SCTS Bulletin Issue 06

the

bulletin

Issue 06

August 2019

Society for Cardiothoracic Surgery in Great Britain and Ireland

Many hands make light work Dual Consultant Operating Day of surgical admission Aortic Dissection: in Adult Cardiac Surgery p8 (DOSA) - One year on p40 A UK Strategy p52

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August 2019

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bulletin

In this issue...

5 8

10

The SCTS website - Time for a change Narain Moorjani

SCTS Executive and 13 Sub-committees

14

83rd Annual SCTS Meeting and Ionescu University, QEII Centre London Maninder Kalkat

18

Carin Van Doorn

SCTS Education tutors’ report Carol Tan, Sunil K Bhudia

28

The Academic Cardiothoracic Trainees Group and the 3rd SCTS National Research Meeting

Marius Roman

SCTS student engagement day 29

Liverpool University

Cindy Cleto, Tom Eadington, Aman Coonar

30

SCTS Annual Meeting 2019: SCTS Student Day report Saad Khan, Aman Coonar

My elective at Royal Papworth 31 Hospital Bernard Badasu

52

48

SCTS AHP Education portfolio

Tara Bartley, Bhuvana Krishnamoorthy

Congenital Cardiac Surgery

26

14

Nursing and Allied Health Professional update Helen Munday

20 SAC report Rajesh Shah 22 Cardiac audit update Uday Trivedi Thoracic surgery audit update 23

Doug West 24

Society for Cardiothoracic Surgery in Great Britain and Ireland

From the Editor Indu Deglurkar From the President: Dual Consultant Operating in Adult Cardiac Surgery Richard Page

15

3

32

The view from the (far) North Keith Buchan

Team training in Transcatheter 48

Aortic Valve Implantation (TAVI)

34

A heart surgery mission to Ghana

Gillian Hardman, Ranjit More, Antony H Walker

38

The Heart Surgery PSP Second Survey: Updates on success and looking to the future

52

Christina Bannister

Joel Dunning

Bethany Tabberer

Day of surgical admission (DOSA) 40

- One year on Cathy Walters

43

Glenfield Part II Cardiac Surgical Wetlab Ahmed Abbas

Cardiothoracics and Cashmere 44

A sub-internship in

cardiothoracic surgery Andrew Hudson

RESOLVE PPI Group 46

Helen Shackleford

47

My first SCTS Annual Meeting Abbie Mae Bolus

Aortic Dissection: A UK Strategy

53

Aortic Dissection diagnosis

54

Cardiothoracic Interdisciplinary Research Network (CIRN)

Graham Cooper

Luke J. Rogers, Ricky Vaja, Julie Sanders, Gavin Murphy

56

SCTS Education report July 2019

59

SCTS–Ionescu Additional Exceptional Fellowships 2019

Sri Rathinam

60 New Consultant Appointments Obituary: Leonard Bailey 61

John Dark, Asif Hasan Openbox

Society for Cardiothoracic Surgery in Great Britain and Ireland

SCTS, 5th Floor, Royal College of Surgeons, 35-43 Lincoln’s Inn Fields, London WC2A 3PE T: 020 7869 6893 E: sctsadmin@scts.org W: www.scts.org

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the bulletin is published on behalf of the SCTS

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August 2019

5

From the Editor Indu Deglurkar, Publishing Secretary, SCTS

“Coming together is a beginning.

Keeping together is progress.

Working together is success.”

– Henry Ford

T

his is a favourite quote that I have often used and indeed very befitting for this edition of the Bulletin. In many ways, this Bulletin showcases some significant changes in clinical practices with Dual Consultant Operating (DCO) which came into force in April 2019 and proposed changes in the training curriculum from April 2020.

We have been taught the importance of developing good hand-eye co-ordination, manual dexterity and focused psychomotor skills but technical competence alone is inadequate for successful surgical outcomes. In the UK, 10% (>850,000) of the hospital admissions suffer an adverse event. The Scottish National Audit of Surgical Mortality attributed only 4.3% to technical errors.

The non-technical aspects such as situational

awareness, decision making, communication, teamwork, leadership, the ability to cope with stress, fatigue and systemic issues played a bigger part in adverse events.

Arguably, DCO is practised in many units but to date if a mortality occurred, it has been borne by one Consultant. Our President, Richard Page, highlights that the

One needs to be a good team player who listens and communicates well with patients and colleagues and empowers them to reach their full potential.

The same nontechnical skills have been highlighted in emergency situations in the Cath Lab and commendable work has been done using simulation by the team at Blackpool following a serious untoward incident.

It exemplifies that all events, however catastrophic, present a learning opportunity to the wider team and this information can be disseminated usefully.

Narain Moorjani makes a strong case for the planned major overhaul of the current SCTS website.

A spread sheet of the SCTS Executive and the members of the subcommittees has been collated which comprehensively identifies members holding various posts in the SCTS.

