendations availability at any time (e.g. via a smartphone). The main disadvantages were felt to be: unexpected events not trusting a robot to respond impersonal approach the human touch is key only a doctor can make the right decisions looking beyond the data and taking into account the context and underlying complexities users understanding the technology. There seems little doubt that AI will enable faster and more accurate diagnoses over the coming decades. However, the prospect of replacing doctors seems less likely although their roles may still need to be redefined. This redefinition will need to include the ability to put machine-generated information into the context of the unique life and needs of the individual patient that which cannot be reduced to an algorithm. Ironically, one of the most powerful effects of AI may be to make healthcare more human and personal if we get it right. It will remove issues caused by the doctor s fallible memory and incomplete knowledge, thereby freeing them to work with patients to shape their specific treatments. This has profound implications for medical training and for how we define a doctor. It will be those who can harness AI to their own medical knowledge, and use it to support their human skills at recognising context and displaying empathy, who will be the leaders of their profession. In this brave new world there will still be a great deal for highly trained people to do. Further reading What doctor? Why AI and robotics will define New Health. PwC, 2017 ( A recent YouGov survey of 11,000 people across 12 countries has indicated an appetite to engage with AI and robots if doing so means better access to healthcare 18 19

12 Society for Education in Anaesthesia (UK) BECOMING MORE RESILIENT Dr Shirley A M Remington, Associate Dean, Health Education England (North West) At the meetings one attends there is often a resilience workshop, and it will be the first one that fills. One can speculate on the reasons for this and the objectives those attending will have, but what is more certain is that as individuals we are becoming more likely to experience burnout, and that mental health issues are more commonly reported. The reasons for this are multiple and complex, but building a reservoir of wellbeing, the key to personal resilience, can be a help in avoiding these problems. The techniques are simple, but they require repetition to become embedded and protective. They have been codified in recent times by advocates of positive psychology, but are seen throughout all cultures, including the philosophy of ancient Greece, Daoism and others, across the whole of human history. Now we have evidence from neuroscience, particularly functional MRI scanning, that the brain exhibits plasticity throughout life, and can be trained relatively easily to enhance areas within it that make the individual more able to withstand the challenges of personal and professional life and enable them to behave resiliently. All approaches to building and maintaining wellbeing have common elements, which are also seen in many self-help books. These are: understanding of one s self and selfmastery; maintenance of physical health; developing a positive approach to life; defining personal goals and values beyond self; engaging with others; focusing on personal growth; and learning from overcoming challenges. Many also suggest the use of role models to help identify resilient approaches that can be cultivated. The very busy lives most of us lead can make these simple activities appear hard to achieve, but most can be easily integrated into daily life. Understanding of self can be achieved in a number of ways, and the process can be started by completing a questionnaire on resilience skills, of which there are many available simply by using google, and then reflecting on the results. Reflection generally aids wellbeing, particularly if the model used requires the challenging of one s personal thoughts in an objective way and looking for thought errors that is, looking for personal responses that would not match the interpretation of an external observer. The simple understanding that the personal outcome of any event depends as much on our response to the event as on the event itself, can be a revelation. The easiest area to change that brings benefit is that of physical health having adequate sleep, exercising regularly, eating and drinking sensibly and avoiding smoking and drinking all have significant value. The key to using these is making small changes that are incorporated into daily life examples are walking rather than taking the car for short trips, good sleep hygiene, using step-counters to encourage increases in activity. There are many exercise apps that are helpful as support for all these. A positive approach to life begins with an understanding of the real significance of events within our lives. How important is that event (on a scale of 1 10) in the totality of life, and will it matter in sixmonths time? If a planned day presents a challenge, accept it, but also be clear that you will come through it and then when you have come through it, The easiest area to change that brings benefit is that of physical health consciously acknowledge that you have, and recognise the things that got you through or that went well. Accept that we can fear events and that doing so is normal, makes us perform better and is a protective response. Using these approaches, and adding the expectation that you will come through events which are challenging, becomes a habit with practice and enhances responses across all aspects of life. Cultivating an optimistic outlook here is also useful, as such an outlook is strongly correlated with increased life expectancy, as well as wellbeing. Recently there have been many studies which show that optimism can be enhanced by simple exercises, and there are many easily accessed apps or websites that provide such exercises to allow one to do this. Defining specific goals in life and having a focus on what one wishes to achieve are important in building wellbeing. What do you want to achieve in the next Simple steps to wellbeing Understand self-resilience questionnaires Use reflection look for thinking errors Develop a positive approach and perspective Take care of personal health sleep, nutrition, exercise Explore personal values and aims regularly Keep meaningful contact with others Do new activities and have fun Look for resilient role models Reflect on and highlight what went well every day five years? What is on your bucket list (and can you start working on any of it to keep it off the bucket list)? What do you really believe in? Paying attention to this area of our lives is often forgotten in general activity, but it gives us the opportunity to think deeply. Such thinking is part of building our mental health, along with activities like mindfulness, meditation and engaging in activities where the level of engagement is such that we lose track of time and of what is going on around us. Getting involved in new activities, and keeping meaningful contact with others together with small acts of kindness are easy and have a significant personal impact. Finally, at the end of every day, spending a few moments to highlight three things that went well will support many of the above actions and, with time, build one s wellbeing and allow a more resilient approach to the next problem

13 National Institute of Academic Anaesthesia (NIAA) SMALL GRANTS AND AWARDS: a how-to guide Since 2009, the RCoA has awarded several small grants distributed through the National Institute of Academic Anaesthesia (NIAA). These are for a variety of projects, from basic science research, quality improvement and educational projects, to travel grants and awards for published papers. Every year, the Small Grants Subcommittee of the NIAA Research Council receives up to 25 applications. The applications are classified as Research, Education or Travel. Research applications are rated against the following criteria: is there is a clear research question? is the proposal original? is it relevant to the aims of the NIAA ( Dr Felicity Plaat, Consultant Anaesthetist, Queen Charlotte s Hospital, London In terms of methodology, the aims and objectives should be clear, and the methodology used rigorous and justifiable. The timescale for the project should be realistic, and the amount of funding requested justifiable. An example of a successful application in 2014 was one for a study of acute hypoxia in healthy human volunteers, using a hypoxic chamber designed for training elite athletes. For the first time, the effects of acute hypoxia on nitricoxide-regulated pulmonary vascular responses were to be studied at rest and following exertion. The relevance of the project was made clear, and the funds requested were justified by a detailed breakdown of costs. There are often overlaps between educational and travel grant applications. In 2016 a grant was awarded for a project to introduce the use of early warning scores into a maternity unit in The Gambia. Another successful scheme involved setting up critical care training for local anaesthetists in Ethiopia. Particularly when projects are based in resource-poor settings, evidence of sustainability is important. Because of this, those that involve teaching will tend to score more highly than ones where the applicant purely intends to provide their clinical services. The project has to be relevant to the setting: planning to set up high-fidelity simulation in an area with a very unreliable power supply is an obvious example of a proposal that is unlikely to be funded. However, the importance for personal development as well as organisational gain is taken into account. The organisation in question may be the applicant s own NHS employer. In common with research grants, applications must be relevant to the NIAA vision, the proposed timescale appropriate and the amount of funding justifiable. Not infrequently grants are awarded to pay for travel to and registration at international meetings. If the applicant is presenting at the meeting or is involved in academic activity relevant to the subject, they are more likely to be successful. Not all awards are for overseas projects. One grant was used to pay the tuition fees to attend the King s Fund course on clinical leadership in London for a senior trainee. Successful applicants are required to write a short report on conclusion of the project, which includes its findings, and submit this to the NIAA for publication on its website. The Small Grants Subcommittee has four members, all of whom are members of the Research Council of the NIAA. Each application is scored by at least three members of the subcommittee, and each of these members will make a global rating, either to strongly recommend funding, to consider funding, or not to fund. The subcommittee tries to supply constructive feedback whatever their decision, (which is almost always unanimous). The Maurice P Hudson Prize, also awarded by this subcommittee, is slightly different. This is awarded to the anaesthetic or intensive care trainee who is the principal author of the best paper relating to the management of acutely ill patients, recently published, or accepted for publication, in a peer-reviewed journal. Last year, it was awarded for a review article on the impact of restrictive versus liberal transfusion strategies on patient outcome in patients with NIAA National Institute of Academic Anaesthesia cardiovascular disease. This had been written as part of the applicant s PhD thesis and published in the BMJ. If any reader is thinking of applying and would like to discuss their application, the chair or members of the subcommittee would be very happy to do so. You should contact us via the NIAA (info@niaa.org.uk), and we will get back to you as soon as possible

14 Small Grants and Awards Applications for all of the grants, awards and prizes featured should be sent to the NIAA Co-ordinator, Ms Pamela Hines, by post and to the Royal College of Anaesthetists, 35 Red Lion Square, The National Institute of Academic Anaesthesia (NIAA) has several Small Grants, funded by the Royal College of Anaesthetists, for the purpose of supporting research, education or travel connected with the study of anaesthesia. Priority will be given to educational projects, the presentation of original work, or the provision of education to developing countries. Applications are invited for the following funds: Ernest Leach Research Fund This fund was established in June 2011 to be utilised for the purposes of research. Value up to 2,500 Sargant Fund For education and research purposes. Value up to 2,500 Belfast Fund To fund grants for educational purposes. Value up to 600 Eligibility All Fellows in good standing and registered trainees are eligible to apply for the above grants. We regret that applications for funding towards registration for higher degrees or college course fees will not be considered. To apply Please visit to view the assessment criteria and download a copy of the application form. The deadline for applications is 5.00 pm on Friday 1 September Payne Stafford Tan Award: An Award for Clinical Excellence This award was originally established through the generosity of an American friend of the College, Mr Norman Knight. The aim of the prize is to mark excellence in clinical practice, teaching or research in anaesthesia, critical care or pain management. The award is open to any Fellow or Member of the College, and comprises a grant (to a maximum of 1,000) to be used for educational purposes such as attendance at a major conference or the purchase of educational materials. The recipient will be expected to provide a short report outlining how the funds have been used. To apply Nominations are now invited for the 2017 award, and must be made by a Fellow or Member of the College. The nomination should be in the form of a letter outlining the particular merits of the individual nominated, and should be sent to the NIAA Coordinator at the address below by 5.00 pm on Friday 1 September Macintosh Professorship The Royal College of Anaesthetists has established a number of initiatives to foster research in anaesthesia, critical care and pain management. Their aim is to encourage experienced researchers as well as those who are in the early stages of developing a research portfolio. Macintosh Professorships are aimed at established clinical or laboratory researchers who are already performing at a high level. Their purpose is to recognise and disseminate the work of the award holders and facilitate their progress in the academic world. Recipients of the award will have a national or international reputation in their field. Their curriculum vitae will be consistent with an individual who is performing at, or is on the cusp of, professorial level through research, innovation, and leadership. Those who Macintosh Professorships are awarded for one year (normally the College academic year). Recipients are required, within that time or soon after, to give a keynote lecture at a meeting organised by the Royal College of Anaesthetists or its associated Faculties, or of other related organisations and specialist societies. The lecture is commemorated by the presentation of a certificate. Applications for Macintosh Professorships are open to Fellows and Members of the Royal College of Anaesthetists and other clinicians and scientists involved in anaesthesia, critical care and pain management within the United Kingdom. Applications will be considered by the Board of the National Institute of Academic Anaesthesia and expert external advisers. The College welcomes nominations from national and/or specialist societies in anaesthesia within the UK. If successful, the title of the Professorship will reflect a joint award from the College and nominating body. To apply Please submit a synopsis of your proposed lecture, along with a CV and covering letter by and post to the NIAA Coordinator at the address below by 5.00 pm on Friday 1 September Maurice P Hudson Prize Dr Maurice Hudson was a consultant anaesthetist in London, took the Diploma in Anaesthetics (DA) in 1936, was awarded the Diploma in Anaesthetics (FFARCS) in 1948 and had a particular interest in dental anaesthesia. The Hudson Harness was one of his innovations. The late Dr Maurice Hudson s daughter generously donated money to the College in memory of her father for an annual prize for the best paper on his favourite subject: resuscitation. The criteria for this prize have now been extended, and the prize will be awarded to the anaesthetic or intensive care trainee who is the principal author of the best paper relating to the management of acutely ill patients published, or accepted for publication, in a peer reviewed journal. To apply If you are such a trainee and would like to apply for the prize, and you have published an article since 1 August 2016, please submit your article by and post to the address below, along with a copy of your CV and a covering letter by 5.00 pm on Friday 1 September A prize of 500 is available this year. Please note that only one article may be submitted per applicant. London WC1R 4SG phines@rcoa.ac.uk NIAA National Institute of Academic Anaesthesia be accompanied by a full curriculum show equivalent excellence in teaching vitae for that individual. Self nominations and education will also be eligible are also permitted. Nominations should for the award

