Integration of robotic surgery into routine practice and impacts on communication, collaboration, and decision making: a realist process evaluation protocol

A realist evaluation of devices used for the prevention of heel pressure ulcers: An ethnographic study of clinical practice

BACKGROUND

It is known that heel offloading devices are widely used in clinical practice for the prevention of heel pressure ulcers, even though there is a lack of robust, good quality evidence to inform their use.

OBJECTIVE

To explore how and why heel offloading devices are used (or not used) and reasoning behind their use in population at high risk of developing heel pressure ulcers.

METHODS

An ethnographic study was conducted as part of a realist evaluation in three orthopaedic wards in a large English hospital. Twelve observations took place, with 49 h and 35 min of patient care observed. A total of 32 patients were observed and 19 members of the nursing team were interviewed and in-depth interviews with the three ward managers were conducted.

RESULTS

Although the focus of the study was on offloading devices, constant low pressure heel specific devices were also observed in use for pressure ulcer prevention, whilst offloading devices were perceived to be for higher risk patients or those already with a heel pressure ulcer. Nursing staff viewed leadership from the ward manager and the influence of the Tissue Viability Nurse Specialists as key mechanisms for the proactive use of devices.

CONCLUSIONS

This study informs trial design as it has identified that a controlled clinical trial of both types of heel specific devices is required to inform evidence-based practice. Involving the ward managers and Tissue Viability Nurse Specialists during set up phase for clinical equipoise could improve recruitment. Tweetable abstract How, for whom, and in what circumstances do devices work to prevent heel pressure ulcers? Observations of clinical practice.

Human Factors Integration in Robotic Surgery

OBJECTIVE

Using the example of robotic-assisted surgery (RAS), we explore the methodological and practical challenges of technology integration in surgery, provide examples of evidence-based improvements, and discuss the importance of systems engineering and clinical human factors research and practice.

BACKGROUND

New operating room technologies offer potential benefits for patients and staff, yet also present challenges for physical, procedural, team, and organizational integration. Historically, RAS implementation has focused on establishing the technical skills of the surgeon on the console, and has not systematically addressed the new skills required for other team members, the use of the workspace, or the organizational changes.

RESULTS

Human factors studies of robotic surgery have demonstrated not just the effects of these hidden complexities on people, teams, processes, and proximal outcomes, but also have been able to analyze and explain in detail why they happen and offer methods to address them. We review studies on workload, communication, workflow, workspace, and coordination in robotic surgery, and then discuss the potential for improvement that these studies suggest within the wider healthcare system.

CONCLUSION

There is a growing need to understand and develop approaches to safety and quality improvement through human-systems integration at the frontline of care.Precis: The introduction of robotic surgery has exposed under-acknowledged complexities of introducing complex technology into operating rooms. We explore the methodological and practical challenges, provide examples of evidence-based improvements, and discuss the implications for systems engineering and clinical human factors research and practice.

The RoboCOS Study: Development of an international core outcome set for the comprehensive evaluation of patient, surgeon, organisational and population level impacts of robotic assisted surgery

BACKGROUND

The introduction of robot-assisted surgery is costly and requires whole system transformation, which makes the assessment of benefits (or drawbacks) complex. To date, there has been little agreement on which outcomes should be used in this regard. The aim of the RoboCOS study was to develop a core outcome set for the evaluation of robot-assisted surgery that would account for its impact on the whole system.

METHODS

Identification of a long-list of potentially relevant outcomes through systematic review of trials and health technology assessments; interviews with individuals from a range of stakeholder groups (surgeons, service managers, policy makers and evaluators) and a focus group with patients and public; prioritisation of outcomes via a 2-round online international Delphi survey; consensus meeting.

RESULTS

721 outcomes were extracted from the systematic reviews, interviews and focus group which were conceptualised into 83 different outcome domains across four distinct levels (patient, surgeon, organisation and population) for inclusion in the international Delphi prioritisation survey (128 completed both rounds). The consensus meeting led to the agreement of a 10-item core outcome set including outcomes at: patient level (treatment effectiveness; overall quality of life; disease-specific quality of life; complications (including mortality); surgeon level (precision/accuracy; visualisation); organisation (equipment failure; standardisation of operative quality; cost-effectiveness); and population (equity of access).

CONCLUSION

The RoboCOS core outcome set, which includes the outcomes of importance to all stakeholders, is recommended for use in all future evaluations of robot-assisted surgery to ensure relevant and comparable reporting of outcomes.

Establishing and integrating a transoral robotic surgery programme into routine oncological management of head and neck cancer - a UK perspective

BACKGROUND

The introduction of transoral robotic surgery into routine management of patients is complex. It involves organisational, logistical and clinical challenges. This study presents our experience of implementing such a programme and provides a blueprint for other centres willing to establish similar services.

METHODS

Implementation of the robotic surgery programme focused on several key domains: training, logistics, governance, multidisciplinary team awareness, pre-operative imaging, anaesthesia, post-operative care, finance, patient selection and consent. Programme outcomes were evaluated by assessing operative outcomes of the first 117 procedures performed.