Joel Dunning gives an account of the charitable work done by the team in Ghana.

A number of teams from the UK have travelled abroad to do charitable work but Joel Dunning’s account showcases the hardships overcome by the team.

Rajesh Shah, Chair of SAC, informs that conditional approval for the curriculum change by the GMC has been granted, which means we will be moving to the new curriculum in August 2020 and the three phases of training have been described.

The regular Education, Audit and Allied Health Professionals article update us about various aspects of services provided by the SCTS. Unfortunately, we have not received any articles for the Candid Column but please do feel free to bring up sensitive issues constructively. n

“The definition of a good surgeon goes beyond a good “pair of hands”. One needs to be a good team player, who listens and communicates well with patients and colleagues and empowers them to reach their full potential.”

Joel Dunning gives an account of the charitable work done by the team in Ghana (Page 34)

reasons behind this are varied (high-risk patient, difficult intra-operative decision making, very long operations, new techniques being introduced, senior training/mentoring of more junior consultants), but they are all examples of great teamwork with a clear manifestation of mutual professional respect between surgeons. A key aspect of developing these skills is the mentoring offered by seniors, and this represents a central part of leadership.

The impact of this welcome change will manifest over the years to come.

The definition of a good surgeon goes beyond a good “pair of hands”.

Ciao! indu.deglurkar@wales.nhs.uk

the 8 bulletin

From the President:

Dual Consultant Operating in Adult Cardiac Surgery Richard Page

T

eam working has been part of cardiothoracic surgery since its inception. Surgeons have led these teams but in many cases teams work in isolation from one another. Indeed looking back into the history of our specialty there has been a healthy competition between surgical teams either between those in the same hospital or in different institutions – who did the first operation of its kind, who did the greatest number of operations, who had the best outcomes etc. Although this competitiveness occasionally led to problems with negative consequences, competitiveness within cardiothoracic surgery is on the whole a positive force and has led to innovation, progress and improvements in patient care.

Things have changed significantly over the last decade or so with surgery becoming a consultant-led service. Surgeons cannot delegate as much of their work to others as previously, which is good for patients but mandates different ways of working.

Weekend consultant post-operative ward rounds are a great example of improved patient care and are becoming more frequent in our specialty. But there is a kick-back as a result, with increased time-off being necessary during the week to allow sufficient time for the weekend rounds. And it also mandates handing over our patients to a

colleague. When I started in my consultant post in 1994 this sort of handover of care hardly existed at all, and the mantra “I am always available for my patients 24/7” was routine, although clearly unachievable. It was another form of competition – which of us could be available the most!

The main reason for this way of working was the belief that the surgeon who carried out a patient’s surgery was the best person to manage any post-operative complications, hence the 24/7 aspiration of availability. But this might actually work

after surgery, rather than the surgeon who has carried out the original operation. My impression is that this works very well on every level, and does not exclude the original surgeon from being involved for advice if required. This is proper team working, and built on the bedrock of mutual trust.

In the pre-operative setting MDTs are now the routine for decision making in all areas of medicine. Surgeons enjoy the lively discussions and sharing of the difficult decisions that are needed. Although MDTs do not supplant the decision between a surgeon and a patient as to whether an operation should be done (or not) or how it should be done, the MDT ethos behind these recommendations is appreciated by surgeons and patients alike.

The last bastion of individual surgeons being autonomous clinicians in patient care may be in the operating theatre. It is pretty obvious that only one person can cut and sew a part of a patient’s anatomy at any one time, which is how the lead surgeon for a specific operation is usually identified. But there is so much more to surgery than cutting and sewing.

There is the intra-operative assessment of the patient’s pathology, how it has affected them and what the options are for treating the patient with surgery. Many cardiothoracic operations last for many hours with the result that mental and

“Things have changed significantly over the last decade or so with surgery becoming a consultant-led service. Surgeons cannot delegate as much of their work to others as previously which is good for patients but mandates different ways of working.” against the patient in some situations, quite apart from the practicalities. Many of us will have seen surgeons who are in denial about complications with the result that patient care can suffer – much better to get an unemotional assessment by a surgeon who hasn’t been involved in the patient’s primary operation to give a view. A good example of this are cardiac surgical teams who have changed their practices such that the on-call surgeon is responsible for managing the 5% or so patients who have significant bleeding

August 2019

physical fatigue of surgeons can be a real issue although not often discussed as such.

When I first started my career in surgery in the 1980s, for a consultant to ask for help during an operation almost never happened and was seen as a sign of weakness by the senior surgeons in that era. Happily it is now very common for surgeons to request the advice of a colleague in the middle of an operation. This is a great example of teamwork – it is valued by the surgeon who needs the advice and is taken as a complement by the surgeon who is asked to help. And the rest of the theatre team are much more reassured by more than one surgeon helping in a difficult situation.