15 As a consultant anaesthetist in a large and felt faintly guilty about not doing want to encourage the effective and district general hospital, which until before moving swiftly on to the next meaningful use of this national data at recently has been in special measures under the intense scrutiny of the CQC, improving the care of our most unwell patients has been one of the top priorities for me and my colleagues. Achieving this has often seemed like an impossible, vast and complex task, but my local team s active participation in national audit projects such as NELA has been crucial in turning round our outcomes for our patients. Now, as I join the NELA team at the Royal College of Anaesthetists as clinical lead, I am really excited to become a part of such a high-impact project, which I know from first-hand experience can really help improve care for patients. pressing task. However, I was asked by a colleague to attend the Emergency Laparotomy Collaborative, a quality improvement (QI) initiative programme led by Niall Quinney, and to establish this at Medway Maritime Hospital. I knew this was not a job to do alone, so I set up a team, which included our Clinical Director for Surgery and for Critical Care, junior doctors, theatre staff, data analysts and a QI nurse. We worked hard to find ways to make it easy for staff to deliver the high standard of care they wanted to by following the standards set by NELA, and by using the tools provided by the Emergency Laparotomy Collaborative (ELC). local level, and to provide the strategies for you to apply changes in your hospital that will make a difference for your patients. On this basis, NELA is going to continue gathering data, and will provide the QI tools to use this data locally to drive effective changes in care for your patients. We will encourage collaborative working, not only with other national audits and QI programs such as the ELC and the Perioperative Quality Improvement Partnership, but with patient groups as well. We will be providing quarterly reports to benchmark your performance (which will be useful when engaging executive support for Medway Maritime is a fairly unique hospital in that it had been in CQC Building upon this with our own ideas, our QI knowledge and an enthusiastic your projects) and real-time data on our website to use locally. National Emergency Laparotomy Audit (NELA) NELA CLINICAL LEAD special measures for longer than any other hospital. However, we have recently celebrated shedding this dubious title, and we are now emerging into our recovery phase. Working in a hospital under such pressures, and leading change under testing team, mortality rates started to fall. Consultant anaesthetists and surgeons engaged with the process of delivering care to our most poorly patients, and led the rest of their teams by their example. Our Chief Executive and Medical Director were soon able to see With this approach we believe we can help support local teams, offer a very powerful means for engaging staff, and provide sustainable techniques for improving patient outcomes in the long term. circumstances, has put me in a perfect a clear improvement in our outcomes Dr Sarah Hare is the new National Clinical Lead of the National Emergency Laparotomy Audit (NELA), taking over the role from Dr Dave Murray, who will now chair the Project Team. She also works with the Healthcare Quality Improvement Partnership (HQIP) and the National Confidential Enquiry into Patient Outcome and Death (NCEPOD). Sarah is a full-time consultant position to understand the challenges faced by clinicians when working to collect robust prospective data and apply it effectively to drive change and improve care. But I also now understand how crucial it is to do this well, doing not only quality improvement but also as we benchmarked ourselves against expected NELA standards, and they supported us, which empowered us further to sustain the changes we were putting in place and really embed them within the culture of our staff. Our theatre staff have also taken ownership and pride in the anaesthetist at Medway Maritime Hospital in Kent, and busy mum to a three-year-old. quality assurance to executive boards and external organisations. When used properly, projects such as NELA do not need to be an added burden but transformation in care we are providing. They now all know that they play a part in saving lives of laparotomy patients, and that in itself is a powerful motivation can help us in making sure that we are for people to keep up this level of care able to deliver the care needed by our for the next patient. patients, and able to demonstrate that we are doing so. NELA might be called an audit, but most importantly our aim is to improve the When NELA first started I confess, it quality of care emergency laparotomy seemed to be one of those audity patients receive through the provision things that we had all forgotten to fill out, of high-quality comparative data. We 26 27

16 National Emergency Laparotomy Audit (NELA) NELA RISK-PREDICTION TOOL Dr Sarah Hare, Consultant Anaesthetist, Medway Maritime Hospital and NELA National Clinical Lead Dr Ramani Moonesinghe, HSRC Director and Consultant in Anaesthesia, Perioperative and Critical Care Medicine, UCLH The National Emergency Laparotomy Audit (NELA) is about to launch a perioperative risk calculator which we have developed specifically for emergency laparotomy patients. The NELA risk calculator aims to standardise the risk calculation for emergency laparotomy patients and support clinical decision making. We have aimed to make it simple to use patients will also need to be considered Over the last three years, the National Emergency Laparotomy Audit has collected data on over 60,000 patients having this type of surgery in England and Wales. Although NELA is primarily an audit, we are also committed to improving the outcomes for all emergency laparotomy patients by promoting adoption of the standards of care that, when combined, reduce mortality. Our ambition at NELA is to not only provide accessible data that can be used at local hospital level to drive improvement in care for patients, but also to provide the tools to enable this. To this end, we have provided quality-improvement tool kits, videos and workshops, and supported collaborative working across the country to share best practice. NELA collects data based on the standards set by National Confidential Enquiry into Patient Outcome and Death (NCEPOD), NHS seven-day services and the Royal College of Surgeons of England regarding risk stratification. One of the overarching messages is is a mandatory part of preoperative assessment, and this should be clearly documented on the consent form and within the patient notes. Since the risks of complex emergency surgery vary between individuals and according to the actual surgery being performed, the ability to stratify risk and calculate a percentage chance of death helps guide doctors and patients in deciding which course of management might be most appropriate. This is even more important when assessing a patient who is potentially at high or highest risk for an emergency surgical procedure, because not only does the clinical team need to have a common language to be able to make good treatment (or palliative) decisions together, but they then need to be able to have this discussion with the patient and their families and explain clearly potential risks to them and why potential ceilings of care are being set. NELA data has shown an improvement in the use of risk scoring over the last three years, but we still have some way compliance with requirements for risk assessment and documentation in the patient records. There are a number of possible reasons for this, including the possibility that people do not have faith in or knowledge of existing riskscoring systems. The Portsmouth-Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity (P-POSSUM) calculator is currently available to use on our website. However, we know that P-POSSUM tends to overestimate a patient s risk of death once this rises above 15%, and it is not specific for emergency laparotomy surgery. Therefore, the NELA team has used the data you have provided to improve the prediction of perioperative risk by developing a risk-prediction tool specifically for emergency laparotomy patients. The NELA calculator will estimate an individual s risk of death within 30 days of emergency laparotomy surgery. Its development has been led by the experts Royal College of Surgeons of England, who are our collaborators on the NELA project team. It has been developed using multi-variable analysis taking into account specific patient characteristics, risk factors and surgical procedures. The development process used data gathered from over 38,000 patients in the first two years of NELA; therefore the calculator is specific to UK patients undergoing emergency laparotomy, although it may have generalisability to similar patient for everyday clinical work, and to support this we will be launching the NELA Mobile App later this year, which will make it easily available. We hope that this will make it easier, more effective and more efficient for all of us to use risk prediction as part of the care we provide for emergency laparotomy patients. We know that the NELA calculator is more accurate than P-POSSUM in the cohort of patients for whom we already have data, and therefore we expect it to provide a more accurate estimate of outcome, even at the extremes of risk (such as >15% predicted risk of death). However, when using the NELA calculator, as with all risk-prediction tools, including the P-POSSUM, Southampton Oxford Retrieval Team (SORT), American College of Surgeons National Surgical Quality Improvement Programme (ACS NSQIP) calculator or exercise testing, it is important to remember that none is 100% reliable or accurate. It is therefore important to use risk calculators as guides in conjunction with clinical judgement. Other factors such as frailty alongside the NELA calculator. However, we hope that this addition to existing risk-prediction systems will support wider adoption of individualised risk assessment in practice, and therefore anticipated improvements in patient care and outcome. NELA thanks the following individuals and organisations for supporting the development of the NELA calculator: Clinical Effectiveness Unit at the Royal College of Surgeons development and internal validation of the NELA risk model NELA Project team clinical input into model development NetSolving Ltd Development of NELA web tool and calculator J-P Lomas, Consultant Anaesthetist, Royal Bolton Hospital and RCoA Council Member Development of NELA model app, For further information, please see: that an individualised risk assessment to go to achieving our target of 100% at the Clinical Effectiveness Unit at the populations in other parts of the world. and specific comorbidities of individual 28 29

17 Bulletin Issue 104 July 2017 Bulletin Issue 104 July 2017 Health Services Research Centre (HSRC) Meet the HSRC Research Fellows The Health Services Research Centre s proudest achievement is the development of its team of research fellows. As well as supporting HSRC projects, the fellowship programme aims to support the development of tomorrow s academic leaders. Since 2012, ten trainees and one post-cct fellow from eight different schools of anaesthesia have worked on projects including, amongst others, the National Emergency Laparotomy Audit (NELA), the Perioperative Quality Improvement Programme (PQIP), and the Sprint National Anaesthesia Projects (SNAPs); three more will start over the next 12 months. All are anaesthetists, from a variety of regions and backgrounds, and none had any significant research experience when appointed. Each gives a brief outline of their experience of their fellowship below. The HSRC advertises posts annually. We are hugely grateful for the support we have had from our funding partners, and are always looking for opportunities to work with research funders and hospitals across the UK. Interested future fellows please contact hsrc@rcoa.ac.uk. DR MIKE BASSETT ST7, North West School; NELA Fellow Funding: The Princess Grace Hospital My interest in NELA was piqued by completing local data entry and seeing personally how sick emergency laparotomy patients were. I wanted to take part in improving care for this group at a national level. The year went incredibly quickly; I helped produce the Second NELA Patient Report and gained useful skills in time management, communication, and data handling. I enjoy supporting Tranmere Rovers, cycling, running and climbing, although recently those have taken a back seat to attending loud children s birthday parties.i would like to emphasise that a prospective fellow does not have to be a research person I didn t consider myself one! DR JAMES BEDFORD ST5 Anaesthetics/ ST4 Intensive Care Medicine, South East School; PQIP Fellow 2016 present. PhD in progress. Funding: The Princess Grace Hospital The HSRC posts seemed an excellent fit for my interests and experience. The initial one-year post allowed me to get a feel for the work, and I have now extended it to three years. I ve recently been learning statistical programming language, creating the PQIP quarterly reports. The more predictable routine of research has allowed me to resume playing football for a local team, something I had given up due to clinical shift patterns. Fellowships give you time and support to learn and develop skills, and are accessible and suitable for people with little or no previous research experience (like me). DR OLIVER BONEY ST6, Barts and The London School; HSRC Fellow 2014 present. PhD in progress. Funding: The London Clinic/RCoA/UCLH Surgical Outcomes Research Centre (SOuRCE) Initially wanting time away from training, and having a young family, health services research looked an attractive proposition. I contacted HSRC out of the blue enquiring after projects open to enthusiastic but unskilled research novices, and was surprised by the overwhelmingly encouraging response. I ve worked on two projects: Core Outcome Measures for Perioperative and Anaesthetic Care, and the Anaesthesia and Perioperative Medicine Priority Setting Partnership. I ve experienced managing a nationwide project, delivering a multicentre research study, and developed a passion for improving the healthcare experiences of patients having major surgery. DR MARIA CHAZAPIS ST7, North Central School. PQIP Fellow 2015 present. PhD in progress. Funding: UCLH/RCoA After blowing up an expensive spectrometer at Med School, I was put off any sort of research until I d navigated the FRCA exams and returned from maternity leave. I designed a study to prospectively measure quality of recovery, which led to a BJA publication. I obtained a Darzi fellowship, learning about healthcare leadership, management and (my favourite) quality improvement. I m currently completing anaesthetic training and working towards a PhD. Every week is filled with challenges, delights, learning and challenges (did I mention those?). My advice to anyone interested in research it s completely worth it and it s never too late to start! 30 31