RESULTS

The success of the transoral robotic surgery programme has been possible because of the scrupulous planning phase before the first procedure, and the time invested on team awareness and training.

CONCLUSION

Implementation of a new transoral robotic surgery service has led to: the development of a dedicated transoral robotic surgery patient care protocol, the performance of progressively more complex procedures, the inclusion of transoral robotic surgery training and the establishment of several research projects.

Comparison of 1-Year Health Care Expenditures and Utilization Following Minimally Invasive vs Open Nephrectomy

IMPORTANCE

Given the widespread adoption and clinical benefits of minimally invasive surgery approaches (MIS) in partial nephrectomy (PN) and radical nephrectomy (RN), assessment of long-term cost implications is relevant.

OBJECTIVE

To compare health care utilization and expenditures within 1 year after MIS and open surgery (OS).

DESIGN, SETTING, AND PARTICIPANTS

This cohort study was conducted using a US commercial claims database between 2013 and 2018. A total of 5104 patients aged 18 to 64 years who underwent PN or RN for kidney cancer and were continuously insured for 180 days before and 365 days after surgery were identified. An inverse probability of treatment weighting analysis was performed to examine differences in costs and use of health care services.

EXPOSURES

Surgical approach (MIS or OS).

MAIN OUTCOMES AND MEASURES

Outcomes assessed included 1-year total health care expenditure, health care utilizations, and estimated days missed from work.

RESULTS

Of the 5104 patients, 2639 had PN (2008 MIS vs 631 OS) and 2465 had RN (1816 MIS vs 649 OS) and most were male (PN: 1657 [62.8%]; RN: 399 [63.1%]) and between 55 and 64 years of age (PN: 1034 [51.3%]; RN: 320 [55.7%]). Patients who underwent MIS had lower index hospital length of stay compared with OS (mean [95% CI] for PN: 2.45 [2.37-2.53] vs 3.78 [3.60-3.97] days; P < .001; for RN: 2.82 [2.73-2.91] vs 4.62 [4.41-4.83] days; P < .001), and lower index expenditure for RN ($28 999 [$28 243-$29 796] vs $31 977 [$30 729-$33 329]; P < .001). For PN, index expenditure was lower for OS than MIS (mean [95% CI], $27 480 [$26 263-$28 753] vs $30 380 [$29614-$31 167]; P < .001). Patients with MIS had lower 1-year postdischarge readmission rate (PN: 15.1% vs 21.5%; odds ratio [OR], 0.65; 95% CI, 0.52-0.82; P < .001; RN: 15.6% vs 18.9%; OR, 0.79; 95% CI, 0.63-1.00; P = .05), and fewer hospital outpatient visits (mean [95% CI] for PN: 4.69 [4.48-4.90] vs 5.25 [4.84-5.66]; P = .01; RN: 5.50 [5.21-5.80] vs 6.71 [6.12-7.30]; P < .001) than those with OS. For RN, MIS was associated with 1.47 fewer missed workdays (95% CI, 0.57-2.38 days; P = .001). The reduction in health care use in MIS was associated with lower or similar total cumulative expenditures compared with OS (mean difference [95% CI] for PN: $331 [-$3250 to $3912]; P = .85; for RN: -$11 265 [-$17 065 to -$5465]; P < .001).

CONCLUSIONS AND RELEVANCE

In this cohort study, MIS was associated with lower or similar total cumulative expenditure than OS in the period 1 year after discharge from the index surgery. These findings suggest that downstream expenditures and resource utilization should be considered when evaluating surgical approach for nephrectomy.

The role of the bedside assistant in robot-assisted surgery: A critical synthesis

INTRODUCTION

Robot-assisted surgery has grown exponentially since its inception and first approval in the United States in the year 2000. The surgeon operating with the assistance of the robot sits remotely to the patient and another practitioner assists at the bedside. The role of the bedside assistant and the training that is required to undertake this role are understudied topics.

AIM

To explore the functions, training and professional development of the bedside assistant in robot-assisted surgery and propose the necessary foundations for the safe enactment of the role in the United Kingdom.

METHODS

Through critical interpretative synthesis, relevant literature was systematically searched and analysed to inform integration of evidence.

RESULTS

Seventy-three studies were retrieved from the literature, across several health care disciplines and surgical specialities. These were critically analysed to inform a theoretically sound account grounded on evidence.

CONCLUSION

The role, functions and skills of the bedside assistant in robot-assisted surgery vary across contexts. These were analysed and critically synthetised to produce several keys to the success of bedside assistants in robot-assisted surgery in the context of the United Kingdom and of its national regulations.

Framework for the development and evaluation of complex interventions: gap analysis, workshop and consultation-informed update

BACKGROUND

The Medical Research Council published the second edition of its framework in 2006 on developing and evaluating complex interventions. Since then, there have been considerable developments in the field of complex intervention research. The objective of this project was to update the framework in the light of these developments. The framework aims to help research teams prioritise research questions and design, and conduct research with an appropriate choice of methods, rather than to provide detailed guidance on the use of specific methods.