Increasingly operations are arranged so that two consultant surgeons are scheduled to carry out the surgery together, as happens almost routinely in many congenital cardiac operations, thoracic aortic surgery or when new procedures are being trialled such as robotic lung resections. The reasons behind this are varied (high-risk patient, difficult intra-operative decision making, very long operations, new techniques being introduced, senior training/mentoring of more junior consultants), but they are all examples of great teamwork with a clear manifestation of mutual professional respect between surgeons.

This lengthy preamble brings me to the concept of Dual Consultant Operating (DCO) for adult cardiac surgery which has become formalised within the SCTS over recent months. It specifically refers to a situation where a decision has been made that an operation should be carried out by two consultant surgeons rather than one, with both surgeons being scrubbed for the operation. The decision to allocate a patient to DCO will be made and recorded prior to surgery, usually in an MDT setting and the appropriate surgeons will be decided upon at this time. As such it only applies to elective and urgent operations, and not emergencies. We anticipate that the vast majority of patients who are allocated for DCO will be those who present a very high risk for surgery, as has been the case for many years at Papworth hospital, the so called “Star Chamber”.

The principle reason behind this initiative is to allow more patients to benefit from potentially life-saving surgery, rather than being turned down by surgeons who are

concerned about their individual published outcomes, i.e. risk-averse behaviour. The latter is difficult to pin down but is an inevitable result of publishing outcomes for individual surgeons. Patients who have their surgery by the DCO route will have their surgery allocated to the Unit for the purposes of reporting of outcomes, rather than an individual surgeon.

From my vantage point as a thoracic surgeon the avoidance of the publication of individual surgical outcomes has been a real benefit. In 2013 somewhat out of the blue NHS England and HQIP wrote to the SCTS mandating publication of operative mortality after lung cancer surgery for individual surgeons, and there was an immediate concern that this would stifle the significant increase in the number of lung cancer patients treated with surgery as had occurred over the preceding five years or so. Surgery leads to more cures for patients who have lung cancer than any other therapy as does pushing the boundaries for resections, despite the recognised increase in post-operative complications and early deaths. Thankfully, after intense lobbying by the SCTS and also non-surgical colleagues in respiratory medicine, HQIP agreed that monitoring surgeons in this way was likely to be counterproductive for patients. This is why we monitor Unit outcomes only in thoracic surgery, along with the lung cancer resection rate as an illustration of the standard of care provided by Units.

DCO was discussed in depth at the March 2019 SCTS Annual General

9

Meeting in London. I was quite surprised at the range of opinion that the proposal generated. Some (mainly senior) surgeons were horrified at the thought of operating with a consultant colleague and quite amusingly suggested that the operation wouldn’t go as well as if they were to carry out the surgery themselves, as they would get in each other’s way! Quite reasonably there were questions about exactly which patients should be allocated to DCO, and suggested that the SCTS made definite and proscriptive recommendations. The possibility of “gaming” emerged, i.e. manipulation of the new system to hide poor performance by surgeons. We have since discussed this extensively within the SCTS Audit Committee and have decided not to make any instructions for DCO, other than that the decision should be made and recorded prospectively usually in an MDT setting, that the two surgeons should agree beforehand as to how the surgery should be carried out and that they should both be scrubbed for the majority of the operation.

DCO surgery will be audited over the years and I am sure there will be differences as to how it applied, as adult cardiac surgical Units vary significantly in their size, their subspecialty expertise and their consultant workforce. It seems likely that the overall profile of patients will change as more highrisk patients are subjected to surgery as a result of DCO being applied, but as long as this translates into better long-term outcomes then this will be a positive development for our specialty and our patients. n

the 10 bulletin

The SCTS website Time for a change Narain Moorjani, Honorary Secretary

W

ith the constant evolution of all the activities of the SCTS, it is more important than ever for the Society to be able to communicate effectively with its members. In addition to email and social media platforms, such as Twitter and Facebook, the SCTS website remains the main focal point of interaction for both patients and professionals with the Society, as well as being the primary mode to allow members to have a firm understanding of the society’s functions and the opportunity to get involved.

In response to comments from patients and cardiothoracic surgical practitioners, we are planning a major overhaul of the current SCTS website. A lot of work has been done to develop the current website, notably from John Butler and the SCTS Administration Team, for which we are very grateful. All agree, however, that it is now time for a significant change and it is with their support that we seek to progress the current website.