18 Bulletin Issue 104 July 2017 Bulletin Issue 104 July 2017 Health Services Research Centre (HSRC) Meet the HSRC Research Fellows DR DAVID GILHOOLY Post-CCT Anaesthesia/Intensive Care Medicine, Ireland; PQIP Fellow August 2015 present. MD(Res) in progress. Funding: London Clinic I am an Irish graduate and trainee, and undertook a fellowship in bariatric anaesthesia at UCLH before applying to the HSRC. I m researching the delivery of care bundles in the acute care setting. I also work on PQIP and support other fellows in their research. Starting research can be quite daunting, but provides a wealth of knowledge through sharing of ideas and experiences. Top tip: find a good outlet removed from medicine so you can rejuvenate. Outside of clinical practice I have been involved in setting up a charity to teach doctors and nurses in developing countries. DR MATT OLIVER ST5, North Central School; NIHR Academic Clinical Lecturer (UCL; 2017 present); NELA Fellow: PhD awarded Funding: London Clinic/NELA Since Med School I d wanted to combine research and clinical work; doing the Final FRCA in ST3 provided impetus to apply for a research post. Three puzzled Annual Review of Competence Progression (ARCP) panels later I returned to Intermediate training! I was appointed NELA s first Fellow in I identified risk tools and standards of care, put together audit questionnaires and reports, and presented at meetings. I ve been lucky enough to write chapters for critical care textbooks and a module for UCL s perioperative medicine MSc. A medical career remains a passport and I cannot recommend enough getting out there and collecting stamps on that passport! DR DUNCAN WAGSTAFF ST5, North Central School; PQIP Fellow 2015 present. MD(Res) in progress. Funding: NIHR ACF/Princess Grace/Health Foundation I got into research a bit haphazardly, without a burning question to answer but keen to explore a big picture view of healthcare. I m researching how we use data to improve care. The best bits about research include autonomy; a flexible working pattern consistent with a young family at home; exposure to new people and ways of thinking; and excitement as new doors open, even if I m not entirely sure where I want them to lead. I m really glad that I ve tried research. Don t assume that you need a lot of experience to get involved! DR ELLIE WALKER ST7, North Central School; SNAP-1 Fellow ; HSRC (paediatric HSR) 2016 present. MD(Res) in progress. Funding: UCLH/Princess Grace/London Clinic. My overwhelmingly positive first experience with research was as trainee lead of SNAP-1. I extended my time out the following year in order to complete an MD(Res). After only a brief return to training, I am once again doing an Out-of-Programme- Research (OOPR) year to complete my thesis and work on paediatric health research projects. Initially daunted by the fact that I had no previous experience in research, I found from speaking to others that I was not alone in these fears! There is likely to be something out there to suit everyone. DR AMAKI SOGBODJOR ST6, Imperial School; HSRC Fellow in Paediatric Perioperative Medicine (August 2016 present). MD(Res) in progress. Funding: London Clinic After ST5, I undertook an MA in Medical Ethics and Law. I enjoyed the professional and personal merits of taking time out of training to focus on an area of particular interest, so I jumped at the opportunity to join the HSRC. The focus of my research is addressing the lack of paediatric-specific quality metrics. Prior to this fellowship my experience of qualitative research was limited, so it has very much been a case of learning on the job. Doing so with the support of the HSRC has made this challenge hugely rewarding. DR DANNY WONG ST5, South East School; SNAP-2 Fellow 2016 present. PhD in progress. Funding: London Clinic/AAGBI Project Grant/UCLH SOuRCE I am just over a year into a planned three-year fellowship leading to a PhD. My main project is SNAP-2, aiming to answer some questions we have around referring patients appropriately to critical care postoperatively. I have learned a tremendous amount, from project management skills, to improving my programming and statistical analysis. The experience has been invaluable! I also cover an ICU in the private sector; this keeps my clinical skills sharp. The rota is managed between the fellows so we have a greater choice in how we split our research, clinical and personal commitments

19 Bulletin Issue 104 July 2017 Bulletin Issue 104 July 2017 Health Services Research Centre (HSRC) A day in the life of an HSRC Fellow Dr Tom Poulton, ST7 anaesthetics/icm, Northern School I am not in an academic training programme, and have never in fact even considered applying for one. Prior to this I had the same hypothetical interest in research that a lot of people have one that never translates into doing any actual research. However, I was sick of the big, empty Research box on job application forms that I d only ever been able to pad out. Raising my lack of research background at my interview, I was assured that this was precisely why the post existed to give research experience to people who could demonstrate enthusiasm and willingness to learn on the job. I joined NELA while the second patient report was in preparation. I was fortunate that Mike Bassett, already in post for a few months, covered a lot of the early work while I was finding my feet. Our progress was reviewed at monthly team meetings, but on a day-to-day basis we largely managed our own time, with input from the wider team when needed. I learnt to use specialist statistical software to analyse data. I now know more about forcing Excel to do things it was never really built for than I care to admit. There is a huge amount of satisfaction to be gained through approaching a problem, and through persistence (and with a little help from Google) making it work. Reports are produced with contributions from the whole Project Team. The fellows create drafts, which are circulated and rewritten following discussions. With much satisfaction, and no small amount of relief, the report was published, on schedule, in July NELA Project Team meetings are a fascinating insight into the processes that keep a large national project moving forward, and have been a privileged opportunity to learn from some incredibly knowledgeable and experienced people. I have worked as hard, if not harder, than in any hospital post, however the nature and flexibility of the work have made it thoroughly enjoyable. The process has helped me develop a wide range of skills, from improving my style of writing on technical subjects, to the practicalities of managing a large and complex document and overcoming the organisational challenges of collaboration in a busy team. I never knew it was within me to care so deeply over whether or not certain nouns were appropriately and consistently capitalised. But then, I am an anaesthetist, so the traits were always there. While I have opted not to count this year towards training, much of the work done could be mapped to Annex G. Table 1 is an example of the outcomes I have covered so far. I admit to catching the research bug, and have used this opportunity to complete an MSc and am now working on an MD(Res). To anyone with a keen interest but no experience, or those who think opportunities like this don t apply to people training outside of London, I encourage you to apply: you are probably the kind of person they are looking for. Table 1 Outcomes mapped to Annex G of the training curriculum Theme Higher and Advanced domain Description Academic/research AR_HK_01 Support quality through auditing clinical outcomes Improvement science, safe and reliable systems AR_HK_03 AR_HK_05 AR_HS_04 AR_HS_09 AR_HS_13 AR_HS_14 AR_HS_18 AR_HS_19 AR_AS_01 AR_AS_02 AR_AS_08 AR_AS_10 IS_K_01 IS_K_02 IS_K_09 IS_K_21 IS_K_26 IS_S_01 Principles of research governance Knowledge of the National Institute of Academic Anaesthesia Use statistical methods to analyse data and estimate probabilities Compare the results of an audit with criteria and standards to reach conclusions Use the findings of an audit to develop and implement change Contribute to a national audit project Use of reference manager software in the production of manuscripts Analyse research data using advanced statistical software Contribute to the development of national clinical guidelines and protocols Champion practice change supported by audit Demonstrate the ability to write a scientific paper Attend relevant national and international meetings Understand the significance of variation within systems Recognise that real improvements come from changing systems, not change within systems Recognise that process drives outcome and quality improvement as the science of process management Understand the fundamentals of Statistical Process Control charts Define outcomes and link how improved outcomes relate to improved processes. Recognise that structure plus process leads to outcome Demonstrate creation of a run chart, and separate random from assignable variation Management MN_AK_10 Understand the role of the commissioning bodies, and how the commissioning groups and providers cooperate and communicate MN_AK_12 MN_AS_03 MN_AS_04 Understand how national service and quality targets are set, and the organisations and processes used to monitor those targets Undertake a project to develop a proposal involving a change of practice Attends national or international meetings relating to service organisation 34 35

20 Health Services Research Centre (HSRC) THE 6TH NATIONAL AUDIT PROJECT (NAP6) Perioperative Anaphylaxis The story so far NAP6 is not only a comprehensive service evaluation; it also intimately involves the allergy and immunology community who have engaged enthusiastically, as have patient representatives. More than any previous National Audit Project, NAP6 is a cross-specialty project. The project is the most comprehensive investigation of the subject ever undertaken, and aims to characterise current patterns in perioperative anaphylaxis,and in its management and investigation. The four phases of NAP6 are: a baseline survey of anaesthetists experiences and perceptions a baseline survey of UK anaesthetic allergy clinics an allergen exposure survey the main registry of clinical reports. The final report will include incidence and relative-risk metrics and recommendations, as necessary. Data collection is now complete. Professor Nigel Harper, NAP6 Clinical Lead Baseline survey for anaesthetists The online survey was completed by 11,104 (77%) UK anaesthetists in 341 (96%) UK hospitals, making it the largest-ever survey on the topic and potentially the largest anaesthetic survey ever. Respondents reported over 1,000 personal experiences of suspected perioperative anaphylaxis during the previous year, half of which had been confirmed on investigation. The survey showed gaps in referral for further investigation and in reporting to national bodies such as the MHRA which has implications for any national data based on such figures. The survey provides data on mortality rates from these events and anaesthetists career anaphylaxis experience Professor Tim Cook, Director of RCoA National Audit Projects capturing a cumulative 154,000 years of anaesthetic experience! Personal perceptions of anaphylaxis risk are an important factor in determining practice, and the survey is the first exploration of this. It captures the agents considered by anaesthetists to be high risk for anaphylaxis, the drugs anaesthetists personally avoid for this reason, and the reasons why. This information is then mapped to the drugs implicated in events, with interesting results. The survey sheds light on the impact of newer agents, including blue dyes, sugammadex and chlorhexidine, in anaphylaxis events. The survey has been written up, and will appear in a forthcoming edition of the British Journal of Anaesthesia. Baseline survey for allergy clinics The first task in undertaking this survey was to identify, for the first time, all those centres performing adult and paediatric anaesthetic allergy testing. A list of such centres is now held at the College and by the allergy/ immunology organisations. The survey compared clinic locations and population density, highlighting variation in the geographical provision of services. The British Society for Allergy and Clinical Immunology national guidelines and AAGBI safety guideline were used as performance benchmarks (e.g. staffing, workload, waiting times, investigation practices, information provided to patients and to relevant clinicians) to enable exploration of compliance with these guidelines and variations in practice. The survey noted areas of good practice where patients are seen jointly by both specialties or multidisciplinary team discussions routinely take place. The paper has been submitted for publication to an immunology journal, and will, we hope, be published soon. Allergen/Activity survey The allergen/activity survey aims to record patterns of exposure to relevant drugs and other trigger agents in all NHS hospitals. It follows the model used in the NAP5 activity survey (using a 2-day collection period randomised by day) and will provide denominator data. The survey was administered by NAP6 local co-ordinators, and the response was again magnificent with more than 300 hospitals responding. It will provide unique, detailed information about usage patterns of potential perioperative allergens, including antibiotics and muscle relaxants. It will also shed further light on anaesthetic activity in general including seven-day working patterns. Responses are currently being analysed. Main case-reporting phase Anonymised online case reporting is the mainstay of NAP6, and we have captured cases for the one-year period up to 5 November Reporting is in two parts: Part A perioperative details, and Part B allergy investigations. Submission of completed case-report forms closed in May As with previous NAPs, a firewall preserved anonymity by ensuring separation of the case-reporting and review processes. More than 400 cases were reported, the most reported to a NAP, and each case undergoes detailed review by a panel of anaesthetists, allergists, immunologists and patient representatives, to extract data and explore emerging themes. What s next? The review panel will complete the review process in the coming months. Data synthesis and quantitative and qualitative analysis will take several months. The final NAP6 report will be published in May 2018, and will contain an analysis of the incidence of perioperative anaphylaxis, its management, outcomes and investigation, as well as recommendations for future practice. Look out for adverts for the launch. Our thanks We would like to thank the local co-ordinators for the huge amount of work they have done to ensure the success of the project. Enthusiastic engagement among practising anaesthetists and allergists/ immunologists has been at the core of the success of NAP6, and their time and effort is much appreciated