METHODS

There were four stages to the update: (1) gap analysis to identify developments in the methods and practice since the previous framework was published; (2) an expert workshop of 36 participants to discuss the topics identified in the gap analysis; (3) an open consultation process to seek comments on a first draft of the new framework; and (4) findings from the previous stages were used to redraft the framework, and final expert review was obtained. The process was overseen by a Scientific Advisory Group representing the range of relevant National Institute for Health Research and Medical Research Council research investments.

RESULTS

Key changes to the previous framework include (1) an updated definition of complex interventions, highlighting the dynamic relationship between the intervention and its context; (2) an emphasis on the use of diverse research perspectives: efficacy, effectiveness, theory-based and systems perspectives; (3) a focus on the usefulness of evidence as the basis for determining research perspective and questions; (4) an increased focus on interventions developed outside research teams, for example changes in policy or health services delivery; and (5) the identification of six 'core elements' that should guide all phases of complex intervention research: consider context; develop, refine and test programme theory; engage stakeholders; identify key uncertainties; refine the intervention; and economic considerations. We divide the research process into four phases: development, feasibility, evaluation and implementation. For each phase we provide a concise summary of recent developments, key points to address and signposts to further reading. We also present case studies to illustrate the points being made throughout.

LIMITATIONS

The framework aims to help research teams prioritise research questions and design and conduct research with an appropriate choice of methods, rather than to provide detailed guidance on the use of specific methods. In many of the areas of innovation that we highlight, such as the use of systems approaches, there are still only a few practical examples. We refer to more specific and detailed guidance where available and note where promising approaches require further development.

CONCLUSIONS

This new framework incorporates developments in complex intervention research published since the previous edition was written in 2006. As well as taking account of established practice and recent refinements, we draw attention to new approaches and place greater emphasis on economic considerations in complex intervention research. We have introduced a new emphasis on the importance of context and the value of understanding interventions as 'events in systems' that produce effects through interactions with features of the contexts in which they are implemented. The framework adopts a pluralist approach, encouraging researchers and research funders to adopt diverse research perspectives and to select research questions and methods pragmatically, with the aim of providing evidence that is useful to decision-makers.

FUTURE WORK

We call for further work to develop relevant methods and provide examples in practice. The use of this framework should be monitored and the move should be made to a more fluid resource in the future, for example a web-based format that can be frequently updated to incorporate new material and links to emerging resources.

FUNDING

This project was jointly funded by the Medical Research Council (MRC) and the National Institute for Health Research (Department of Health and Social Care 73514).

Role reconfiguration: what ethnographic studies tell us about the implications of technological change for work and collaboration in healthcare

New technologies including digital health and robotics are driving the evolution of healthcare. At the same time, healthcare systems are transitioning from a multiprofessional model approach of healthcare delivery to an interprofessional model. The concurrence of these two trends may represent an opportunity for leaders in healthcare because both require renegotiation of the complex division of work and enhanced interdependency. This review examines how the introduction of new technologies alters the role boundaries of occupations and interdependencies among health occupations. Based on a scoping review of ethnographic studies of technology implementation in a variety of contexts (from primary care to operating room) and of diverse technologies (from health informatics systems to robotics), we develop the concept of role reconfiguration to capture simultaneous adjustments of multiple, interdependent roles during technological change. Ethnographic and qualitative studies provide rich, detailed accounts of what people actually do and how their work and role is changed (or not) when a new technology arrives. Through a synthesis of these studies, we develop a typology of four types of role reconfiguration: negotiation, clarification, enlargement and restriction. We discuss leadership challenges in managing role reconfiguration and formulate four leadership priorities. We suggest that leaders: redesign roles proactively, paying attention to interdependencies; offer opportunities for collective learning about new technologies; ensure that knowledge of new technologies is distributed across roles and prepare to address resistance.

An Evaluation of Human Conversational Preferences in Social Human-Robot Interaction

To generate context-aware behaviors in robots, robots are required to have a careful evaluation of its encounters with humans. Unwrapping emotional hints in observable cues in an encounter will improve a robot's etiquettes in a social encounter. This article presents an extended human study conducted to examine how several factors in an encounter influence a person's preferences upon an interaction at a particular moment. We analyzed the nature of conversation preferred by a user considering the type of conversation a robot could have with its user, having the interaction initiated by the robot itself. We took an effort to explore how such preferences differ as the factors present in the surrounding alter. A social robot equipped with the capability to initiate a conversation is deployed to conduct the study by means of a wizard-of-oz (WoZ) experiment. During this study, conversational preferences of users could vary from “no interaction at all” to a “long conversation.” We changed three factors in an encounter which can be different from each other in each circumstance: the audience or outsiders in the environment, user's task, and the domestic area in which the interaction takes place. Conversational preferences of users within the abovementioned conditions were analyzed in a later stage, and critical observations are highlighted. Finally, implications that could be helpful in shaping future social human-robot encounters were derived from the analysis of the results.