Whilst retaining some of the broader principles, the current website will be redeveloped in terms of style, functionality and content. As well as details about the SCTS itself, the website will be divided into areas for patients and professionals. The professionals’ area of the website will be further sub-divided into sections, which predominantly mirror the subcommittee infrastructure of the SCTS, on Adult Cardiac Surgery, Thoracic Surgery, Congenital Cardiac Surgery, Audit, Education, Research, Publications and Resources, Annual Meeting and one dedicated for Nursing & Allied Health Professional members of the specialty. A brief overview of each section is described here:

l Activities

The SCTS

l Clinical

l About

the SCTS – principles, aims, history and constitution of the SCTS, responsibilities of the Trustees, past presidents, contact details for the SCTS and information on the SCTS Administration and Executive members.

of the SCTS – educational courses & fellowships, SCTS meetings & conferences, publications and interaction with other societies, associations and government organisations.

l Membership

Categories – annual subscriptions and joining fees for the different SCTS membership categories, benefits of membership and application form.

l Executive

Committee & Sub-Committees – overview of the SCTS sub-committees, current members and terms of reference.

l Board

of Representatives (BORS) – terms of reference, current unit representatives and presentations from previous BORS meetings.

l Lifetime

Achievement Awards – previous recipients with a short synopsis of their contribution to cardiothoracic surgery.

Patients l Cardiothoracic

Surgical conditions and operations – patient information sheets and videos.

l Patient

Journey – outpatient visit, preassessment clinic, preparation for surgery (including cancellations & delays), hospital stay (including the intensive care unit), discharge planning, expectations following discharge (including physiotherapy, rehabilitation, driving and returning to work), follow-up and post-operative medications.

l Support

Groups – contact details of national and local support groups, and the SCTS Lay Representative.

Outcomes – linked to the Audit section of the SCTS website by surgeon and unit, as appropriate.

l Find

a Cardiothoracic Surgeon – search by name, hospital or region, with photograph, biography and outcomes of the surgeon available, as appropriate.

Adult Cardiac Surgery l Service

development – best practice and quality improvement projects (such as Day of Surgery Admission (DOSA) programme and Enhanced Recovery after Cardiac Surgery (ERAS) project), and introduction of evolving technology and techniques (such as minimally invasive mitral valve surgery, endoscopic saphenous vein harvesting and aortic valve repair), with protocols and business cases available.

l Practice recommendations and guidelines –

national recommendations (National Institute for Health and Clinical Excellence (NICE) guidance, NHS England Cardiac Surgery Service Specification, Cardiothoracic Surgery Getting It Right First Time (GIRFT) report and national trauma guidelines); international practice guidelines (from North America and Europe on myocardial revascularisation, valvular heart disease, thoracic aortic disease, atrial fibrillation and heart failure); and recent important trials and Cochrane reviews that help guide contemporary clinical practice (such as the ART trial and PARTNER 3 trial). l Education – videos pertaining to contemporary

clinical cardiac surgical practice, including SCTS-Ionescu University cardiac surgery videos and an advanced operative techniques video library (such as collections of videos on aortic valve repair, complex mitral valve repair, aortic arch and descending aortic surgery and minimally invasive cardiac surgery), as well access to the most popular cardiac surgery, cardiology and medical journals. There would also be links to the Education section of the SCTS website (see below) to gain access to the training courses and travelling fellowships provided by the Society. l Research

– ongoing cardiac surgical trials internationally, as well as those being run nationally through the Heart Surgery Priority Setting Partnership and Cardiothoracic Interdisciplinary Research

August 2019

Network (CIRN), such as on Surgical Site Infection (SSI), with a link to the Research section of the SCTS website. l Surgical

outcomes – link to the Audit section of the SCTS website, with outcome data available by unit and surgeon, as well as EuroSCORE and STS risk calculators.

Thoracic Surgery Similar format as Adult Cardiac Surgery section.

Congenital Cardiac Surgery Similar format as Adult Cardiac Surgery section.

Education l Ionescu Legacy – tribute to Mr Marian Ionescu. l Courses

– calendar, dates, programmes, course directors, registration, feedback, course material and location map of the venue.

l Fellowships

– advertisement, application form and list of previous winners (including reports and videos).

l SCTS-Ionescu

University – most recent and previous years’ programmes (including videos).

l SCTS

Education Operative video prize – list of videos to be created, list of previous winners (including videos) and operative video library.

l Guidance

& Support – bullying & harassment, international fellowship database of previous trainees, Gold Guide, JCIE Exam application process, ARCP and CCT application, regional training programme reports, JCST Cardiothoracic Surgery Curriculum and National Selection.

l National

Student Engagement Programme for Cardiothoracic Surgery.

l SCTS

Accreditation of non-SCTS Cardiothoracic Surgery Training courses – guidance, application form and fee structure.

Audit l National clinical outcome data – presented at

unit and surgeon specific level, as appropriate, for adult cardiac surgery, thoracic surgery, congenital cardiac surgery and trans-catheter aortic valve implantation (TAVI). l National

audit reports - Cardiothoracic Surgery Getting It Right First Time (GIRFT) Report, Combined National Institute for Cardiovascular Outcomes Research (NICOR) National Cardiac Audit Programme (NCAP) report, Lung Cancer Clinical Outcomes Publication (LCCOP) report, NHS Blood and Transplant (NHSBT) Cardiothoracic

Transplantation Report and NHSBT Mechanical Circulatory Support Report. l Blue

books – Cardiac Surgery and Thoracic Surgery blue book publications.

l SCTS

guidance – high risk MDT & dual consultant operating, consultant outlier policy and Picker report.