21 SAS and Specialty Doctors SAS anaesthetists and the training programme Dr Lucy Williams, RCoA SAS Member of Council The College runs a specialist postgraduate training programme in anaesthesia, designed to produce a general anaesthetist who will be skilled to deal with most clinical scenarios in a general hospital by the time they achieve their Certificate of Completion of Training (CCT). The programme is approved by the General Medical Council (GMC), which regulates training and registration of all doctors. On achieving a CCT, an anaesthetist can join the Specialist Register and is eligible to apply for a UK consultant post. The Certificate of Eligibility for Specialist Registration (CESR) is another route to the Specialist Register. The applicant must demonstrate, with a portfolio of evidence, that they have knowledge and skills equivalent to a recent CCT holder. Anaesthesia runs an uncoupled rather than a run-through training programme. This is split into core training and specialty training (ST3 onwards). Entry is by a national competitive process at both stages. Successful completion of core training does not guarantee entry to ST3. These two stages are the only two points for an individual to enter the approved training programme. To apply for an ST3 training number, the candidate must have the Primary FRCA. The only exception is for EEA nationals. Many other foreign anaesthetists will have experience and qualifications that are not recognised. The rules for this come from the GMC, not the College, and apply across all specialties. In November 2016 the RCoA ran a survey of SAS doctors in order to ascertain what their career aspirations were and what the College could do to support them more. This survey suggested that many SAS doctors would like to return to training after a break or enter training having moved to this country from abroad. Anaesthetists with experience abroad will have to enter the training programme at ST3, but progress is then assessed at the Annual Review of Competence Progression. At this point it may be possible to review the training still required. Adjusting the remaining programme depends heavily on local circumstances and the availability of particular training slots at different levels. For doctors with a lot of prior experience, CESR may be a better way forward if they can provide the documentary evidence of their training. Some anaesthetists take a break in their training and then return. If they have passed the Primary exam, this pass is valid for seven years under the current GMC and RCoA rules. There is some flexibility, for example for maternity leave, and this is considered on a case by case basis by the Examinations Committee. All previous attempts are counted for both exams. The regulations for exam entry are on the College website. 1 All the rules and regulations for training are laid out in a document known as the Gold Guide. 2 It may seem unfair to have to go back to more junior training posts, but successful progression through the programme may be worth the temporary step backwards. There is incomplete fill of ST3 training places nationally. Being flexible about where you work can open up training opportunities in areas with a shortage. It is a good time to apply for the training programme if you meet the criteria. These can be found on the Health Education England website. 3 The alternative is a CESR application, which is a major undertaking. Collecting the evidence takes on average two years, and is very laborious. Top-up training may be needed to cover all required areas of the curriculum, and this can be difficult to arrange. Whether you consider a return to training or a CESR application will depend on your previous experience and personal circumstances. There may be alternative ways to develop your career that you have not considered. The Regional Adviser is available to assist with career guidance, and your College Tutor or the College can put you in touch with them. References 1 Examination Regulations. ( 2 The Gold Guide. COPMeD UK, London ( 3 Person Specification. Specialty Training. Health Education England, London ( On achieving a CCT, an anaesthetist can join the Specialist Register and is eligible to apply for a UK consultant post 38 39

22 The Isle of Man is a picturesque island in the middle of the Irish Sea. Boasting the longest running continuous parliament in the world, the 33-milelong island has its own government and is not part of the UK. The health service is free at the point of use, funded by taxation, linked into clinical networks in the north-west of England, referring patients for tertiary services in England but not part of the NHS. Dr Kate Teare, Consultant Anaesthetist, Medical Lead for the Isle of Man Air Ambulance Service, Noble s Hospital, Isle of Man ISLE OF MAN MAJOR TRAUMA TRANSFERS In 1903, the UK introduced a national speed limit, effectively prohibiting motor racing on public roads. The Automobile Association of Great Britain and Ireland approached the Isle of Man government for permission to race on closed public roads. The road races became the now world famous Isle of Man TT. Motorbike races are held over two weeks in June, with further racing over two weeks in August. The population of the Isle of Man is 86,000, increasing to about 130,000 during the racing periods. Every year the bikes get faster. The winning riders have an average speed of 130 mph over the 37-mile-course. The roads have sharp bends, stone walls and hump-back bridges, and are lined by thousands of spectators. Most visitors bring their motorcycles with them and ride the course between races, when the roads are re-opened to the public. Noble s Hospital Noble s Hospital is a modern 300-bed unit on a greenfield site located close to the capital Douglas. Three helicopter landing-pads are located next to the Emergency Department (ED). The radiology department, with CT and MRI scanners, is located next to ED, with the six operating theatres and six critical care beds close by. The permanent members of the anaesthetic department include 12 Consultants and three SASgrade anaesthetists. During the race periods we reduce elective operating. One orthopaedic ward is converted into a trauma ward. We employ a few extra staff one transfer nurse, one orthopaedic surgeon and several army medics who act as healthcare assistants, but most of the service is provided by the permanent staff. Higher military orthopaedic surgery trainees are frequently seconded to the hospital during the TT fortnight. In 2016, an ST7 anaesthetic trainee undertook the remote and rural anaesthesia module at Noble s Hospital to provide cover for both the TT and Grand Prix races. The prehospital and helicopter emergency medical service for the racers is provided by a charity organisation. All non-racer injuries and illnesses are attended to by the Isle of Man ambulance service, operating a helicopter and road ambulances. We joined the Mersey and Cheshire critical care and major trauma network in Prior to joining the network, trauma cases were mostly managed locally. Now, all arriving patients are assessed in the emergency department by a full trauma team, are stabilised, and if necessary are given a CT scan. Then, if appropriate, and following discussion with colleagues at Aintree Hospital, they are transferred to the mainland by air ambulance

23 Bulletin Issue 104 July 2017 PERIOPERATIVE JOURNAL WATCH The air ambulance service transfers 450 patients per year to the mainland Air ambulance Since joining our local trauma network, the major trauma workload has changed from ED stabilisation and in-theatre trauma management to ED stabilisation and aeromedical transfer to Aintree Hospital in Liverpool. The air ambulance service transfers 450 patients per year to the mainland. Civil Aviation Authority regulations limit medical flights over water to specifically adapted helicopters, and therefore we utilise a fixed-wing aircraft based at Ronaldsway airport. The aircraft and pilots are contracted from a private company, and the clinical staff and equipment are supplied by the hospital. Over 90% of patients transferred need only ward-level care or less, and these are escorted by nurses. The critical care and major trauma transfers are accompanied by an anaesthetist and a critical care nurse. All staff involved undertake a three-day course followed by buddy flights where they shadow a colleague to familiarise themselves with the aircraft environment and equipment. Staff only transfer patients requiring skills that fall within their area of clinical competence. The service has specialty-specific staff including neonatal specialists and midwives. The door-to-door journey from our emergency department to Aintree takes two and a half hours. Planning begins soon after the patient arrives in the emergency department, often before a CT scan confirms the suspected injuries. The single entry point to the network at Aintree is ideal; if we waited for a bed before leaving, it might be taken by the time we arrive. Traditional transfer training advises keeping the patient in a place of safety until stability is ensured. Without neurosurgery, cardiothoracic surgery, and pelvic surgery services, with limited blood products and interventional radiology on site, and without road links to a tertiary centre, a balance must be struck between time spent ensuring stability and the time thus lost in expediting transfer. When transferring hot trauma patients there is always potential for deterioration; the aircraft is an isolated place no phone reception, cramped, limited kit, and only two pairs of hands. The logistics are not straightforward. The airport shuts overnight but can be reopened for emergencies. Given the geographical location of the Isle of Man, inclement weather over the Irish Sea hampering flying conditions is not uncommon, particularly in winter. Multiple casualty incidents mean triaging the most urgent and unloading the patient and transfer team at Liverpool airport for onward journey to Aintree Hospital, thus freeing the aircraft to return to collect a second transfer team and patient. TT 2016 During the fortnight of TT 2016 there were 29 trauma calls to the emergency department, and ten major trauma patients were transferred from our emergency department to Aintree Hospital. Nine patients went with an anaesthetist, five of whom were intubated and ventilated. Head injuries, spinal injuries, multiple rib-fractures with lung contusions, and pelvic fractures with co-existing limb injuries accounted for the majority of our transfers. Dr Maeve Henry, Dr Tom Poyser, Dr Tom Salih Perioperative Medicine Fellows, University College London Hospitals Dr John Whittle, ST7, Central London School of Anaesthesia Perioperative Journal Watch is written by TRIPOM (Trainees with an Interest in Perioperative Medicine and is a brief distillation of recent important papers and articles on perioperative medicine from across the spectrum of medical publications. Survival associated with volume for frail patients: a retrospective population-based cohort study Frailty is a risk factor for impaired perioperative outcome. In this study, 63,381 frail patients were identified. Survival in frail patients was significantly improved in centres that looked after higher volumes of frail patients (hazard ratio 0.51; 95% CI, ; p<0.01). The complication rate between the centres was not significantly different. This suggests the underlying difference in outcome is due to improved structures and processes of care at highervolume centres. McIsaac et al. Anaesthesiol 2017;126(4): Benefits of a perioperative surgical home Much attention has been focused on the perioperative surgical home (PSH) concept in the United States. This study looked at the introduction of a PSH for patients undergoing laparoscopic cholecystectomy. This involved patient education, reorganising surgical administration processes, and reducing handoffs between staff. Patients assigned to the PSH model had reduced length of stay compared to the pre-implementation group (162±308 vs 369 ±790mins,p<0.01), with no increase in readmission rates. Chunyan Q et al. Anesth Analg 2017;124(3): New persistent opioid use an under recognised surgical complication? National audits in the UK: fancy acronyms or real patient benefit? This editorial sets out the case for continued interest in and enthusiasm for national audits (or service evaluations) such as the NAP projects, SNAP, NELA, and now PQIP. The authors remind of us of the usefulness of these national projects: they provide outcomes, estimate risk, can impact on hospital structures and process as with NELA and, most importantly, can change clinician behaviour. Moppett IK et al. Br J Anaesth 2017;118(4): Pleiotropic effects of statins in the perioperative period Statins have been heralded as a panacea. Aside from their cholesterol-reducing effects, statins have been shown to improve endothelial function, inhibit oxidative pathways, and to have anti-inflammatory effects. This review looks at the evidence supporting (and opposing) the use of statins in the perioperative period. Galyfos F et al. Ann Card Anaesth 2017;20(1):S Given the increased attention being focused on prescription-opioid-related deaths, especially in the United States, this article is timely. This population-based study looked at 36,177 surgical patients having a variety of minor and major surgical procedures. It found that % of opioid-naive patients continued to use opioids 90 days after surgery. There was no significant difference in persistent opioid use between minor and major surgery, suggesting opioid use was not related to pain. Other factors such as emotional distress, educational achievement level and degree of co-morbidities may all play a role in persistent opioid use. Considering the potential consequences of opioid dependence, this article highlights both the incidence of the problem and addressable patient factors. Brummett C et al. JAMA Surg 2017 (doi: /jamasurg ). The RCoA is committed to developing a collaborative programme for the delivery of perioperative care across the UK