Frontiers in human factors: embedding specialists in multi-disciplinary efforts to improve healthcare

Despite the application of a huge range of human factors (HF) principles in a growing range of care contexts, there is much more that could be done to realize this expertise for patient benefit, staff well-being and organizational performance. Healthcare has struggled to embrace system safety approaches, misapplied or misinterpreted others, and has stuck to a range of outdated and potentially counter-productive myths even has safety science has developed. One consequence of these persistent misunderstandings is that few opportunities exist in clinical settings for qualified HF professionals. Instead, HF has been applied by clinicians and others, to highly variable degrees-sometimes great success, but frequently in limited and sometimes counter-productive ways. Meanwhile, HF professionals have struggled to make a meaningful impact on frontline care and have had little career structure or support. However, in the last few years, embedded clinical HF practitioners have begun to have considerable success that are now being supported and amplified by professional networks. The recent coronavirus disease of 2019 (COVID-19) experiences confirm this. Closer collaboration between healthcare and HF professionals will result in significant and ultimately beneficial changes to both professions and clinical care.

Implementing large-system, value-based healthcare initiatives: a realist study protocol for seven natural experiments

INTRODUCTION

Value-based healthcare delivery models have emerged to address the unprecedented pressure on long-term health system performance and sustainability and to respond to the changing needs and expectations of patients. Implementing and scaling the benefits from these care delivery models to achieve large-system transformation are challenging and require consideration of complexity and context. Realist studies enable researchers to explore factors beyond 'what works' towards more nuanced understanding of 'what tends to work for whom under which circumstances'. This research proposes a realist study of the implementation approach for seven large-system, value-based healthcare initiatives in New South Wales, Australia, to elucidate how different implementation strategies and processes stimulate the uptake, adoption, fidelity and adherence of initiatives to achieve sustainable impacts across a variety of contexts.

METHODS AND ANALYSIS

This exploratory, sequential, mixed methods realist study followed RAMESES II (Realist And Meta-narrative Evidence Syntheses: Evolving Standards) reporting standards for realist studies. Stage 1 will formulate initial programme theories from review of existing literature, analysis of programme documents and qualitative interviews with programme designers, implementation support staff and evaluators. Stage 2 envisages testing and refining these hypothesised programme theories through qualitative interviews with local hospital network staff running initiatives, and analyses of quantitative data from the programme evaluation, hospital administrative systems and an implementation outcome survey. Stage 3 proposes to produce generalisable middle-range theories by synthesising data from context-mechanism-outcome configurations across initiatives. Qualitative data will be analysed retroductively and quantitative data will be analysed to identify relationships between the implementation strategies and processes, and implementation and programme outcomes. Mixed methods triangulation will be performed.

ETHICS AND DISSEMINATION

Ethical approval has been granted by Macquarie University (Project ID 23816) and Hunter New England (Project ID 2020/ETH02186) Human Research Ethics Committees. The findings will be published in peer-reviewed journals. Results will be fed back to partner organisations and roundtable discussions with other health jurisdictions will be held, to share learnings.

Searching for Programme theories for a realist evaluation: a case study comparing an academic database search and a simple Google search

BACKGROUND

Realist methodologies are increasingly being used to evaluate complex interventions in health and social care. Programme theory (ideas and assumptions of how a particular intervention works) development is the first step in a realist evaluation or a realist synthesis, with literature reviews providing important evidence to support this. Deciding how to search for programme theories is challenging and there is limited guidance available. Using an example of identifying programme theories for a realist evaluation of Pressure Ulcer Risk Assessment Instruments in clinical practice, the authors explore and compare several different approaches to literature searching and highlight important methodological considerations for those embarking on a programme theory review.

METHODS

We compared the performance of an academic database search with a simple Google search and developed an optimised search strategy for the identification primary references (i.e. documents providing the clearest examples of programme theories) associated with the use of Pressure Ulcer Risk Assessment Instruments (PU-RAIs). We identified the number of primary references and the total number of references retrieved per source. We then calculated the number needed to read (NNR) expressed as the total number of titles and abstracts screened to identify one relevant reference from each source.

RESULTS

The academic database search (comprising CINAHL, The Cochrane Library, EMBASE, HMIC, Medline) identified 2 /10 primary references with a NNR of 1395.The Google search identified 7/10 primary references with a NNR of 10.1. The combined NNR was 286.3. The optimised search combining Google and CINAHL identified 10/10 primary references with a NNR of 40.2.

CONCLUSION

The striking difference between the efficiency of the review's academic database and Google searches in finding relevant references prompted an in-depth comparison of the two types of search. The findings indicate the importance of including grey literature sources such as Google in this particular programme theory search, while acknowledging the need for transparency of methods. Further research is needed to facilitate improved guidance for programme theory searches to enhance practice in the realist field and to save researcher time and therefore resource.

How to report educational videos in robotic surgery: an international multidisciplinary consensus statement

The swift endorsement of the robotic surgical platform indicates that it might prevail as the preferred technique for many complex abdominal and pelvic operations. Nonetheless, use of the surgical robotic system introduces further layers of complexity into the operating theatre necessitating new training models. Instructive videos with relevant exposition could be optimal for early training in robotic surgery and the aim of this study was to develop consensus guidelines on how to report a robotic surgery video for educational purposes to achieve high quality educational video outputs that could enhance surgical training. A steering group prepared a Delphi survey of 46 statements, which was distributed and voted on utilising an electronic survey tool. The selection of committee members was designed to include representative surgical trainers worldwide across different specialties, including lower and upper gastrointestinal surgery, general surgery, gynaecology and urology. 36 consensus statements were approved and classified in seven categories: author’s information and video introduction, case presentation, demonstration of the surgical procedure, outcomes of the procedure, associated educational content, review of surgical videos quality and use of surgical videos in educational curricula. Consensus guidelines on how to report robotic surgery videos for educational purposes have been elaborated utilising Delphi methodology. We recommend that adherence to the guidelines presented could support advancing the educational quality of video outputs when designed for training.

