All Publications

  • Assessing trauma care systems in low-income and middle-income countries: a systematic review and evidence synthesis mapping the Three Delays framework to injury health system assessments. BMJ global health Whitaker, J., O'Donohoe, N., Denning, M., Poenaru, D., Guadagno, E., Leather, A. J., Davies, J. I. 2021; 6 (5)


    BACKGROUND: The large burden of injuries falls disproportionately on low/middle-income countries (LMICs). Health system interventions improve outcomes in high-income countries. Assessing LMIC trauma systems supports their improvement. Evaluating systems using a Three Delays framework, considering barriers to seeking (Delay 1), reaching (Delay 2) and receiving care (Delay 3), has aided maternal health gains. Rapid assessments allow timely appraisal within resource and logistically constrained settings. We systematically reviewed existing literature on the assessment of LMIC trauma systems, applying the Three Delays framework and rapid assessment principles.METHODS: We conducted a systematic review and narrative synthesis of articles assessing LMIC trauma systems. We searched seven databases and grey literature for studies and reports published until October 2018. Inclusion criteria were an injury care focus and assessment of at least one defined system aspect. We mapped each study to the Three Delays framework and judged its suitability for rapid assessment.RESULTS: Of 14 677 articles identified, 111 studies and 8 documents were included. Sub-Saharan Africa was the most commonly included region (44.1%). Delay 3, either alone or in combination, was most commonly assessed (79.3%) followed by Delay 2 (46.8%) and Delay 1 (10.8%). Facility assessment was the most common method of assessment (36.0%). Only 2.7% of studies assessed all Three Delays. We judged 62.6% of study methodologies potentially suitable for rapid assessment.CONCLUSIONS: Whole health system injury research is needed as facility capacity assessments dominate. Future studies should consider novel or combined methods to study Delays 1 and 2, alongside care processes and outcomes.

    View details for DOI 10.1136/bmjgh-2020-004324

    View details for PubMedID 33975885

  • The PanSurg-PREDICT Study: Endocrine Surgery During the COVID-19 Pandemic. World journal of surgery Van Den Heede, K., Chidambaram, S., Winter Beatty, J., Chander, N., Markar, S., Tolley, N. S., Palazzo, F. F., Kinross, J. K., Di Marco, A. N., PanSurg Collaborative and the PREDICT-Endocrine Collaborative, Beatty, J. W., Chidambaram, S., Markar, S., Kinross, J. K., Di Marco, A. N., Kulshreshtha, A., Aseem, R., Deurloo, E. K., Quinnen, N. C., Cruz, N. J., Yiu, A. J., Khan, N., Markiewicz, O., Goh, E. T., Denning, M., Aggarwal, R., Mason, S., Erridge, S., Dryden, S. D., Clarke, J. M., Sounderajah, V., Acharya, A., Rabinowicz, S., Yalamanchili, S., Martin, G., Warren, L., Scott, A. J., Burgnon, E., Purkayastha, S., Mechera, R., Glover, A., Papachristos, A., Xuan, R., Glover, A., Dhondt, B., Azab, M. A., Azzam, A. Y., Balalis, D., Fradelos, E., Korkolis, D. P., Skotsimara, A., Baili, E., Kyros, E., Felekouras, E., Vagios, I., Karydakis, L., Mpoura, M., Syllaios, A., Davakis, S., Liakakos, T., Charalabopoulos, A., Fulop, A., Szijarto, A., Bhat, J., Parray, F., Aziz, G., Chowdri, N., Wani, R., Shah, Z., Andrabi, S. M., Mehraj, A., Fowler, A., Chaudhary, A., Murphy, B., van der Hoef, D., Ryan, E., O Beirn, E., Marzouk, F., McKevitt, K., Nizami, K., Grewal, H., Hennessy, O., Roden, Y., Elwahab, S. A., Collins, C., Ayed, S., Alwade, H., Aldaya, M., Magboul, N. A., Ali, A. M., Borgstein, A., Voeten, D., Gisbertz, S. S., Van Berge Henegouwen, M. I., Engelsman, A. F., Yalcinkaya, A., Sahin, C., Yavas, M., Yavuz, A., Gobut, H., Bostanci, H., Sare, M., Yuksel, O., Kozan, R., Altiner, S., Leventoglu, S., Kocatas, A., Bozkurt, M. A., Kara, Y., Aybar, E., Sari, A. C., Colak, E. M., Rooney, S., Nandasena, M., Balakrishnan, A., De Jong, M. C., Mihai, R., Khan, S., Van Den Heede, K., Chander, N., Chidambaram, S., Palazzo, F., Tolley, N., Di Marco, A., Parkins, K., Spencer, N., Egan, R. J. 2021