24 Bulletin Issue 104 July 2017 Dr Anne-Marie Bougeard, RCoA Perioperative Medicine Fellow and ST5 Anaesthesia Torbay Hospital News from the perioperative medicine programme The last few months have been busy for the perioperative medicine programme in an ever-changing political landscape. Here are a few of the highlights. Survey of Local Leads The results of our comprehensive survey of perioperative medicine services in the UK are published in July s edition of Anaesthesia (A survey of UK perioperative medicine: preoperative care. Anaesth 2017:72. DOI anae.13934). Shared decision-making We have identified a demand for more training and support in delivering shared decision-making consultations. This theme was further developed during our Local Leads meeting in January, where clinicians expressed a desire for more training in the use of cardiopulmonary exercise testing and different riskprediction models that would enable the more confident communication of these risks to patients to support them in making decisions on surgery. We have taken this forward through collaboration with a number of specialties, and have partnered with the Academy of Medical Royal Colleges to deliver a package consisting of online material, face-to-face training and workshops. We hope to be able to run the first sessions later in the year. Anaemia Another theme we are developing is the management of anaemia in the perioperative period. We know that screening for anaemia is happening across the country, and most units have access to interventions such as oral or intravenous iron, but delivery is inconsistent. We have recently heard of an example of collaborative working across hospitals in the north east to develop an anaemia pathway by sharing experience and expertise to help trusts which have no pathway in place. We will be running an anaemia workshop for Perioperative Medicine Leads in January Perioperative medicine and the direction of the NHS In the March edition of the Bulletin, Dr Liam Brennan discussed the Sustainability and Transformation Plans (STPs) for the NHS. As a group we have been responding to enquiries as to how perioperative medicine aligns with the current priorities of the NHS. We firmly believe that perioperative medicine is an example of how an integrated and patient-centred pathway can deliver efficient and effective healthcare. We have looked at the published STPs and, encouragingly, there are themes we have in common, in particular exploiting the teachable moment in the perioperative journey, as there is a big focus on improving lifestyles and empowering patients to manage their long-term health conditions (e.g. Diabetes). We encourage you to look at the plans for your area, and investigate what services you might be able to use to aid the development of perioperative pathways in your institution. We are already hearing examples of hospitals which have done this. Continuing this theme, in March we held a meeting with representatives from a number of Royal Colleges as well as from NHS England, the Getting it Right First Time (GIRFT) team, the Faculty of Pain Medicine, Dietetics, Primary Care, Clinical Pharmacy and the AAGBI to enlist their collaboration in delivering the Perioperative Medicine Programme. We had a productive discussion, and agreed that we are heading in the right direction. However, there was also acknowledgement that, in the current climate, demonstrating the economic case for our interventions and aligning them with the current aims of the Department of Health is essential. Events A joint event was held in March between the Royal College of Surgeons of Edinburgh and RCoA, focusing on prehabilitation in perioperative care. We heard interesting talks on the psychology of behaviour change, and the use of exercise programmes to optimise fitness prior to surgery. We had an interesting talk from a GP leader who encouraged us to share our work and engage more with GPs, particularly in addressing modifiable risk factors early in the perioperative pathway. Education The first Massive Open Online Course (MOOC) for perioperative medicine goes live on 3 July. This is a four-week course and we would encourage all clinicians with an interest in perioperative medicine to take part. It is free, and interactive, giving you the opportunity to discuss themes with other professionals nationally and internationally. The more who get involved the more successful it will be. Sign up at: Case studies We are developing case studies, both on our website and for promotion through other platforms, for example, the King s Fund and the NHS Innovation Hub. We are always looking for more examples of good perioperative medicine practice. Please send a short description to perioperative@rcoa.ac.uk and I will get in touch. Please keep an eye on the RCoA Perioperative Medicine microsite for more resources and toolkits for implementing POM services in your organisation: periopmed/case-studies 44 45

25 YEARS 25 REASONS I AM A FELLOW OR MEMBER 2nd Annual CTN Autumn Meeting Wednesday 2 November 2017 Crowne Plaza, Manchester City Centre Along with the presentation of major new trial proposals, plenary sessions will include: qualitative data more than just numbers big data the future? using clinical research to influence policy working together with surgeons to deliver perioperative studies. The meeting will also offer small group interactive training sessions on: who is the Chief Investigator? surviving the approval process how can the CRN help you? With lectures from distinguished health care leaders, delegates will also have the opportunity to provide and receive constructive feedback on future studies and network with fellow researchers across the UK. This is a full day not to be missed! Delegate Rate is % discount for medical students and AHPs POMCTN is open to new members and encourages trial submissions for presentation at its meetings. For more information, please go to: PLACES ARE LIMITED SO PLEASE APPLY EARLY Applications are now open for the Chief Investigator Scheme The UK Perioperative Medicine Clinical Trials Network (POMCTN) has opened the application process for its Chief Investigator mentoring scheme. The Chief Investigator scheme is intended to provide training and mentorship for a small number of talented individuals who wish to lead their own clinical trials in perioperative medicine. Applicants will be existing members of the POMCTN Local or Principal Investigator scheme, with a proven track record of recruitment to clinical trials as a local investigator and ideally with experience of a complete research cycle as a grant co-applicant, from outline application through to publication and dissemination of results. The CTN welcomes applications from individuals of any clinical background of relevance to perioperative medicine. Applications will close on 31 August For more information, please go to: or contact: Are you passionate about anaesthesia and proud to be a fellow or member of the Royal College of Anaesthetists? We are in the early stages of creating a College booklet detailing all the benefits of RCoA membership, as some fellows or members may be unaware of the wide range of benefits that exist. In celebration of our 25th Anniversary this year, this booklet will also feature 25 of the most compelling responses from you, our membership, about why you are a fellow or member. Simply go to to contribute. Please note that by participating, you are consenting to us using your feedback across various College communication channels to help us promote our membership and to advance the specialty we all care deeply about. If you would like to be part of shaping the future work and strategy of your College and your specialty, you are welcome to join our Membership Engagement Panel. More information can be found here:

26 Bulletin Issue 104 July 2017 Bulletin Issue 104 July 2017 The 96 Hillsborough fans who died on 15 April Used with permission from The Hillsborough Family Support Group. Indemnity organisations are increasingly limiting cover for junior trainees (FY1 ST4) Individual responsibilities for doctors with a background of chronic illness), attendance at which contributes to include administration (indemnity, event injuries, and opportunistic presentation Continuous Professional Development. schedules, secondary employment (longstanding stable problems). Doctors Completion of MIMMS (Major Incident requirements, licensing, etc). Of major should also seek information about the Medical Management and Support) or Events medicine services: anaesthesia s central role The last decade has witnessed high-profile interactions between medical personnel and competitors or coaches in professional sport, for example, with on-field cardiac arrest, concussion, public disputes and performance-enhancing drugs. 1 Given such high-profile cases, it is often forgotten that professional sport also requires medical cover for spectators. To this end, a working party (sponsored by the Hillsborough Family Support Group) is highlighting the need for spectator care and is providing pragmatic guidance for delivering this care. 2 Events medicine is able to provide such cover at sporting events, however guidance from the Department for Culture, Media and Sport has changed little in 25 years, stating, for example, that crowds greater than 2,000 require a doctor on site, but Dr Joe Cosgrove, Consultant in Anaesthesia and Intensive Care Medicine, Freeman Hospital, Newcastle upon Tyne paramedics aren t required until numbers reach 5,000.3 This limits doctors ability to work with skilled assistance. Additionally, there is limited consideration given to medical risk assessments, i.e. crowd demographics, venue geography and medical facilities. The guidance may also encourage tick-box approaches by organisers, and the provision of inadequate cover, particularly in light of high levels of medical cover provided at London 2012 and the Rugby World Cup importance are indemnity and licensing. Indemnity organisations are increasingly limiting cover for junior trainees (FY1 ST4) unless there is significant supervision. With respect to licensing, the General Medical Council has only offered generic advice. It is therefore incumbent on doctors to be clear about roles, experiences and training, for example, audits and attendance at the Crowd Doctor Course (Faculty of Prehospital Care, Royal College of Surgeons of Edinburgh). Likewise, appraisers require an overview of necessary skills and responsibilities. Doctors (as independent practitioners) must be able to deal with the initial management of acutely ill or injured adults and children, and must possess working knowledge of local healthcare structures, particularly with reference to acute hospitals and the nearest major trauma centre. Collective responsibilities include interactions with other medical and safety providers before, during and after the event. This can be greatly facilitated by the formation of a Medical Advisory Group, which enables mutual understanding of roles and the minimisation of conflict. It also enhances risk assessment and resource allocation, for example, the number and nature of presentations, hospital referrals, and treatments on site. Audit data is limited, but presentations at different events vary between 1 and 24 in 10,000 and hospital referrals vary between 1 and 8 in 50,000 for spectators.4 They include acute respiratory and cardiovascular disease (often numbers of wheelchair-using spectators and those under 16 years of age. In the north-east of England, approximately 5% of season-ticket holders at Newcastle United and Sunderland football events are under-16s. Cup fixtures during school holidays can result in 40 45% of spectators being under-16s. In addition to acute illness and injury, there is the potential for hypothermia and drug/ alcohol intoxication. Accompanying adults for minors may be absent or similarly intoxicated, and safeguarding is therefore a consideration. St John Ambulance and British Red Cross have officers who carry out this safeguarding function, however doctors should enquire as to whether other medical providers or sporting institutions have equivalent safeguarding cover. Finally, additional issues arise in the provision of medical cover in larger venues and at one-off events such as those relating to the Olympics, World Cups, and Cup Finals, where there may be a determination to attend by seriously (and terminally) ill spectators. Examples of conditions encountered include metastatic cancer, recent bone-marrow and solid-organ transplantation, dialysis patients distant from their dialysis unit, and home ventilation. Providing cover for VIPs may also be necessary. There is also always the possibility of masscasualty incidents the HM Coroner Hillsborough Inquest (2016) returned a unanimous verdict of Yes when asked if medical responses had contributed to spectator deaths. Venues may arrange major-incident table-top exercises, JESIP (Joint Emergency Service Intra- Operability) training can further add to understanding of roles in such situations. 5 In conclusion, Events Medicine is in its infancy and, whilst it involves doctors from many specialties, the skills and knowledge of anaesthetists can greatly enhance the organisation and delivery of care. To date, the working party has published guidance on practice and offered commentary to the Department for Culture, Media and Sport and the Sports Grounds Safety Authority. The next phase, supported by Professor David Lockey, Chair of the Faculty of Pre-hospital Care, Royal College of Surgeons of Edinburgh, is to further highlight pitfalls and co-ordinate audit. References 1 Booth R. Eva Carneiro begins constructive dismissal case against Chelsea. Guardian, 6 January Smith S et al. A practical approach to Events Medicine provision. Emerg Med J 2016 (doi: /emermed ). 3 Guide to safety at sports grounds. Department of Media Culture and Sport 5th Edition. HMSO, London Bhangu A et al. The Villa Park experience: crowd consultations at an English Premiership football stadium, season Emerg Med J 2010;27: Joint Emergency Services Interoperability Programme (JESIP) (