How do team experience and relationships shape new divisions of labour in robot-assisted surgery? A realist investigation

Safe and successful surgery depends on effective teamwork between professional groups, each playing their part in a complex division of labour. This article reports the first empirical examination of how introduction of robot-assisted surgery changes the division of labour within surgical teams and impacts teamwork and patient safety. Data collection and analysis was informed by realist principles. Interviews were conducted with surgical teams across nine UK hospitals and, in a multi-site case study across four hospitals, data were collected using a range of methods, including ethnographic observation, video recording and semi-structured interviews. Our findings reveal that as the robot enables the surgeon to do more, the surgical assistant's role becomes less clearly defined. Robot-assisted surgery also introduces new tasks for the surgical assistant and scrub practitioner, in terms of communicating information to the surgeon. However, the use of robot-assisted surgery does not redistribute work in a uniform way; contextual factors of individual experience and team relationships shape changes to the division of labour. For instance, in some situations, scrub practitioners take on the role of supporting inexperienced surgical assistants. These changes in the division of labour do not persist when team members return to operations that are not robot-assisted. This study contributes to wider literature on divisions of labour in healthcare and how this is impacted by the introduction of new technologies. In particular, we emphasise the need to pay attention to often neglected micro-level contextual factors. This can highlight behaviours that can be promoted to benefit patient care.

Human factors in robotic assisted surgery: Lessons from studies 'in the Wild'

This article reviews studies conducted "in the wild" that explore the "ironies of automation" in Robotic Assisted Surgery (RAS). Workload may be reduced for the surgeon, but increased for other team members, with postural stress relocated rather than reduced, and the introduction of a range of new challenges, for example, in the need to control multiple arms, with multiple instruments; and the increased demands of being physically separated from the team. Workflow disruptions were not compared with other surgeries; however, the prevalence of equipment and training disruptions differs from other types of surgeries. A consistent observation is that communication and coordination problems are relatively frequent, suggesting that the surgical team may need to be trained to use specific verbal and non-verbal cues during surgery. RAS also changes the necessary size of the operating room instrument cleaning processes. These studies demonstrate the value of clinically-based human factors engineers working alongside surgical teams to improve the delivery of RAS.

Factors supporting and constraining the implementation of robot-assisted surgery: a realist interview study

OBJECTIVE

To capture stakeholders' theories concerning how and in what contexts robot-assisted surgery becomes integrated into routine practice.

DESIGN

A literature review provided tentative theories that were revised through a realist interview study. Literature-based theories were presented to the interviewees, who were asked to describe to what extent and in what ways those theories reflected their experience. Analysis focused on identifying mechanisms through which robot-assisted surgery becomes integrated into practice and contexts in which those mechanisms are triggered.

SETTING

Nine hospitals in England where robot-assisted surgery is used for colorectal operations.

PARTICIPANTS

Forty-four theatre staff with experience of robot-assisted colorectal surgery, including surgeons, surgical trainees, theatre nurses, operating department practitioners and anaesthetists.

RESULTS

Interviewees emphasised the importance of support from hospital management, team leaders and surgical colleagues. Training together as a team was seen as beneficial, increasing trust in each other's knowledge and supporting team bonding, in turn leading to improved teamwork. When first introducing robot-assisted surgery, it is beneficial to have a handpicked dedicated robotic team who are able to quickly gain experience and confidence. A suitably sized operating theatre can reduce operation duration and the risk of de-sterilisation. Motivation among team members to persist with robot-assisted surgery can be achieved without involvement in the initial decision to purchase a robot, but training that enables team members to feel confident as they take on the new tasks is essential.

CONCLUSIONS

We captured accounts of how robot-assisted surgery has been introduced into a range of hospitals. Using a realist approach, we were also able to capture perceptions of the factors that support and constrain the integration of robot-assisted surgery into routine practice. We have translated these into recommendations that can inform future implementations of robot-assisted surgery.

Implementation Science in Perioperative Care

There is a 17-year gap between the initial publication of scientific evidence and its uptake into widespread practice in health care. The field of implementation science (IS) emerged in the 1990s as an answer to this "evidence-to-practice gap." In this article, we present an overview of implementation science, focusing on the application of IS principles to perioperative care. We describe opportunities for additional training and discuss strategies for funding and publishing IS work. The objective is to demonstrate how IS can improve perioperative patient care, while highlighting perioperative IS studies and identifying areas in need of additional investigation.