    BACKGROUND: In the midst of the COVID-19 pandemic, patients have continued to present with endocrine (surgical) pathology in an environment depleted of resources. This study investigated how the pandemic affected endocrine surgery practice.METHODS: PanSurg-PREDICT is an international, multicentre, prospective, observational cohort study of emergency and elective surgical patients in secondary/tertiary care during the pandemic. PREDICT-Endocrine collected endocrine-specific data alongside demographics, COVID-19 and outcome data from 11-3-2020 to 13-9-2020.RESULTS: A total of 380 endocrine surgery patients (19 centres, 12 countries) were analysed (224 thyroidectomies, 116 parathyroidectomies, 40 adrenalectomies). Ninety-seven percent were elective, and 63% needed surgery within 4weeks. Eight percent were initially deferred but had surgery during the pandemic; less than 1% percent was deferred for more than 6months. Decision-making was affected by capacity, COVID-19 status or the pandemic in 17%, 5% and 7% of cases. Indication was cancer/worrying lesion in 61% of thyroidectomies and 73% of adrenalectomies and calcium 2.80mmol/l or greater in 50% of parathyroidectomies. COVID-19 status was unknown at presentation in 92% and remained unknown before surgery in 30%. Two-thirds were asked to self-isolate before surgery. There was one COVID-19-related ICU admission and no mortalities. Consultant-delivered care occurred in a majority (anaesthetist 96%, primary surgeon 76%). Post-operative vocal cord check was reported in only 14% of neck endocrine operations. Both of these observations are likely to reflect modification of practice due to the pandemic.CONCLUSION: The COVID-19 pandemic has affected endocrine surgical decision-making, case mix and personnel delivering care. Significant variation was seen in COVID-19 risk mitigation measures. COVID-19-related complications were uncommon. This analysis demonstrates the safety of endocrine surgery during this pandemic.

    View details for DOI 10.1007/s00268-021-06099-z

    View details for PubMedID 33877392

  • Grass-roots junior doctor communication network in response to the COVID-19 pandemic: a service evaluation. BMJ open quality Sivananthan, A., Machin, M., Zijlstra, G., Harris, A., Radhakrishnan, S. T., Crook, P., Phillips, G., Denning, M. C., Patel, N., Russell, G., Darzi, A., Kinross, J., Brown, R. 2021; 10 (2)


    BACKGROUND: COVID-19 was declared a worldwide pandemic on 11 March 2020. Imperial College Healthcare NHS Trust provides 1412 inpatient beds staffed by 1200 junior doctors and faced a large burden of COVID-19 admissions.LOCAL PROBLEM: A survey of doctors revealed only 20% felt confident that they would know to whom they could raise concerns and that most were getting information from a combination of informal work discussions, trust emails, social media and medical literature.METHODS: This quality improvement project was undertaken aligning with Standards for Quality Improvement Reporting Excellence 2.0 guidelines. Through an iterative process, a digital network (Imperial Covid cOmmunications Network; ICON) using existing smartphone technologies was developed. Concerns were collated from the junior body and conveyed to the leadership team (vertical-bottom-up using Google Form) and responses were conveyed from leadership to the junior body (vertical-top-down using WhatsApp and Zoom). Quantitative analysis on engagement with the network (members of the group and number of issues raised) and qualitative assessment (thematic analysis on issues) were undertaken.RESULTS: Membership of the ICON WhatsApp group peaked at 780 on 17 May 2020. 197 concerns were recorded via the Google Form system between 20 March and 14 June 2020. There were five overarching themes: organisational and logistics; clinical strategy concerns; staff safety and well-being; clinical (COVID-19) and patient care; and facilities. 94.4% of members agreed ICON was helpful in receiving updates and 88.9% agreed ICON improved collaboration.CONCLUSIONS: This work demonstrates that a coordinated network using existing smartphone technologies and a novel communications structure can improve collaboration between senior leadership and junior doctors. Such a network could play an important role during times of pressure in a healthcare system.