27 Table 1 Responses of CUPPA investigators to survey questions RANDOM CONTROLLED TRAINEES? The South West Anaesthesia Research Matrix (SWARM) SWARM is a trainee-led research collaborative, set up to break through the glass ceiling preventing trainees from being credible Principal or Chief Investigators. Individual trusts and funders are hesitant to invest in doctors on rotations who have insufficient time to gain traction at a hospital before moving on. Accordingly, a recent report reflects a deficiency of research engagement from those in specialty training. 1 The network model overcomes these issues. The collective, sustained by consultant mentors, can grow research ideas from inception to delivery. An economy of scale, whereby projects are run in parallel at six sites, achieves meaningful volume quickly. Set up with the energy and vision of its first Chairs, Tom Clark and Danielle Franklin, and drawing on the patronage of our President, Professor Rob Sneyd, SWARM has grown from strength to strength ( Our membership is over 200, and we have seen more than ten highquality projects through to conclusion, resulting in regional and national presentation and publication. 2,3 To date, almost 2,500 patients have been recruited to National Institute for Health Research Clinical Research Network (NIHR CRN) portfolio studies. Dr Charly Gibson, Consultant Anaesthetist, Royal Devon and Exeter Hospital Dr Gary Minto, Consultant in Anaesthetics, Plymouth Hospital For full contributor list please see In 2015, we decided to up the level of complexity with a home-grown randomised controlled trial (RCT)- CUPPA (Comprehensive mouth-care to reduce Postoperative PneumoniA), portfolio badged and NIAA-grant funded. The premise was simple regular oral disinfection has long been standard ICU care for intubated patients, could rigorous attention to oral hygiene reduce postoperative pneumonia in ward-based patients undergoing major abdominal surgery? Intervention-group patients had to use 0.2% chlorhexidine mouthwash daily, along with disclosing Dr Tori Field, ST6 Anaesthetics, Plymouth Hospital tablets to stain-up their dental plaque so they could brush it all off with 1% chlorhexidine toothpaste. The project was led by Chief Investigator Charly Gibson an ST6 at the time. We were hosted by Plymouth University school of Dentistry, and in Professor David Moles we found an expert co-investigator to advise on protocol design and deliver dental training. Realising our limitations we designed a feasibility project, the primary question being: Can a trainee network, led by a trainee Chief Investigator, deliver a moderately complex RCT? The short answer is Just about. Data collection started in June 2015 and ended in July 2016 (n=120 with three dropouts). Teams of SWARM trainees recruited at all six sites, generally but not universally assisted by CRN Nurses. Gratifyingly, information from CUPPA was incorporated as major pilot data into the design of COMMAS (ChlOrhexidine Mouthwash prior to anaesthesia in patients undergoing Major open Abdominal Surgery). This is a multicentre RCT involving over 6,000 patients, endorsed by the NIAA Clinical Trials Network. We hope to publish the CUPPA study results elsewhere, and will not upstage ourselves by presenting them here! Egalitarianism is a guiding principle of SWARM. Put differently, being a consultant anaesthetist does not necessarily make you a consultant investigator. But there s no doubt that a trainee Chief Investigator struggles with clout. Ownership of recruitment and follow up was a problem. Each site had a trainee local lead, and these varied in their dogged persistence at cajoling their teams. Absolutely crucial to supplement our NIAA grant was the support from the Peninsula Collaboration for Leadership in Applied Health Research and Care for the inaugural SWARM fellow, Tori Field, who project-managed delivery, and has followed up, analysed and written up the results. These tasks are not easily achieved without protected time. On completion of the project we conducted an online survey, which returned an overall response rate of 64% from 11 out of 14 local leads (Principal Investigator equivalents), 14 out of 16 research nurses, and 14 out of 31 local investigators. Nearly all investigators spontaneously volunteered that they had participated to get more research experience and boost their CVs. No local leads claimed a good understanding of how to set up an RCT prior to their involvement in CUPPA, and all felt that that they had a better understanding of the process afterwards. In general, involvement in CUPPA was seen as a positive experience. One lead found it stressful to ensure proper follow up, and one had tough discussions getting local surgeons on-board. Trainee-led research networks are still a relatively new concept, but something that the research nurses surveyed looked upon favourably. Clear delegation of roles might be more explicit in future. This one study has therefore provided valuable research experience to at least 45 anaesthetic trainees throughout the South West, allowing involvement at a level that is appropriate for them and that is tailored to their academic interests and clinical commitments, with the support of experienced and highly motivated consultant colleagues. Links for the future have been forged with research and development teams. Leads (n=11) Investigators (n=14) Previously collected data for SWARM projects 7 (63.6%) 5 (35.7%) Previously helped with an RCT 2 (18.2%) 3 (21.4%) Trainees who felt their involvement with CUPPA had been beneficial 11 (100%) 14 (100%) Trainees who would volunteer as PI in future 10 (90.9%) 13 (92.9%) Interested in being a CI in the future 5 (45.5%) 13 (92.9%) Now confident to recruit to portfolio studies 10 (90.9%) 13 (92.9%) Feedback from participants included: Regardless of the trial outcome, this study has had far reaching and hopefully much more long-lasting effects on research in general, opening doors and minds for interested trainees to engage with research in the future, and allowing them to see it as an accessible avenue to pursue alongside their clinical careers, and one that is not the limited preserve of the laboratory professor. References I have more understanding of the amount of work it takes to set up something like this, and that s just implementation at a local site... Good experience of co-ordinating and communication with lots of different healthcare professions (research nurses, specialist nurses, pharmacy, budget managers, surgical consultants). 1 Research for all: building a research active medical workforce. RCP, London 2016 ( 2 A survey of trainee research experience within the south west peninsula deanery prior to the establishment of a trainee research collaborative (Abstract). SWARM. Anaesth 2013;68(S3):151 3 Sedation practice in six acute hospitals: a snapshot survey. SWARM. Anaesth 2015;70(4):

28 Bulletin Issue 104 July 2017 Bulletin Issue 104 July 2017 critically ill children. National audit data from PICA-NET (the Paediatric Intensive Care Audit Network) 3 show that PICUs in the United Kingdom deliver 125,306 bed-days annually, and that there are over 13,000 transport events. PICM has a challenging, diverse and interesting patient group and is a highly rewarding specialty. Dr Helen Turnham, Consultant in Paediatric Critical Care, Oxford University Hospitals NHS Foundation Trust Dr Anna Barrow, Specialty Trainee in Paediatric Intensive Care Medicine, Great Ormond Street Hospital Training in paediatric intensive care medicine Paediatric intensive care medicine (PICM) has emerged as a result of advances in paediatric surgery, cardiopulmonary bypass for children with congenital heart disease, and neonatology. Anaesthetists were the first group of doctors to transfer the principles of invasive ventilation and manipulation of paediatric physiology outside of the surgical theatre, thereby creating paediatric intensive care units (PICU). 1 Training in PICM in the UK is accredited by the Royal College of Paediatrics and Child Health (RCPCH), and overseen by the Paediatric Intensive Care Medicine Intercollegiate Specialty Advisory Committee (PICM ISAC). All trainees wishing to train in PICM must be part of a programme prospectively agreed by PICM ISAC. Paediatric doctors choosing PICM complete general paediatric training until ST5, and then apply to a two-year advanced training programme in PICM via the RCPCH training grid. This is a nationally competitive programme with between seven and 20 places nationwide annually. Trainees must satisfy the programme s requirements in general paediatric intensive care, paediatric cardiac intensive care, and acute transport competencies. For anaesthetists the training path is more complicated. In addition to PICM competencies, basic, intermediate and higher anaesthesia competencies must also be achieved. Thus, overall, training is extended between 12 and 18 months. PICM can count for 12 months of advanced training competencies within the anaesthesia CCT. I realised early in my anaesthesia career that I wished to pursue a career in PICM. Following basic training in the Acute Care Common Stem programme and anaesthesia, I passed my Primary and Final FRCA and completed intermediate anaesthesia training. I undertook an OOPE (Out of Programme Experience) in PICM. During this time, I applied for and gained a place on the RCPCH national training programme based at Great Ormond Street Hospital. During this time I also completed a masters degree in medical law and ethics that has complemented my PICM training. Following completion of PICM training, I returned to my anaesthesiatraining deanery, completed my higher modules, and gained a CCT in anaesthesia with a letter of recognition of training in PICM. I believe that anaesthetists in PICM bring a number of complementary skills to intensive care management with their paediatric colleagues not just in terms of practical skills but through a different approach to the sick child. In the PICM world I have been met with encouragement and enthusiasm for the different skill set I have acquired during my training. I started my training in the Acute Care Common Stem and anaesthesia. I quickly realised that my favourite areas were paediatric anaesthesia and intensive care, and therefore paediatric intensive care might be something I would enjoy. I did some observer shifts and a threemonth post in Great Ormond Street PICU to make sure. I discovered that the route to advanced training in PICM was not straightforward. Focusing your CV on PICM from an early stage is useful, as there is little time after the final FRCA and the requirements of intermediate training before applications for training posts. As PICM training from anaesthesia remained relatively uncommon, I decided to apply for a dual training number in adult ICM, given that I would still be able to do some intensive care and paediatric anaesthesia. During my ST6 year I took a 12-month OOPT (Out of Practice Training) in paediatric anaesthesia at Great Ormond Street Hospital. I applied for RCPCH Grid Training and was successful. During the last couple of years, changes have been made within the Faculty of Intensive Care Medicine to facilitate trainees from an adult ICM pathway entering PICM. The first European PICU was established in Sweden in 1955, but it was not until 1981 that the Society of Critical Care Medicine recognised PICM as a sub-specialty in its In the United Kingdom, most trainees in recognised PICM training programmes come from a background of general paediatrics, but it is also possible to train Paediatric intensive care is a diverse, tertiary-centre specialty, encompassing the management of the critically ill medical and surgical child, the child with References 1 Epstein D, Brill JE. A history of pediatric critical care medicine. Pediatr Res 2005;58(5): Paediatric ICM. ( 3 Summary Annual Report. PICAnet, 2016 ( own right. 1 The Paediatric Intensive Care in PICM from anaesthesia or adult critical congenital or acquired heart disease, Society was established in care programmes. and the stabilisation and transfer of 52 53

29 Bulletin Issue 104 July 2017 Bulletin Issue 104 July 2017 Technology Strategy Programme LIFELONG LEARNING: what will be different? Dr Jamie Strachan, RCoA TSP Fellow and ST7 Anaesthetics, Oxford University Hospitals The Technology Strategy Programme (TSP) is a three-year change programme which will impact on every aspect of College technology. The first phase is focused on improving your learning tools which means new e-portfolio, Logbook, CPD and exams systems. After a rigorous selection process (described in the TSP May Bulletin article if you would like to know more), Nomensa was chosen as the supplier to develop the new Lifelong Learning platform with the College. Nomensa is a user-experience specialist which prioritise system-user input from the outset of the system design. This means we can tailor what the system does and how it does it to reflect what we need from our learning system. The new Lifelong Learning platform will be different from our current set-up in a number of ways: the initial rollout will include a new e-portfolio and core aspects of a new online logbook, so that you can record cases, procedures and sessions alongside your e-portfolio reflections and report on it all for your Annual Review of Competence Progression (ARCP) the next step will be to add CPD functionality to the system along the lines of the current CPD diary all elements of the Lifelong Learning platform will be fully supported by the training team at the College. There are opportunities for involvement now and in the future to shape what the system looks like and ensure that it is in full working order before rollout. This includes face-toface and web consultation. e-portfolio Cases Procedures Logbook If you are interested please get in touch at TSP@rcoa.ac.uk Assessments Lifelong Learning Sessions Training Documentation Reflection CPD Log CPD Diary 54 55

30 This column has long provided historical insights into anaesthesia, medicine and life. It was originally compiled by the late Dr David Zuck, past President of the History of Anaesthesia Society, doyen of those with that interest, and one of the few to have acquired the Diploma in the History of Medicine. Now the Heritage Committee will oversee the column. AS WE WERE... Professor Tony Wildsmith, Editor, Lives of the Fellows Project Figure 1 Dr Robert James Minnitt MSc(Hon) MD FFARCS FRCOG FRCGP DA Robert James Minnitt Producing biographies of our eminent predecessors for the Lives project is a simple exercise, but I will admit to one problem distraction! On their dusty shelves (and equally in the dustless digital archives) medical libraries have a wealth of material to catch the eye and lead the reader far from the primary subject. Similarly, there may be something related to the subject that does not quite fit the Lives format so that, no matter how interesting, it is excluded. Fortunately, one of this column s functions is to provide opportunities to share such distractions, and here is one of mine. Robert James Minnitt (Figure 1) is a major figure in the history of obstetric analgesia (arguably second after James Young Simpson), so finding information on his life, work and career was simple. Compressing the material into the Lives format was more of a challenge, but the references will direct those who want to know more. So what distracted me? Well, every account of Minnitt s work makes a similar comment: he combined nitrous oxide with air rather than oxygen for obvious reasons. However, no hint of those reasons appears, and this believer in oxygen was distracted! Minnitt (see qualified from Liverpool in 1915 and, after junior hospital posts, established himself in General Practice, quickly acquiring anaesthetic sessions in several hospitals, including Liverpool Maternity. The early 1930s were years of increasing awareness of the need for better analgesia in labour, and Minnitt had been consulted locally before attending a meeting of the Royal Society of Medicine s Obstetrics Section. As the contemporary accounts (JRSM 1932;25: and JRSM 1943;37:45 48) are reviewed, the obvious reasons slowly become apparent. Nitrous oxide inhalation, in combination with oxygen, was in use, but required complex equipment and medical supervision in a hospital setting. However, in the 1930s midwives managed most deliveries in domiciliary settings heated by open fires. Thus, any device had to be simple (i.e. of fixed performance), light (for ease of transport by bicycle!), and minimise fire risk. Dr Howard Jones (of spinal anaesthesia fame) suggested air instead of oxygen (mainly to avoid the weight of a second cylinder), but it was Minnitt who pursued the idea and, in collaboration with instrument maker Charles King, modified a McKesson oxygen therapy apparatus (Figures 2a and 2b). The essence of the device was a small rubber bag inside a metal drum, a valve stopping the flow of nitrous oxide if the patient did not inhale and the bag expanded (see Thomas KB The Development of Anaesthetic Apparatus, London: Blackwell, 1975: pp ). During inspiration, air mixed with nitrous oxide, the standard apparatus allowing a 50:50 ratio. Effectiveness was shown, but the safety of administering only 10.5% oxygen to women in labour needed proving. Studies revealed that the oxygen content of umbilical vein blood did not show any marked variation although there was some decrease of that of maternal blood. The processes of oxygen delivery seem to have sufficient reserve for the short-term administration of a reduced F I O 2. Minnitt devoted much of the rest of his life to promoting and teaching the technique, although its introduction had to overcome some hurdles. Initially, Minnitt felt that the technique should only be used under medical supervision, but some hospitals ignored this, and the Central Midwives Board (CMB) obstructed progress. Fortunately the technique was a last minute inclusion in a major study of labour analgesia by the (then) British College of Obstetrics and Gynaecology, and its results persuaded the CMB to approve the use of recognised apparatus by trained, but unsupervised midwives. Today, even the notion of administering an hypoxic gas mixture to a woman in labour can produce extreme reaction, but remember, Minnitt s work was a pragmatic solution to a contemporary problem. The impact was huge. Feted in the press as the man who killed the agony of childbirth, he received many honours, notably the placing (during his life) of a plaque in the Liverpool Maternity Hospital. He also made huge contributions to the British Journal of Anaesthesia and to the establishment of Liverpool s University Department of Anaesthesia, all while continuing to work in General Practice! For such a revolutionary technique, Gas and Air did not last long, less than 30 years, with a study from Oxford (Anaesthesia 1962;17: ) showing how close it took women to hypoxaemia, and that some machines delivered even less than 10% oxygen all just as Entonox came on the scene. I doubt if Minnitt minded given his 1934 comments: What has been done is not a terminus. It is a thoroughfare to greater possibilities for painless labour. So may there dawn renewed hope in the hearts of women. Acknowledgement I thank the Association of Anaesthetists of Great Britain and Ireland for permission to use the illustrations, and Sarah Dixon-Smith for her help in obtaining them. Figure 2a Early Minnitt apparatus... Figure 2b...and contemporary transport system! For more information please visit:

31 Bulletin Issue 104 July 2017 Letters to the Editor YEARS ANAESTHESIA RESEARCH INNOVATION EDUCATION SCIENTIFIC In celebration of our 25th Anniversary, our free online ARIES Talks feature a variety of high profile speakers delivering short, informative and entertaining talks on areas of relevance to anaesthesia, critical care and pain medicine. If you would like to submit a letter to the editor please bulletin@rcoa.ac.uk Professor Monty Mythen, Editor Xtreme Everest 10 years on by Professor Mike Grocott Xtreme Everest ( Cancer and anaesthesia by Professor Donal Buggy Dear Editor, Alphabetical code of conduct I wondered, in view of the 25th anniversary celebrations of the College this year, how I can link the number 25 with anaesthesia. It occurred to me that it would be a good idea to design a code of good practice for anaesthesia and for anaesthetists which includes twenty-five basic principles of practice of anaesthesia. As the alphabet has 25 letters excluding Z, I decided to design the code in an alphabetical order. To my great surprise it worked out rather well. I think that these could be put on a poster and hung in the anaesthetic department and operating theatres and probably referred to for guidance. Always see your patient before you anaesthetise; always observe strict Asepsis before an invasive procedure; ensure all Alarms are appropriately set. Breathing circuits are checked for patency and normal function. Cannulae are in place, patent and working before induction; Critical incidents are recorded and discussed with appropriate reflection; remember your duty of Candour. Documentation is comprehensive and contemporaneous (when possible), dated and signed. Emergency drugs should be immediately available if required. Fluids consider and address fluid balance in the perioperative period. Gases ensure piped gases are attached and working and, where used, adequate cylinder supply is readily available. Hand over formally to recovery or ICU with structured documentation. Intubation all equipment is available and checked; Injections and Infusions all drugs checked and labeled. Join up the perioperative pathway of the patient with good communications. Kits ensure all emergency equipment is readily available. Local anaesthetic always consider local anaesthetic options. Monitors always observe at least minimum monitoring standards. Nil by mouth make sure that all the patients have fasted appropriately. Personnel make sure that all the personnel are present before the start of the list; Pain relief consider and discuss postoperative pain-relief options. Question and clarify whenever unsure. Recovery detail recovery plans and Review whenever necessary. Sign for everything you prescribe and administer; Safety is of utmost importance. Do not compromise safety at any time Throat pack document insertion and removal. Utilise appropriate guidelines and checklists. Vigilance at all times. WHO checklist must be fully completed. X-rays are reviewed. You are responsible. I would like to acknowledge Dr Akbar Vohra for his help in this project. Dr Ramana Alladi RCoA Education Programme Adviser and Past Member of RCoA Council Anaesthesia and space by Dr Kevin Fong The talks will be available on our YouTube channel: Watching them can be recorded as a personal CPD activity attracting two internal CPD credits when accompanied by reflection. Lessons from the battlefield by Surgeon Commander Kate Prior The full schedule of ARIES Talks can be found at: Oxygenate prior to induction. Royal College of Anaesthetists, Churchill House, 35 Red Lion Square, London WC1R 4SG 58

32 REPORT OF MEETINGS OF COUNCIL At a meeting of Council held on Wednesday 19 April 2017 the following appointments/re-appointments were approved (re-appointments marked with an asterisk): Regional Advisers There were no appointments this month. Deputy Regional Advisers West of Scotland Dr K Walker (The Ayr Hospital) in succession to Dr C Whymark College Tutors Wales Dr V C Hilton (Royal Glamorgan General Hospital) in succession to Dr M E Absolom Dr J Petterson (University Hospital of Wales, Cardiff) in succession to Dr S C Rees Barts and the London Dr S Murray (Homerton University Hospital) in succession to Dr A Shah North Central Dr M Lambert (Royal National Throat, Nose & Ear Hospital) in succession to Dr P Suaris Northern Dr S Nair (Northumbria Healthcare NHS Foundation Trust) in succession to Dr N Corbitt Mersey *Dr S Swaraj (Royal Liverpool University Hospital) North West Dr R Cockerham (Trafford General Hospital) in succession to Dr N P A Greenwood Dr G Flett (Manchester Royal Infirmary) in succession to Dr K Maclennan Birmingham Dr S Natarajan (Queen Elizabeth Hospital) in succession to Dr L J Tasker Stoke Dr S Annadurai (Princess Royal Hospital, Telford) in succession to Dr J C Wright South Yorkshire Dr M B Balasa (Doncaster Royal Infirmary) in succession to Dr R Dobson West Yorkshire Dr C C Tordoff (St James University Hospital) in succession to Dr D Odedra Head of School Dr R Leighton (in succession to Dr A Norris) for East Midlands. Certificate of Completion of Training To note recommendations made to the GMC for approval, that CCTs/CESR (CP)s be awarded to those set out below, who have satisfactorily completed the full period of higher specialist training in Anaesthesia, or Anaesthesia with Intensive Care Medicine or Pre-Hospital Emergency Medicine where highlighted. East Midlands North Dr Shafiu Durojaiye Dr Helen Fenner East Midlands South Dr Akeeban Maheswaran East of England Dr Laura Perry Kent, Surrey & Sussex Dr Sebastian Hormaeche Imperial Dr Shahan Nizar North Central London Dr Henna Khetani Dr Emilie Martinoni Hoogenboom Bart s & The London Dr Eleanor Ferreira South East Dr Roger Davies (Joint ICM) St George s Dr Ibrahim Ibrahim Dr Alice Myers (Joint ICM) Dr Ashley Hague Dr Natalie Forshaw Dr James McKinlay (Joint ICM) Dr Olivia Davies Mersey Dr Matthew Bridge Dr Benjamin Lane North West Dr Surrah Leifer Northern Dr Ranj Khaffaf Northern Ireland Dr Alison White Oxford Dr Jacquelyn Parker Dr Tauheedur Shaikh Dr Julia Rudolph South East Scotland Dr Cariad Findlater West of Scotland Dr Nicola Doody Dr Myra McAdam Peninsula Dr Theresa Hinde Dr Jeremy Preece Wales Dr Nigel Jenkins Dr Rhidian Jones Wessex Dr Ilana Delroy-Buelles Dr James Gaynor Dr Thomas Pratt (Joint ICM) Birmingham Dr Hannah Bawdon Stoke Dr James Pittaway East & North Yorkshire Dr Balaji Rajamani West Yorkshire Dr Josephine Jones Dr Gunchu Randhawa (Joint ICM) At a meeting of Council held on Friday 19 May 2017 the following appointments/re-appointments were approved (re-appointments marked with an asterisk): Regional Advisers East of Scotland Dr F Cameron (Ninewells Hospital) in succession to Dr W McClymont Deputy Regional Advisers There were no appointments this month. College Tutors East of England Dr H Gooneratne (Colchester General Hospital) in succession to Dr P Bishop *Dr H C Goddard (Norfolk and Norwich University Hospital) London Barts & the London Dr S P Murray (Homerton Hospital) in succession to Dr A Shah Imperial Dr G D Frunza (Chelsea & Westminster Hospital) in succession to Dr N Barker Dr P B Williamson (St Mary s Hospital) in succession to Dr R K Dhesi South East Dr M A Sicinski (Guy s and St Thomas NHS Foundation Trust) in succession to Dr P Kelly Mersey Dr S J Ridler (Countess of Chester Hospital) in succession to Dr A Troy Northern Dr N Hirschauer (Freeman Hospital) in succession to Dr V J Addison Severn Dr M J McDonald (Royal United Hospital, Bath) in succession to Dr J Tuckey Certificate of Completion of Training To note recommendations made to the GMC for approval, that CCTs/CESR (CP)s be awarded to those set out below, who have satisfactorily completed the full period of higher specialist training in Anaesthesia, or Anaesthesia with Intensive Care Medicine or Pre-Hospital Emergency Medicine where highlighted. Defence Dr Peter Lax (Joint ICM) East Midlands South Dr Mahadevappa Lohit Kent, Surrey & Sussex Dr Neeraj Singh (Joint ICM) North Central London Dr Bindiya Varma Dr Kavitha Aravinth Dr Ioannis Ioannou Dr Nathalie Stevenson (Joint ICM) Bart s & The London Dr Joana Neves South East Dr Iain Carroll (Joint ICM) St George s Dr Thomas Breen Dr Samanthi De Silva North West Dr Jessica Chapman Dr Pandurangam Yadagiri Dr Craig Brandwood (Joint ICM) Northern Dr Feras Eljelani Dr Andrew Lowes (Joint ICM) Scotland North of Scotland Dr Claire Wallace Wales Dr Sabeen Tufail West Yorkshire Dr Stephanie Jinks Due to an administrative error, details of trainees who had been awarded joint certificates in Anaesthesia and Intensive Care Medicine were not made available for publication in the January 2017 Bulletin. This is being addressed and any trainees affected by this error will have their names correctly published in the September issue

33 APPOINTMENT OF FELLOWS TO CONSULTANT AND SIMILAR POSTS The College congratulates the following Fellows on their consultant appointments: Dr Sam Andrews, Gloucestershire Hospitals NHS Foundation Trust Dr Parthipan Jegendirabose, Colchester General Hospital Dr Caroline Pocknall, Ashford and St Peter s Hospital, Chertsey Dr Viv Sathianathan, Northwick Park Hospital, London YEARS PHOTOGRAPHY Competition CERTIFICATE OF ELIGIBILITY FOR SPECIALIST REGISTRATION (CESR) To note recommendations approved by the General Medical Council, that a Certificate of Eligibility for Specialist Registration be awarded to those set out below: Dr Arun Sengottaiyan, Northern Ireland Dr Mohammed Dessoky, Tyne and Wear Dr Murthy Ritesh, Essex Dr Nazia Ijaz, Luton Dr Talkad Sudarshana, Essex Deadline for entries: 28 August 2017 FRCA Examinerships for academic year The College invites applications for vacancies to the Board of Examiners in the Fellowship of the Royal College of Anaesthetists, for the academic year Examiners will be recruited to the Primary examination in the first instance. The number of Examiners required will reflect the number of retirements from the current Board of Examiners. Applicants will be assessed against a comprehensive Person Specification which, along with the Job Description and applications forms for this role, can be downloaded from the examination pages of the College website: An outline of the key essential requirements for the role of FRCA Examiner is set out below (although applicants must read the person specification and job description before applying). Essential 1 Fellow by Examination, a Fellow ad eundem, or a Fellow by Election of the Royal College of Anaesthetists. 2 In good standing with the College. 3 Holds full registration, without limitation, with the General Medical Council. 4 At least five years experience as a substantive Consultant/SAS grade. 5 Shall currently be active in clinical practice in the NHS. 6 On 1 September 2018 shall have the expectation of completing at least ten years as an FRCA examiner. 7 Can demonstrate active involvement in the training and assessment of trainees. 8 Within the past five years shall have visited a Primary or Final FRCA examination. 9 Good written and verbal communication skills. 10 Ability to work as part of a team. As part of the College s 25th Anniversary celebrations, we are running our first ever photographic competition for fellows and members in partnership with the Royal Photographic Society. We welcome entries from beginners to advanced photographers. The theme for the competition is In Safe Hands. We would like to encourage you to take a snapshot of your world and our specialty in one of the many and varied locations in which anaesthetists practice 24/7. Whether it is in the operating theatre, liaising with patients, delivering training or working in partnership with colleagues, capturing that moment is what this competition is all about. Abstract, creative and broad interpretations of the theme are encouraged. There are cash prizes to be won and the successful entries will take pride of place at the College and be used more widely to promote our specialty. Information on how to enter can be found at: 11 Documentary evidence of satisfactory completion of Equal Opportunities training in the last three years and willingness to undertake further exam-specific E&D training on an annual basis. 12 Able to commit to long-term and active involvement in examiner duties including the ability to devote a minimum of 12 days per academic year to the role. This includes both the delivery and development of the examinations. Desirable Shall demonstrate a special interest(s) directly relevant to the balance of expertise required in the Board of Examiners. Copies of the person specification, job description and application form can also be obtained by contacting: Mr Graham Clissett, Examinations Manager via Tel: or gclissett@rcoa.ac.uk. THE CLOSING DATE FOR RECEIPT OF COMPLETED APPLICATION FORMS IS: MONDAY 16 OCTOBER