Joint consensus on abdominal robotic surgery and anesthesia from a task force of the SIAARTI and SIC

Minimally invasive surgical procedures have revolutionized the world of surgery in the past decades. While laparoscopy, the first minimally invasive surgical technique to be developed, is widely used and has been addressed by several guidelines and recommendations, the implementation of robotic-assisted surgery is still hindered by the lack of consensus documents that support healthcare professionals in the management of this novel surgical procedure. Here we summarize the available evidence and provide expert opinion aimed at improving the implementation and resolution of issues derived from robotic abdominal surgery procedures. A joint task force of Italian surgeons, anesthesiologists and clinical epidemiologists reviewed the available evidence on robotic abdominal surgery. Recommendations were graded according to the strength of evidence. Statements and recommendations are provided for general issues regarding robotic abdominal surgery, operating theatre organization, preoperative patient assessment and preparation, intraoperative management, and postoperative procedures and discharge. The consensus document provides evidence-based recommendations and expert statements aimed at improving the implementation and management of robotic abdominal surgery.

Quality and reporting standards, resources, training materials and information for realist evaluation: the RAMESES II project

Background

Many of the problems confronting policy- and decision-makers, evaluators and researchers today are complex, as are the interventions designed to tackle them. Their success depends both on individuals’ responses and on the wider context of people’s lives. Realist evaluation tries to make sense of these complex interventions. It is a form of theory-driven evaluation, based on realist philosophy, that aims to understand why these complex interventions work, how, for whom, in what context and to what extent.

Objectives

Our objectives were to develop (a) quality standards, (b) reporting standards, (c) resources and training materials, (d) information and resources for patients and other lay participants and (e) to build research capacity among those interested in realist evaluation.

Methods

To develop the quality and reporting standards, we undertook a thematic review of the literature, supplemented by our content expertise and feedback from presentations and workshops. We synthesised findings into briefing materials for realist evaluations for the Delphi panel (a structured method using experts to develop consensus). To develop our resources and training materials, we drew on our experience in developing and delivering education materials, feedback from the Delphi panel, the RAMESES JISCMail e-mail list, training workshops and feedback from training sessions. To develop information and resources for patients and other lay participants in realist evaluation, we convened a group consisting of patients and the public. We built research capacity by running workshops and training sessions.

Results

Our literature review identified 152 realist evaluations, and when 37 of these had been analysed we were able to develop our briefing materials for the Delphi panel. The Delphi panel comprised 35 members from 27 organisations across six countries and five disciplines. Within three rounds, the panels had reached a consensus on 20 key reporting standards. The quality standards consist of eight criteria for realist evaluations. We developed resources and training materials for 15 theoretical and methodological topics. All resources are available online (www.ramesesproject.org). We provided methodological support to 17 projects and presentations or workshops to help build research capacity in realist evaluations to 29 organisations. Finally, we produced a generic patient information leaflet for lay participants in realist evaluations.

Limitations

Our project had ambitious goals that created a substantial workload, leading to the need to prioritise objectives. For example, we truncated the literature review and focused on standards and training material development.

Conclusions

Although realist evaluation holds much promise, misunderstandings and misapplications of it are common. We hope that our project’s outputs and activities will help to address these problems. Our resources are the start of an iterative journey of refinement and development of better resources for realist evaluations. The RAMESES II project seeks not to produce the last word on these issues, but to capture current expertise and establish an agreed state of the science. Much methodological development is needed in realist evaluation but this can take place only if there is a sufficient pool of highly skilled realist evaluators. Capacity building is the next key step in realist evaluation.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

The challenge of complexity in evaluating health policies and programs: the case of women's participatory groups to improve antenatal outcomes

Background

During the last years, randomized designs have been promoted as the cornerstone of evidence-based policymaking. Also in the field of community participation, Random Control Trials (RCTs) have been the dominant design, used for instance to examine the contribution of community participation to health improvement. We aim at clarifying why RCTs and related (quasi-) experimental designs may not be the most appropriate approach to evaluate such complex programmes.

Results

We argue that the current methodological debate could be more fruitful if it would start from the position that the choice of designs should fit the nature of the program and research questions rather than be driven by methodological preferences. We present how realist evaluation, a theory-driven approach to research and evaluation, is a relevant methodology that could be used to assess whether and how community participation works. Using the realist evaluation approach to examine the relationship between participation and action of women groups and antenatal outcomes would enable evaluators to examine in detail the underlying mechanisms which influence actual practices and outcomes, as well as the context conditions required to make it work.

Conclusions

Realist research in fact allows opening the black boxes of “community” and “participation” in order to examine the role they play in ensuring cost-effective, sustainable interventions. This approach yields important information for policy makers and programme managers considering how such programs could be implemented in their own setting.

Guideline Implementation: Minimally Invasive Surgery, Part 1

Since its inception in the early 1990s, technological developments have made minimally invasive surgery the preferred approach for many operative procedures. However, perioperative personnel have had to develop new skills and techniques to manage this technology. The advent of robotic-assisted procedures in the early 2000s added another level of complexity to the perioperative arena. The updated AORN "Guideline for minimally invasive surgery" provides guidance for creating a safe environment for patients undergoing a wide range of procedures in which complex, advanced equipment and techniques are used. This article focuses on key points of the guideline that address OR configuration for minimally invasive surgery, safe practices for robotic-assisted procedures, and reducing risks associated with gas insufflation media. Perioperative RNs should review the complete guideline for additional information and for guidance when writing and updating policies and procedures.