    View details for DOI 10.1136/bmjoq-2020-001247

    View details for PubMedID 33941538

  • Determinants of burnout and other aspects of psychological well-being in healthcare workers during the Covid-19 pandemic: A multinational cross-sectional study. PloS one Denning, M., Goh, E. T., Tan, B., Kanneganti, A., Almonte, M., Scott, A., Martin, G., Clarke, J., Sounderajah, V., Markar, S., Przybylowicz, J., Chan, Y. H., Sia, C., Chua, Y. X., Sim, K., Lim, L., Tan, L., Tan, M., Sharma, V., Ooi, S., Winter Beatty, J., Flott, K., Mason, S., Chidambaram, S., Yalamanchili, S., Zbikowska, G., Fedorowski, J., Dykowska, G., Wells, M., Purkayastha, S., Kinross, J. 2021; 16 (4): e0238666


    The Covid-19 pandemic has placed unprecedented pressure on healthcare systems and workers around the world. Such pressures may impact on working conditions, psychological wellbeing and perception of safety. In spite of this, no study has assessed the relationship between safety attitudes and psychological outcomes. Moreover, only limited studies have examined the relationship between personal characteristics and psychological outcomes during Covid-19. From 22nd March 2020 to 18th June 2020, healthcare workers from the United Kingdom, Poland, and Singapore were invited to participate using a self-administered questionnaire comprising the Safety Attitudes Questionnaire (SAQ), Oldenburg Burnout Inventory (OLBI) and Hospital Anxiety and Depression Scale (HADS) to evaluate safety culture, burnout and anxiety/depression. Multivariate logistic regression was used to determine predictors of burnout, anxiety and depression. Of 3,537 healthcare workers who participated in the study, 2,364 (67%) screened positive for burnout, 701 (20%) for anxiety, and 389 (11%) for depression. Significant predictors of burnout included patient-facing roles: doctor (OR 2.10; 95% CI 1.49-2.95), nurse (OR 1.38; 95% CI 1.04-1.84), and 'other clinical' (OR 2.02; 95% CI 1.45-2.82); being redeployed (OR 1.27; 95% CI 1.02-1.58), bottom quartile SAQ score (OR 2.43; 95% CI 1.98-2.99), anxiety (OR 4.87; 95% CI 3.92-6.06) and depression (OR 4.06; 95% CI 3.04-5.42). Significant factors inversely correlated with burnout included being tested for SARS-CoV-2 (OR 0.64; 95% CI 0.51-0.82) and top quartile SAQ score (OR 0.30; 95% CI 0.22-0.40). Significant factors associated with anxiety and depression, included burnout, gender, safety attitudes and job role. Our findings demonstrate a significant burden of burnout, anxiety, and depression amongst healthcare workers. A strong association was seen between SARS-CoV-2 testing, safety attitudes, gender, job role, redeployment and psychological state. These findings highlight the importance of targeted support services for at risk groups and proactive SARS-CoV-2 testing of healthcare workers.

    View details for DOI 10.1371/journal.pone.0238666

    View details for PubMedID 33861739

  • Insights from a global snapshot of the change in elective colorectal practice due to the COVID-19 pandemic PLOS ONE Mason, S. E., Scott, A. J., Markar, S. R., Clarke, J. M., Martin, G., Winter Beatty, J., Sounderajah, V., Yalamanchili, S., Denning, M., Arulampalam, T., Kinross, J. M., PanSurg Collaborative 2020; 15 (10): e0240397


    There is a need to understand the impact of COVID-19 on colorectal cancer care globally and determine drivers of variation.To evaluate COVID-19 impact on colorectal cancer services globally and identify predictors for behaviour change.An online survey of colorectal cancer service change globally in May and June 2020.Attending or consultant surgeons involved in the care of patients with colorectal cancer.Changes in the delivery of diagnostics (diagnostic endoscopy), imaging for staging, therapeutics and surgical technique in the management of colorectal cancer. Predictors of change included increased hospital bed stress, critical care bed stress, mortality and world region.191 responses were included from surgeons in 159 centers across 46 countries, demonstrating widespread service reduction with global variation. Diagnostic endoscopy was reduced in 93% of responses, even with low hospital stress and mortality; whilst rising critical care bed stress triggered complete cessation (p = 0.02). Availability of CT and MRI fell by 40-41%, with MRI significantly reduced with high hospital stress. Neoadjuvant therapy use in rectal cancer changed in 48% of responses, where centers which had ceased surgery increased its use (62 vs 30%, p = 0.04) as did those with extended delays to surgery (p<0.001). High hospital and critical care bed stresses were associated with surgeons forming more stomas (p<0.04), using more experienced operators (p<0.003) and decreased laparoscopy use (critical care bed stress only, p<0.001). Patients were also more actively prioritized for resection, with increased importance of co-morbidities and ICU need.The COVID-19 pandemic was associated with severe restrictions in the availability of colorectal cancer services on a global scale, with significant variation in behaviours which cannot be fully accounted for by hospital burden or mortality.