Research l SCTS

driven nationally coordinated clinical trials in Cardiothoracic Surgery through the Heart Surgery Priority Setting Partnership (PSP) and Cardiothoracic Interdisciplinary Research Network (CIRN), such as on Surgical Site Infection (SSI).

l SCTS

National Research Meeting – most recent and previous years’ programmes (including presentations), registration and location map of the venue.

l Ongoing

major clinical trials in cardiothoracic surgery – such as the UK mini-mitral trial and the CoMICS trial.

Nursing AHP l SCTS

Annual Meeting CT Forum – most recent and previous years’ programmes (including presentations and abstracts).

l Courses

– calendar, dates, programmes, course directors, registration, feedback, course material and location map of the venue.

l Fellowships

– advertisement, application form and list of previous winners (including reports and videos).

l Nursing

and Allied Health Professional Research Group (NARG) – current members, research opportunities, research support directory and resource library.

l Cardiothoracic

Interdisciplinary Research Network (CIRN) – current members, unit representatives and ongoing projects.

l Patient

Liaison Groups – such as Heart Valve Voice (HVV) and Aortic Dissection Awareness patient association.

l Nursing

and allied health professional workforce – current status and opportunities for the future.

Annual Meeting l Forthcoming

Annual Meeting, SCTSIonescu University and CT Forum – dates, programmes, registration details, location map of the venue, accommodation and abstract submission.

l SCTS

Annual Meeting – previous years’ programmes (including presentations and abstracts).

11

l SCTS-Ionescu

University – previous years’ programmes (including presentations).

l SCTS

Annual Meeting CT Forum – previous years’ programmes (including presentations and abstracts).

Publications & Resources l SCTS

Bulletin – current and previous

issues. l Perspectives

(SCTS-Ionescu University) – current and previous editions.

l Cardiothoracic

Surgery Journals – access to contemporary cardiothoracic surgery, cardiology, respiratory and medical journals, such as the Journal of Thoracic and Cardiovascular Surgery, Annals of Thoracic Surgery, European Journal of Cardio-Thoracic Surgery, Circulation, Chest, New England Journal of Medicine and the Lancet.

l Cardiothoracic

Surgery books – links to purchase textbooks (such as Cardiac Surgery in the Adult, Shields’ General Thoracic Surgery), revision books (such as Key Questions in Cardiac Surgery, Core Topics in Thoracic Surgery) and popular books (such as Fragile Lives and the Naked Surgeon).

l SCTS

Publications – Workforce Report, Cardiac Surgery Blue Books, Thoracic Surgery Blue Books and Maintaining patients’ trust: modern medical professionalism.

l Professional

Guidance – High risk MDT & Dual Consultant Operating, Team working & professional behaviours, Invited review mechanism – lessons learnt, Job planning, Revalidation and Clinical Excellence Awards.

l Support

– information and contacts for support of those beginning as a newlyappointed consultant, working less than full time, returning to work after maternity leave or requiring mentoring following a period of adverse outcomes.

l Royal

College of Surgeons Good Practice Guidance – Good Surgical Practice, Consent: Supported Decision-Making, Duty of Candour, High Performing Surgical Team, Surgical Leadership and Mentoring.

Whilst this article provides an overview of some of the planned content for the SCTS website moving forward, we would value your feedback. Please let us know if you have any suggestions or requests for the website or if you would like to get involved. n