Quality of Communication in Robotic Surgery and Surgical Outcomes

Background and Objectives:

Robotic surgery has introduced unique challenges to surgical workflow. The association between quality of communication in robotic-assisted laparoscopic surgery and surgical outcomes was evaluated.

Methods:

After each gynecologic robotic surgery, the team members involved in the surgery completed a survey regarding the quality of communication. A composite quality-of-communication score was developed using principal component analysis. A higher composite quality-of-communication score signified poor communication.

Objective parameters, such as operative time and estimated blood loss (EBL), were gathered from the patient's medical record and correlated with the composite quality-of-communication scores.

Results:

Forty robotic cases from March through May 2013 were included. Thirty-two participants including surgeons, circulating nurses, and surgical technicians participated in the study. A higher composite quality-of-communication score was associated with greater EBL (P = .010) and longer operative time (P = .045), after adjustment for body mass index, prior major abdominal surgery, and uterine weight. Specifically, for every 1-SD increase in the perceived lack of communication, there was an additional 51 mL EBL and a 31-min increase in operative time. The most common reasons reported for poor communication in the operating room were noise level (28/36, 78%) and console-to-bedside communication problems (23/36, 64%).

Conclusion:

Our study demonstrates a significant association between poor intraoperative team communication and worse surgical outcomes in robotic gynecologic surgery. Employing strategies to decrease extraneous room noise, improve console-to-bedside communication and team training may have a positive impact on communication and related surgical outcomes.

Evaluating the implementation of a national clinical programme for diabetes to standardise and improve services: a realist evaluation protocol

BACKGROUND

Over the last three decades in response to the growing burden of diabetes, countries worldwide have developed national and regional multifaceted programmes to improve the monitoring and management of diabetes and to enhance the coordination of care within and across settings. In Ireland in 2010, against a backdrop of limited dedicated strategic planning and engrained variation in the type and level of diabetes care, a national programme was established to standardise and improve care for people with diabetes in Ireland, known as the National Diabetes Programme (NDP). The NDP comprises a range of organisational and service delivery changes to support evidence-based practices and policies. This realist evaluation protocol sets out the approach that will be used to identify and explain which aspects of the programme are working, for whom and in what circumstances to produce the outcomes intended.

METHODS/DESIGN

This mixed method realist evaluation will develop theories about the relationship between the context, mechanisms and outcomes of the diabetes programme. In stage 1, to identify the official programme theories, documentary analysis and qualitative interviews were conducted with national stakeholders involved in the design, development and management of the programme. In stage 2, as part of a multiple case study design with one case per administrative region in the health system, qualitative interviews are being conducted with frontline staff and service users to explore their responses to, and reasoning about, the programme's resources (mechanisms). Finally, administrative data will be used to examine intermediate implementation outcomes such as service uptake, acceptability, and fidelity to models of care.

DISCUSSION

This evaluation is using the principles of realist evaluation to examine the implementation of a national programme to standardise and improve services for people with diabetes in Ireland. The concurrence of implementation and evaluation has enabled us to produce formative feedback for the NDP while also supporting the refinement and revision of initial theories about how the programme is being implemented in the dynamic and unstable context of the Irish healthcare system.

Robotic surgery and its impact on teamwork in the operating theatre

Effective teamwork in the operating theatre is important for safe patient care. In robotic surgery, the surgeon is physically separated from the operating theatre team, which could potentially have an impact on teamwork. With robotic surgery increasing internationally, this article reviews relevant published literature on teamwork in the operating theatre and reflects on how this might be impacted by robotic surgery. We conclude by describing a research study we are currently undertaking on this topic.

Developing a methodological framework for organisational case studies: a rapid review and consensus development process

Background

Organisational case study proposals can be poorly articulated and methodologically weak, raising the possible need for publication standards in this area.

Objectives

To develop reporting standards for organisational case study research, with particular application to the UK National Health Service.

Design

Rapid evidence synthesis and Delphi consensus process.

Data sources

Relevant case studies and methods texts were identified through searches of library catalogues, key text and author searches, focused searching of health and social science databases and some targeted website searching.

Review methods

The reporting standards were developed in three stages: (1) a rapid review of the existing literature to identify items; (2) a modified Delphi consensus process to develop and refine content and structure; and (3) application of the high-consensus Delphi items to two samples of organisational case studies to assess their feasibility as reporting standards. Items for the Delphi consultation were identified from published organisational case studies and related methodological texts. Identified items were sent to a Delphi expert panel for rating over two rounds. Participants were also asked whether or not the provisional framework in which items were presented was appropriate, and were given the opportunity to adapt this alongside the content. In both rounds, the high-consensus threshold was set at 70% agreement among respondents for each item. High-consensus items from the Delphi consultation were then applied to previously identified case study publications to determine their relevance to the reporting of real-world organisational case studies and to better understand how the results of the Delphi consultation might best be implemented as a reporting standard.

