Stephen Bolsin

Background: Regular, routine, multimodal analgesia provides better pain relief following Caesarean section than reliance on “as required” opiate dosing. This quality improvement report describes the effective use of an education programme coupled with a highlighted, preprinted medication chart, employing “Nudge Theory” principles to achieve significant improvements in the administration of analgesic medications to patients after Caesarean section operations.Problem: An acute pain service audit identified a serious deficiency with delivery of regular postoperative analgesic medications to patients following Caesarean section operations.Methods: An audit of pain medication delivery to patients following Caesarean section demonstrated that postoperative analgesia was not being administered in line with local prescribing guidelines. Two interventions were planned: Education sessions for anaesthetic recovery and ward staff. Introduction of a new preprinted and highlighted medication chart. A postintervention audit was then conducted.Results: There were statistically significant improvements in all medications administered to patients following the two interventions. For analgesic medications, the rate of administration of drugs in compliance with guidelines rose from 39.6% to 89.9% (P < 0.001 using 2‐sample z test). Each subgroup of medications also showed statistically significant improvements in administration compliance.Conclusion: A combined approach, including application of “Nudge Theory” to the administration of analgesic medication after Caesarean section, considerably improved delivery of medications prescribed for postoperative analgesia.

Clinical engagement has supplemented clinical governance in healthcare to strengthen the contribution of medical professionals to the assessment of clinical outcomes for patients. Assessments of clinical engagement have, until now, been qualitative; this case study introduces the concept of quantitative assessment of clinical engagement by measuring the number of patients managed according to specialist society guidelines. Such an assessment engages all staff (medical, nursing, allied health and pharmacy) involved in patients receiving treatment according to such guidelines and provides an assessment of individual and organisational compliance with those guidelines. Clinical engagement is then quantified as the percentage of patients that have been documented to receive specialist society- or college-approved guideline-compliant treatment, relative to the total number who could receive such treatment, in any healthcare organisation. What is known about the topic?: Clinical engagement has emerged in recent years as a virtue to be encouraged in healthcare organisations because of its association with improved patient outcomes and employee satisfaction. Assessments have relied on repeated staff surveys in order to gauge engagement. What does this paper add?: This paper proposes a novel means of measuring clinical engagement in an organisational setting. The vision put forward is that adherence to clinical guidelines in an organisation measures clinician engagement across professional disciplines. What are the implications for practitioners?: The implications are that organisations will contribute to measuring the adherence of specialty groups of clinicians to guidelines that the clinicians select and use the data for individual and organisational accreditation.

Editor—We were disappointed to read the content of the recent article by Hajibandeh and colleagues¹ in the British Journal of Anaesthesia. Since the early, implausible reports of long-term benefit attributable to short-term perioperative beta-blockade, there has been increasing scepticism of this treatment among both anaesthetists and cardiologists.^2–8 Following the early criticisms of publications by Mangano and colleagues and Poldermans’ group, the specialty of anaesthesia has discovered that the conclusions of these workers were baseless.⁹ This is because of a flawed analysis on the basis of ‘intention to treat’ with respect to the study by Mangano and colleagues and a seriously discredited first author in the case of the Poldermans’ study.^2,8,3

Effective revalidation processes based on performance measurement would be cost-effective and could lead to cost savings

We believe that the answer to this question is not in the esoteric realms of educational theory. It is in the hands of the specialty of anaesthesia itself.

Godlee is right to highlight the need for patients to be properly informed at the time they give consent to treatment.1 The Bolam principle, which was enunciated as advice to a jury in …

The article by Westaby dealing with publication of surgical mortality data is at best a superficial examination of the issue and at worst misleading.1 The evidence has been irrefutable for many years that the collection and feedback of risk adjusted mortality data will reduce death rates by as much as 40% in cardiac surgery …

Editor—We were interested to read the editorial by Pierre Foex and John Sear on the cardioprotective effect of β-blockers in the perioperative period.¹ While citing their original work and the seminal study of Mangano and colleagues,² they fail to highlight the unsound nature of that publication. As we have pointed out, several major flaws exist in this study, which led Devereaux and colleagues to exclude the results from their meta-analysis justifying the POISE study.^3–6

We were pleased to see that the European Society of Cardiology partially corrected its erroneous 2009 recommendations on perioperative β blockade.1 2 However, the Joint Task Force still included the widely discredited study of Mangano et al, even though its …