the 12 bulletin

Presidents of the Society since 1934 1934

Mr H Morrison Davies

1980

Mr J R Belcher

1936

Mr J R H Roberts

1981

Mr M Bates

1938

Mr A Tudor Edwards

1982

Mr J M Hill

1945

Mr J B Hunter

1983

Mr J F Dark

1947

Mr W M Anderson

1984

Mr D N Ross

1948

Mr R B Purse

1985

Mr M Paneth

1950

Mr A Graham Bryce

1986

Mr M V Baimbridge

1952

Sir C Price Thomas

1987

Sir K Ross

1954

Mr H Reid

1988

Professor W H Bain

1956

Mr B Dick

1989

Mr W G Williams

1958

Sir R Brock

1991

Professor D I Hamilton

1959

Mr G A Mason

1992

Professor G H Smith

1961

Sir T Holmes Sellors

1994

Mr B Ross

1963

Mr R F J Henry

1995

Mr J Bailey

1964

Mr N R Barrett

1996

Professor H Matthews

1966

Mr V C Thompson

1997

Professor D Wheatley

1968

Mr P R Allison

1999

Mr J Dussek

1969

Mr A L d’Abreu

2000

Mr J Monro

1970

Mr A Logan

2002

Mr C Hilton

1971

Mr O S Tubbs

2004

Mr P Magee

1972

Mr F R Edwards

2006

Professor Sir B Keogh

1973

Mr J L Collis

2008

Mr L Hamilton

1974

Mr R H R Belsey

2010

Professor D Taggart

1975

Mr R S Barclay

2012

Mr J Roxburgh

1976

Mr W P Cleland

2014

Mr T Graham

1977

Mr H R S Harley

2016

Mr G Cooper

1978

Mr R Abbey-Smith

2018

Mr R Page

1979

Mr R P Moore

August 2019

13

SCTS Executive and Sub-committees Executive

Representative

Term of Office

Audit

Representative

Term of Office

Meeting

Representative

Term of Office

President

Richard Page

2018

2020

Co-chair

Doug West

2019

2022

Meeting Secretary

Maninder Kalkat

2019

2021

Executive co-chair

Simon Kendall

2018

2020

Cha Rajakaruna

2019

2023

Cardiac Lead

Uday Trivedi

2019

2022

Deputy Meeting Secretary

Thoracic Lead

Doug West

2019

2022

Clinton Lloyd

2019

2020

Congenital Lead

Carin Van Doorn

2019

2022

Associate Meeting Secretary

Nursing & AHP Representative

Julie Sanders

2016

Nursing & AHP Representative

Daisy Sandeman

2019

2022

CO: NICOR Representative

Andrew Goodwin

Conference organiser

Isabelle Ferner

Exhibition organiser

Tilly Mitchell

Nursing & AHP

Representative

Term of Office

Congenital

Representative

Term of Office

Chair

Helen Munday

2017

2022

Co-chair

Rafael Guerrero

2019

2022

Meeting Lead

Daisy Sandeman

2019

2022

Executive co-chair

Richard Page

2018

2020

Cardiac Lead

Helen Munday

2017

2022

Appointed Member

Chuck McLean

2019

2022

Thoracic Lead

Amanda Walthew

2016

2021

Appointed Member

Andrew Parry

2019

2022

Congenital Lead

Karen Byrne

2016

2021

Audit Lead

Carin Van Doorn

2019

2022

Education Lead

Attilio Lotto

2019

2022

Nursing & AHP Representative

Karen Byrne

2016

2021

President Elect

Simon Kendall

2018

2020

Honorary Secretary

Narain Moorjani

2018

2023

Treasurer

Amal Bose

2019

2024

Meeting Secretary

Maninder Kalkat

2019

2021

Elected Trustee 1

Stephen Clark

2017

2020

Elected Trustee 2

Mahmoud Loubani 2018

2021

Elected Trustee 3

Marjan Jahangiri

2018

2021

Elected Trustee 4

Carin Van Doorn

2019

2022

Elected Trustee 5

Mobi Chaudhry

2019

2022

Lay Representative

Sarah Murray

2019

2022

Education Secretary

Sri Rathinam

2016

2021

Senior Trainee Rep

Duncan Steele

Junior Trainee Rep

Abdul Badran

2016

2019

Audit

Julie Sanders

2016

2021

Nursing & AHP Rep

Helen Munday

2017

2022

Education

Tara Bartley

2016

2021

Perfusion Rep

Phil Botha

2017

2020

Education

Bhuvana Bibleraaj

2016

2021

Trainee Representative Joseph George

2019

2022

Perfusion Rep

Chris Efthymiou

2019

2022

Research

Julie Sanders

2016

2021

Deputy Audit Lead

2019

2022

Patient Liaison

Chrissie Bannister

2016

2021

CO: Representatives of units not covered by above positions

Thoracic

Representative

Term of Office

Research

Representative

Term of Office

Serban Stoica

Co-opted Members of Executive

Representative

Term of Office

Thoracic Committee

Steve Wooley

2019

2022

Co-chair

Steve Woolley

2019

2022

Co-chair

Gavin Murphy

2015

2020

Congenital Committee

Rafael Guerrero

2019

2022

Executive co-chair

Narain Moorjani

2018

2020

Executive co-chair

Richard Page

2018

2020

Appointed Member

Juliet King

2019

2022

Cardiac Lead

Mahmoud Loubani 2015

2020

Appointed Member

Kandadai Rammohan

2019

2022

Thoracic Lead

Eric Lim

2015

2020

Appointed Member

Babu Naidu

2019

2022

Congenital Lead

Massimo Caputo

2015

2020

Audit Lead

Doug West

2019

2022

Serban Stoica

2019

2022

Education Lead

Sri Rathinam

2016

2019

Deputy Congenital Audit Lead

Nursing & AHP Representative

Amanda Walthew

2016

2021

Nursing & AHP Representative

Julie Sanders

2016

2021

2017

2020

Trainee Representative Thomas Theologou 2018

2021

Audit Committee