Results

One hundred and three unique reporting items were identified from 25 methodological texts; eight example case studies and 12 exemplar case studies did not provide any additional unique items. Thirteen items were ultimately rated as ‘Should be reported for all organisational case studies’ by at least 70% of respondents, with the degree of consensus ranging from 73% to 100%. As a whole, exemplar case studies [which had been provided by the National Institute for Health Research (NIHR)’s Health Services and Delivery Research (HSDR) programme as examples of methodologically strong projects] more consistently reported the high-consensus Delphi items than did case studies drawn from the literature more broadly.

Limitations

Time and resource constraints prevented an initial ‘item-generation’ round in the Delphi consensus process. Items are therefore likely to have been influenced by the content, wording and assumptions of available literature.

Conclusions

The high-consensus items were translated into a set of 13 reporting standards that aim to improve the consistency, rigour and reporting of organisational case study research, thereby making it more accessible and useful to different audiences. The reporting standards themselves are intended primarily as a tool for authors of organisational case studies. They briefly outline broad requirements for rigorous and consistent reporting without constraining methodological freedom.

Future work

These reporting standards should be included as part of the submission requirements for all organisational case studies seeking funding. Though these reporting standards do not mandate specific methods, if a reporting item is not reported for legitimate methodological reasons, the onus is on the author to outline their rationale for the reader.

Funding

The NIHR HSDR programme.

Impact of Robotic Surgery on Decision Making: Perspectives of Surgical Teams

There has been rapid growth in the purchase of surgical robots in both North America and Europe in recent years. Whilst this technology promises many benefits for patients, the introduction of such a complex interactive system into healthcare practice often results in unintended consequences that are difficult to predict. Decision making by surgeons during an operation is affected by variables including tactile perception, visual perception, motor skill, and instrument complexity, all of which are changed by robotic surgery, yet the impact of robotic surgery on decision making has not been previously studied. Drawing on the approach of realist evaluation, we conducted a multi-site interview study across nine hospitals, interviewing 44 operating room personnel with experience of robotic surgery to gather their perspectives on how robotic surgery impacts surgeon decision making. The findings reveal both potential benefits and challenges of robotic surgery for decision making.

Interventions in randomised controlled trials in surgery: issues to consider during trial design

Until recently, insufficient attention has been paid to the fact that surgical interventions are complex. This complexity has several implications, including the way in which surgical interventions are described and delivered in trials. In order for surgeons to adopt trial findings, interventions need to be described in sufficient detail to enable accurate replication; however, it may be permissible to allow some aspects to be delivered according to local practice. Accumulating work in this area has identified the need for general guidance on the design of surgical interventions in trial protocols and reports. Key issues to consider when designing surgical interventions include the identification of each surgical intervention and their components, who will deliver the interventions, and where and how the interventions will be standardised and monitored during the trial. The trial design (pragmatic and explanatory), comparator and stage of innovation may also influence the extent of detail required. Thoughtful consideration of surgical interventions in this way may help with the interpretation of trial results and the adoption of successful interventions into clinical practice.

Protocol--the RAMESES II study: developing guidance and reporting standards for realist evaluation

INTRODUCTION

Realist evaluation is an increasingly popular methodology in health services research. For realist evaluations (RE) this project aims to: develop quality and reporting standards and training materials; build capacity for undertaking and critically evaluating them; produce resources and training materials for lay participants, and those seeking to involve them.

METHODS

To achieve our aims, we will: (1) Establish management and governance infrastructure; (2) Recruit an interdisciplinary Delphi panel of 35 participants with diverse relevant experience of RE; (3) Summarise current literature and expert opinion on best practice in RE; (4) Run an online Delphi panel to generate and refine items for quality and reporting standards; (5) Capture 'real world' experiences and challenges of RE-for example, by providing ongoing support to realist evaluations, hosting the RAMESES JISCmail list on realist research, and feeding problems and insights from these into the deliberations of the Delphi panel; (6) Produce quality and reporting standards; (7) Collate examples of the learning and training needs of researchers, students, reviewers and lay members in relation to RE; (8) Develop, deliver and evaluate training materials for RE and deliver training workshops; and (9) Develop and evaluate information and resources for patients and other lay participants in RE (eg, draft template information sheets and model consent forms) and; (10) Disseminate training materials and other resources.Planned outputs: (1) Quality and reporting standards and training materials for RE. (2) Methodological support for RE. (3) Increase in capacity to support and evaluate RE. (4) Accessible, plain-English resources for patients and the public participating in RE.

DISCUSSION

The realist evaluation is a relatively new approach to evaluation and its overall place in the is not yet fully established. As with all primary research approaches, guidance on quality assurance and uniform reporting is an important step towards improving quality and consistency.

Current considerations in colorectal cancer surgery

Colorectal cancer is one of the most common cancers in the world. The last decades improvement in survival in all stages of the disease has been achieved. Many factors contributes to this improvement; earlier diagnosis, better pre-operative staging, neoadjuvant radiochemotherapy, better surgical method and approach, introduction of pre- and post-operative multidisciplinary team conferences and adjuvant chemotherapy. Currently, new modalities are developing; robotics and organ preserving through wait-and-watch will give colorectal surgeons even more treatment options. This article highlights important aspects of colorectal cancer management now and in the future.