    View details for DOI 10.1371/journal.pone.0240397

    View details for Web of Science ID 000581809800004

    View details for PubMedID 33031464

    View details for PubMedCentralID PMC7544024

  • What Has Been the Impact of Covid-19 on Safety Culture? A Case Study from a Large Metropolitan Healthcare Trust INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH Denning, M., Goh, E., Scott, A., Martin, G., Markar, S., Flott, K., Mason, S., Przybylowicz, J., Almonte, M., Clarke, J., Winter Beatty, J., Chidambaram, S., Yalamanchili, S., Tan, B., Kanneganti, A., Sounderajah, V., Wells, M., Purkayastha, S., Kinross, J. 2020; 17 (19)


    Covid-19 has placed an unprecedented demand on healthcare systems worldwide. A positive safety culture is associated with improved patient safety and, in turn, with patient outcomes. To date, no study has evaluated the impact of Covid-19 on safety culture. The Safety Attitudes Questionnaire (SAQ) was used to investigate safety culture at a large UK healthcare trust during Covid-19. Findings were compared with baseline data from 2017. Incident reporting from the year preceding the pandemic was also examined. SAQ scores of doctors and "other clinical staff", were relatively higher than the nursing group. During Covid-19, on univariate regression analysis, female gender, age 40-49 years, non-White ethnicity, and nursing job role were all associated with lower SAQ scores. Training and support for redeployment were associated with higher SAQ scores. On multivariate analysis, non-disclosed gender (-0.13), non-disclosed ethnicity (-0.11), nursing role (-0.15), and support (0.29) persisted to a level of significance. A significant decrease (p < 0.003) was seen in error reporting after the onset of the Covid-19 pandemic. This is the first study to investigate SAQ during Covid-19. Differences in SAQ scores were observed during Covid-19 between professional groups when compared to baseline. Reductions in incident reporting were also seen. These changes may reflect perception of risk, changes in volume or nature of work. High-quality support for redeployed staff may be associated with improved safety perception during future pandemics.

    View details for DOI 10.3390/ijerph17197034

    View details for Web of Science ID 000587192300001

    View details for PubMedID 32993013

    View details for PubMedCentralID PMC7579589

  • Use of the HoloLens2 Mixed Reality Headset for Protecting Health Care Workers During the COVID-19 Pandemic: Prospective, Observational Evaluation JOURNAL OF MEDICAL INTERNET RESEARCH Martin, G., Koizia, L., Kooner, A., Cafferkey, J., Ross, C., Purkayastha, S., Sivananthan, A., Tanna, A., Pratt, P., Kinross, J., PanSurg Collaborative 2020; 22 (8): e21486


    The coronavirus disease (COVID-19) pandemic has led to rapid acceleration in the deployment of new digital technologies to improve both accessibility to and quality of care, and to protect staff. Mixed-reality (MR) technology is the latest iteration of telemedicine innovation; it is a logical next step in the move toward the provision of digitally supported clinical care and medical education. This technology has the potential to revolutionize care both during and after the COVID-19 pandemic.This pilot project sought to deploy the HoloLens2 MR device to support the delivery of remote care in COVID-19 hospital environments.A prospective, observational, nested cohort evaluation of the HoloLens2 was undertaken across three distinct clinical clusters in a teaching hospital in the United Kingdom. Data pertaining to staff exposure to high-risk COVID-19 environments and personal protective equipment (PPE) use by clinical staff (N=28) were collected, and assessments of acceptability and feasibility were conducted.The deployment of the HoloLens2 led to a 51.5% reduction in time exposed to harm for staff looking after COVID-19 patients (3.32 vs 1.63 hours/day/staff member; P=.002), and an 83.1% reduction in the amount of PPE used (178 vs 30 items/round/day; P=.02). This represents 222.98 hours of reduced staff exposure to COVID-19, and 3100 fewer PPE items used each week across the three clusters evaluated. The majority of staff using the device agreed it was easy to set up and comfortable to wear, improved the quality of care and decision making, and led to better teamwork and communication. In total, 89.3% (25/28) of users felt that their clinical team was safer when using the HoloLens2.New technologies have a role in minimizing exposure to nosocomial infection, optimizing the use of PPE, and enhancing aspects of care. Deploying such technologies at pace requires context-specific information security, infection control, user experience, and workflow integration to be addressed at the outset and led by clinical end-users. The deployment of new telemedicine technology must be supported with objective evidence for its safety and effectiveness to ensure maximum impact.