Doug West

2019

2022

Research Committee

Gavin Murphy

2015

2020

SAC Chairperson

Rajesh Shah

2016

2019

Ex-Officio Members of Executive

Representative

Term of Office

Chair of InterCollegiate Board

Rana Sayeed

Cardiothoracic Dean

Jonathan Hyde

2014

2019

Thoracic Tutor

Carol Tan

2016

2021

Cardiac Tutor

Sunil Bhudia

2016

2021

2019

2022

Trainee Representative Thomas Tsitsias

CO: SAC Representative Steve Clark

CO: British Thoracic Society

David Baldwin

CO: NICOR Rep

Andrew Goodwin

CO: Commissioning Lead

John Duffy

CO: ACL Representative

Marius Roman

Richard Steyn

CO: Associate Surgical Specialty Lead

Luke Rogers

CO: Associate Surgical Specialty Lead

Ricky Vaja

Communications

Representative

Term of Office

Cardiac

Representative

Term of Office

CO: Trauma Representative

Co-chair

Marjan Jahangiri

2018

2021

Education

Representative

Term of Office

Executive co-chair

Simon Kendall

2018

2020

Co-chair

Sri Rathinam

2016

2021

Appointed Member

Chris Satur

2019

2022

Executive co-chair

Narain Moorjani

2018

2020

Appointed Member

Steven Billing

2019

2022

Cardiac Tutor

Sunil Bhudia

2016

2021

Website design

John Butler

2016

2021

Thoracic Tutor

Carol Tan

2016

2021

Website design

Clinton Lloyd

2019

2024

Congenital Lead

Attilio Lotto

2019

2022

Publications

Indu Deglurkar

2018

2023

Nursing & AHP Representative

Bhuvana Bibleraaj

2016

2021

Professional Standards Representative

Term of Office

Trainee Representative Sudeep Das De

2018

2021

Co-chair

Sarah Murray

2019

2022

Consultant Lead

Donald Whitaker

2017

2020

Non-NTN Lead

Uday Dandekar

2018

2021

Executive co-chair

Simon Kendall

2018

2020

Medical Student Lead

Aman Coonar

2018

2021

Nursing & AHP Representative

Helen Munday

2017

2022

Accreditation Lead

Mahmoud Loubani 2018

2021

Appointed Member

Doug West

2018

2021

Appointed Member

Shakil Farid

2019

2022

Audit Lead

Uday Trevedi

2019

2022

Education Lead

Sunil Bhudia

2018

2021

Nursing & AHP Representative

Helen Munday

2017

2022

Trainee Representative Jonathan Afoke CO: NICOR Audit Lead

Andrew Goodwin

CO: UK Aortic Surgery

Geoff Tsang

2019

2022

83rd Annual SCTS Meeting and Ionescu University, QEII Centre London Maninder Kalkat, SCTS Organising Committee

T

he 83rd Annual SCTS Meeting, Nursing & AHP CT forum and SCTS-Ionescu University was held at the Queen Elizabeth II Conference Centre. The venue, located in the heart of London, is surrounded by historic buildings including Westminster Abbey, the Houses of Parliament and the Thames river which was much appreciated by the attendees.

Nearly 1200 delegates and members of industry participated in the meeting held from 10th to 12th March 2019 and educational content was delivered by national and international experts in the field of Cardiothoracic Surgery. The number of high-quality abstracts accepted for the meeting required addition of few parallel sessions and extended the meeting by half a day. Building on the success of the previous meeting, a simulation session for minimally invasive surgery ran over two days and was well attended.

The plenary session was held in the magnificent Churchill auditorium and was packed to capacity. The patient’s perspective on adult congenital heart disease was particularly poignant and demonstrated the high quality service provided by dedicated teams of individuals working collaboratively.

The life-time achievement award was presented to Prof Marc de Leval which he graciously accepted. The acknowledgment

by Eric Lim of the contributors to the VIOLET study was an encouraging gesture.

The student engagement session led

by Aman Coonar has expanded further by the inclusion of sixth formers and allowing participation in the Wet lab. It was heartening to see young students getting engaged, stimulated and interested in pursuing a career in the speciality.

The gala dinner at the Shakespeare Underglobe theatre, with its sweeping

staircase, high ceiling and built-in stage was a highlight of the meeting. The sit-down meal was interspersed with acts from Shakespeare plays and was followed by music and dance.

Gratitude and congratulations are due to the meeting secretary Clinton Lloyd, an embodiment of grit and determination who single-handedly, literally, having injured his arm, organised and delivered a successful meeting. He was of course assisted by the

efforts of Isabelle Ferner, Tilly Mitchell, Helen Munday and a team of other dedicated individuals. Cha Rajakaruna and Daisy Sandeman have joined the team of organisers and are gearing up to give a spectacular show at ICC Wales in March 2020. n

Abstract Submission open on 1st September.