34 Bulletin Issue 104 July 2017 Bulletin Issue 104 July 2017 CONSULTATIONS The following is a list of consultations which the RCoA has responded to in the last two months. Those published on the RCoA website via our Responses to Consultations area ( are marked with an asterisk. Originator Department of Health National Institute for Health and Care Excellence National Institute for Health and Care Excellence Consultation Expanding undergraduate medical education* Draft guideline consultation Cataracts in adults: management End of life care for infants, children and young people quality standard consultation DEATHS With regret, we record the death of those listed below. Dr Morag Bastable York Dr Neil G P Butler Exeter Dr Peter M E Drury Liverpool Dr Richard P H Dunnill Dorset Dr Geoffrey Hall-Davies Worcestershire Dr Maureen E Hardeman West Midlands Dr Eric Holmes Isle of Man Dr David Pearson Cumbria Dr Donald A Thomas Essex Please submit obituaries of no more than 500 words, with a photo if desired, of fellows, members or trainees to: website@rcoa.ac.uk. All obituaries received will be published on the College website ( HM Treasury Consultation on alcohol structures 64 65

35 Bulletin Issue 104 July 2017 Bulletin Issue 104 July 2017 THE MSA SAQ WRITERS CLUB The Writers Club has seen more than 700+ trainees through the SAQ Papers with a successful pass rate for those who have kept to the necessary disciplines. But many trainees apply far too close to the examination to derive anything like the full benefit from membership. That full benefit includes free admission to the SAQ Weekend Courses, the acquisition of a large and useful collection of answer sheets and a valuable motivation towards sustained revision. Membership fee: a single payment of 400 Members are entitled to all benefits until successful in the SAQ Paper Attendance to the SAQ Weekend Courses free of charge Writers Club Motto: Within the Discipline, Lies the Reward Candidates are urged to join before September 2017 for the Spring 2018 Examination to reap maximum benefit Enquiries to: writersclub.msa@gmail.com Courses for the Royal College of Anaesthetists Examinations Courses Dates 2017/2018 Capacity Primary SBA/MCQ July 6 12 October No Limit Primary OSCE Weekend October December Primary Viva Weekend October January 2018 No Limit Primary OSCE/Orals 27 Oct 3 Nov January Final SBA/MCQ August February 2018 No Limit Final SAQ Weekend August February 2018 No Limit Final Written Booker August February Final Viva Revision 4 9 November May 2018 No Limit Final Viva Weekend November June I just wanted to write and say thank you for the excellent courses you ran pre exam in February. I passed my Written FRCA on my first attempt and whilst I haven t received the letter with breakdown of marks, I am confident that the use of the Mersey Method for the SAQ paper helped me stay alert and focused for the MCQ/SBA in the afternoon and likely score as highly as possible. It was the first time I have left a morning examination with a smile on my face and the appetite to eat a two course lunch before the afternoon session! I also wanted to say a special thanks to the kind faculty member who took me across to the Women s Hospital during the SAQ weekend when I was worried about my baby. I m sorry I have forgotten their name but I really appreciated the kindness and empathy shown when they had plenty of other things to be doing. I looking forward to returning to Mersey next year for VIVA prep baby is due the week of the June viva this time so best not risk it! Final Written Candidate, March 2017 I recently sat the FFICM OSCE and Viva. It bears the format of the Primary FRCA and some content overlap with the Final FRCA. I couldn t believe I was back studying again, having passed the FRCA over a year ago. I have to say, I was craving a Mersey Course to dive into and emerge exhausted, full of sugar, but well prepared for the exam! And although there was no such course this time, I was able to put into practice what I had learned from all those weeks I spent in Liverpool in Despite my morning OSCE being a total shocker. I remained calm and composed and jumped back into the game for the afternoon vivas, with everything to play for. I was smiling and enthusiastic and kind to my examiners, my viva technique well honed from round robin sessions in Whiston. Even though I didn t know all the answers I carried on smiling. Somehow I passed the OSCE, but thanks to my Mersey approach, I scored full marks in the viva. Even a year on, my learned behaviour is truly engrained! Thank you! MSA ICM EXAM PREPARATION COURSES COMING SOON! To see details of all of our courses please visit: or contact us at: enquiries@msoa.org.uk 66 67

36 AIRWAY WORKSHOPS CPD credits ( 180 for RCoA registered trainees) RCoA UPDATES in anaesthesia, critical care and pain management The airway workshops provide an opportunity to learn core airway management techniques from experienced consultants. There is hands-on practical experience with commonplace airway equipment as well as plenty of discussion on airway management including current UK guidelines. Appropriate for all grades of anaesthetic CPD STUDY DAYS ANAESTHETISTS AS EDUCATORS COURSES trainees, specialty doctors and consultants. CPD credits September 2017 at (Advanced Airway) #RCoACPD 6 8 SEPTEMBER DECEMBER 2017 Royal Welsh College of Music and Drama, Cardiff 490 #RCoAUpdates Our update events are three-day meetings consisting of lectures and topical discussion. The meeting is intended for doctors engaged in clinical anaesthesia, pain management and intensive care medicine (i.e. Consultants, Staff and Associate Specialist Grades or their overseas equivalent) who would benefit from a refresher of the latest updates in areas of practice they may be exposed to regularly or only occasionally. Experts will present up-todate information on a wide range of topics, informing participants on updates in basic sciences relevant to anaesthesia and allied specialties. The learning objectives of the events is to facilitate familiarisation with the latest developments and to make participants aware of progress in a structured manner, bringing a better understanding of how changes in practice, based on new information, will benefit their patients. 12 October 2017 at G&V Royal Mile Hotel, Edinburgh 7 February 2018 at 18 April 2018 at UK TRAINING IN EMERGENCY AIRWAY MANAGEMENT (TEAM) COURSE OCTOBER NOVEMBER 2017 Edinburgh Royal Infirmary Education Centre 450 Our simulator-based course provides the knowledge, skills and attitudes required to safely manage the airway and post-intubation period in an emergency situation outside the operating theatre. CPD credits 10 Our CPD Days are designed for busy doctors, to efficiently maintain competence and aid with revalidation in anaesthetic and surgical practice. These study days will provide updates on new treatments and techniques, including top tips on improving your performance, from specialists in the clinical field. You will also have access to experts who will equip you with new skills to cope better with the demands of everyday working life. CPD credits 10 CPD STUDY DAYS (TWO DAYS) 355 ( 270 for RCoA registered trainees) September 2017 CPD credits 5 CPD STUDY DAYS (ONE DAY) 200 ( 150 for RCoA registered trainees) 2 October November 2017 Britannia Royal Hotel, Hull 22 November February 2018 AN INTRODUCTION 27 SEPTEMBER JUNE ( 165 for RCoA registered trainees) TEACHING AND TRAINING IN THE WORKPLACE SEPTEMBER FEBRUARY ( 320 for RCoA registered trainees) SIMULATION UNPLUGGED 13 OCTOBER ( 165 for RCoA registered trainees) CPD credits 5 CPD credits 10 CPD credits 5 The Anaesthetists as Educators series of events supports clinical educators in delivering high quality education and training in the workplace. The programme offers a number of professional development courses and educational resources in the areas of teaching and learning in the workplace; assessment and feedback; and educational supervision and appraisal. The course content is mapped to the GMC s seven domains for the recognition and approval of trainers and participation in the courses will provide supporting evidence towards the GMC approval process for trainers. 68 Book your place at: Book your place at: 69

37 JOINT RCoA/AAGBI LESS THAN FULL TIME TRAINING MEETING (LTFT) JOINT RCoA/LSORA REGIONAL ANAESTHESIA PRACTICAL WORKSHOP AND SYMPOSIUM This meeting is a joint venture between the RCoA and the London Society of Regional Anaesthesia (LSORA). These joint events aim to attract all budding and more experienced regional anaesthetists. RCoA WINTER SYMPOSIUM: Excellence NOVEMBER ( 295 for RCoA registered trainees) This November the RCoA Winter Symposium will bring together over 20 world class speakers, for two days of thought provoking and engaging topics across anaesthesia, perioperative medicine, critical care and pain medicine. With the theme of Excellence, the programme will focus on how to improve patient outcomes, discussing controversial topics such as the weekend effect and fasting times. With 10 CPD points available the Winter Symposium will provide you with food for thought for your own personal development, offering the chance to learn and interact with the experts whilst networking with delegates from all areas of the profession. This year s event will offer valuable insights into the cutting edge of the specialty, through succinct, punchy presentations. There will also be the opportunity to have discussions with speakers and delegates at dedicated Q+A sessions as well as sharing learning via Twitter debate. Last year s event sold out, and with limited availability you will need to book soon to avoid disappointment. CPD credits 10 #RCoAWinter 12 OCTOBER This event provides the opportunity for trainees, trainers and programme directors to learn how to get the most from or develop their LTFT programme. Workshops will address the important issues faced by LTFTs plus our expert panel will deliver an in depth question and answer session. LEADERSHIP AND MANAGEMENT COURSES 220 (one day) 395 (two days) The Leadership and Management series of events offers a range of interactive workshops designed specifically for anaesthetists with a balance of plenary sessions, group work and exercises with the emphasis on real life issues, open discussions, up-to-date information and one-to-one discussions. AN INTRODUCTION September May 2018 PERSONAL EFFECTIVENESS 29 September 2017 WORKING WELL IN TEAMS AND MAKING AN IMPACT 22 November 2017 LEADING AND MANAGING CHANGE SUCCESS WITH SERVICE DEVELOPMENT 16 March 2018 PRACTICAL WORKSHOP 13 DECEMBER ( 180 for RCoA registered trainees) This workshop will be hands-on scanning with expert faculty. Candidates will be asked their skill level and streamlined into appropriate groups. There will be plenty of opportunity to discuss novel blocks with international experts during the stations and more comprehensively during the ask the experts sessions. A reduced rate of 340 ( 260 for RCoA registered trainees) is available for those attending both RCoA/LSORA events CPD credits 5 SYMPOSIUM 14 DECEMBER ( 150 for RCoA registered trainees) The symposium will be a series of exciting lectures provided by world experts. Topics include: latest blocks in regional anaesthesia including serratus anterior recent advances in regional anaesthesia education in regional anaesthesia, how to achieve it and where are we now? future technologies in regional anaesthesia what should we measure? Outcomes in regional anaesthesia. SAVE THE DATE! ANAESTHESIA 2018 International Meeting of the Royal College of Anaesthetists May British Museum, London CPD credits ( 295 for RCoA registered trainees) Book your study leave now for our new two-day conference focused on supporting professional development and enhancing your knowledge of the forefront of anaesthetic advances in perioperative medicine, critical care and pain medicine. The programme, built using your feedback, will be delivered by a number of national and world renowned experts, who will cover a diverse range of interesting and engaging subjects from the world of anaesthesia and its related specialties. Suitable for those just starting training to doctors at the peak of their careers. The event will also offer the chance to learn and interact with experts whilst networking with delegates from all areas of the profession. CPD credits Book your place at: Book your place at: 71