    View details for DOI 10.2196/21486

    View details for Web of Science ID 000575054100016

    View details for PubMedID 32730222

    View details for PubMedCentralID PMC7431236

  • Changing the Paradigm of Surgical Research During a Pandemic ANNALS OF SURGERY Markar, S. R., Martin, G., Penna, M., Yalamanchili, S., Beatty, J., Clarke, J., Erridge, S., Sounderajah, V., Denning, M., Scott, A., Purkayastha, S., Kinross, J., PanSurg Collaborative Grp 2020; 272 (2): E170–E171

    View details for DOI 10.1097/SLA.0000000000004000

    View details for Web of Science ID 000562697800042

    View details for PubMedID 32675530

    View details for PubMedCentralID PMC7268840

  • The Modified Crescenteric Anterior Intercostal Perforator Flap PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN Denning, M., Hayes, P., Tsang, F., Leff, D., Thiruchelvam, P., Hadjiminas, D. 2020; 8 (5): e2785


    Lower pole breast cancers are challenging to manage because conventional wide local excision may produce a "bird's beak" deformity. In an era of oncoplastic surgery, techniques that balance oncological results with cosmetic outcomes such as local flaps have extended the role of breast-conserving surgery. Local flaps are particularly useful for partial breast reconstruction due to the relative simplicity of the surgical procedure and reduced morbidity. Intercostal artery perforator flaps have a shorter duration of surgery than free flaps and do not require microsurgical anastomoses. Anterior intercostal artery perforator (AICAP) flaps provide excellent cosmesis, yet traditional crescenteric harvest yields limited volume for reconstruction. We describe a modification to an established reconstructive technique for lower pole breast defects. The technique is based on 3 extensions of tissue, providing a larger volume of tissue replacement compared with traditional AICAP flaps. The technique is particularly suitable for small- and medium-sized non-ptotic breasts, with lower pole tumors. The modified crescenteric AICAP technique can be used to increase the available tissue when performing lower pole reconstructions.

    View details for DOI 10.1097/GOX.0000000000002785

    View details for Web of Science ID 000542292800010

    View details for PubMedID 33133888

    View details for PubMedCentralID PMC7572179

  • Assessing trauma care health systems in low- and middle-income countries, a protocol for a systematic literature review and narrative synthesis SYSTEMATIC REVIEWS Whitaker, J., Denning, M., O'Donohoe, N., Poenaru, D., Guadagno, E., Leather, A., Davies, J. 2019; 8: 157


    Trauma represents a major global health problem projected to increase in importance over the next decade. The majority of deaths occur in low- and middle-income countries (LMICs) where survival rates are lower than their high-income country (HIC) counterparts. Health system level changes in care for injured patients have been attributed to significant improvements in care quality and outcomes in HIC settings. There is a need for further research to assess trauma care health systems in LMICs to inform health system strengthening for the care of the injured. This study aims to conduct a narrative synthesis of a systematic search of the literature on the assessment of trauma care health systems in LMICs in order to inform the further development of trauma care health system assessment.The review will include primary quantitative, qualitative or mixed method studies and secondary literature reviews. No restriction will be placed on language or date. Reports and publications identified from the grey literature including from relevant national and international health organisations will be included. Articles will be screened by two independent reviewers with a third reviewer resolving any persisting disagreement. The search will reveal heterogenous studies not suitable for meta-analysis. A narrative synthesis of the identified papers will be conducted to identify key methodological ideas and paradigms used to assess trauma care health systems. The analysis will consider how the differing methodological approaches could be adopted to understand barriers and delays to seeking, reaching and receiving care within a "Three Delays" framework. An iterative approach will be adopted to categorise identified articles, with the results presented as both within and across study analysis.The results of the review will be disseminated through publication in a peer-reviewed academic journal. The study forms part of a PhD project. The results will inform the development of a trauma care health system assessment applicable to LMICs. As this is a review of secondary data, no formal ethical approval is required.PROSPERO CRD42018112990.

    View details for DOI 10.1186/s13643-019-1075-8

    View details for Web of Science ID 000473644500002

    View details for PubMedID 31266537

    View details for PubMedCentralID PMC6607522