For further details, go to www.scts.org

“Nearly 1200 delegates and members of industry participated in the meeting held from 10th to 12th March 2019.”

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Nursing and Allied Health Professional update Helen Munday, SCTS Nursing and AHP Representative

A

s the Brexit uncertainty continues to dominate the headlines, one could be forgiven for losing sight of all the other things that have been happening in the first half of 2019, but for those of us working in the NHS, it’s been a busy time. The (delayed) launch of the NHS Long Term plan happened, a new president of the Royal College of Nursing began her term of office, a new chief nursing officer for England took up her position in the newly formed NHS Executive Group, a new NMC chief executive and registrar took over from the interim chief executive and the NMC opened the register to nursing associates. And that was just in January!

More recently, Royal Papworth Hospital completed a three-week move to one of the largest life science clusters in the UK at the Cambridge Biomedical Campus, alongside the Laboratory for Molecular Biology and AstraZeneca’s corporate headquarters and research and development centre. The move has been widely anticipated for many years and promises to offer cutting-edge technology to cardiothoracic patients.

However, there can be little doubt (in my mind anyway!) in what the major highlight and talking point was for the year so far…… the SCTS Annual Meeting and CT Forum at the QEII centre, in the heart of London. Not only did delegates have access

to a varied scientific programme, but they were also treated to a ringside view of all the guests and dignitaries (including most senior members of the British royal family) arriving at Westminster Abbey for The Celebration of the Commonwealth Service. A real spectacle of London at its best, and all the more special for our international guests and faculty colleagues.

Keen eyed television viewers will have spotted the SCTS banners waving outside the conference centre as the Queen was captured on camera. What brilliant publicity!

The CT Forum followed a format that has proved successful and popular over the past few years with a practical, hands-on university day on the Sunday followed by a two-day programme of plenary speakers and abstract presentations.

The cardiac and thoracic wet-lab and skill stations at the CT Forum university day continue to receive highly positive and favourable feedback. Participants have the opportunity to gain a greater understanding of cardiac anatomy and practice surgical techniques on animal tissue, as well as refresh their knowledge of various clinical treatments and diagnostic investigations such as cardiac pacing, angiogram interpretation, ultrasound and CT imaging. As always, this day would not be possible without our expert teaching faculty and the support from Kevin Austen at Wetlabs. We are enormously grateful to everyone for their hard work AHP CT Forum Wetlab faculty and commitment. >>

the 16 bulletin

SCTS-Ionescu Nursing and Allied Health Professional Fellowships 2019 We are enormously grateful to Mr Marian Ionescu for his overwhelming generosity in supporting nursing and AHP travel fellowships. All associate members of the SCTS are eligible to apply to support a visit to a cardiothoracic centre(s) or other educational opportunity, which enhances the experience of the applicant to further their career in the cardiothoracic surgery specialty. The fellowship can be used for further development of clinical skills, management, leadership skills or service improvement and applicants are expected to demonstrate how their fellowship will enhance the specialty of cardiothoracic surgery and the wider NHS. Successful nursing and AHP applicants (in no particular order) this year are: Amy Millichope and team from University Hospitals of Birmingham to visit multiple aortic centres in the USA, Europe and UK. Jonathan Johnston and team from Royal Sussex Hospital Brighton to learn about near patient ultrasound in the UK and Udine, Italy.

Michelle Gibb and team from University Hospitals of Leicester to visit various centres in UK and Ireland to focus on enhanced recovery and nurse led services.

Kathyrn Smith from New Cross Hospital Wolverhampton to visit the aortic unit at Penn Heart and Vascular Centre, Pennsylvania USA.

One of the wet lab stations

The subsequent two days were a mix of abstract presentations and plenary talks from invited speakers under the following themed sessions; cardiac, thoracic, research, quality and safety, transplant reflections, health and well-being and ERAS. There were so many outstanding talks, audience participation, questions and discussions that I hope delegates will be encouraged to submit abstracts for the 2020 meeting in Cardiff. Abstract submission will open in early September for two months, closing on 5th November. It is the intention of the programme committee to try to encompass something for everyone within the content of the Forum meeting, but

if you feel that your specialty or area of work is under-represented, please do contact me so that we can address this. Suggested themes for next year so far are, cardiac surgical care practitioners, human factors and nursing associates. I am particularly keen to hear from allied health professionals to know what you would like included in the programme.

The prize for the best Forum presentation this year went to Amy Barter from Brighton and Sussex Medical School for “Enhanced recovery after surgery (ERAS) improves outcomes in coronary artery bypass graft (CABG) patients.�

Congratulations Amy!

Julie Sanders from Barts Health to visit Ryerson University, Toronto General Hospital and the University of Pennsylvania to explore how international centres have developed NAHP cardiothoracic research and to explore opportunities for collaboration.

Rosalie Magboo from Barts Health to visit Ryerson University and Toronto General Hospital to develop collaborative research on the care of patients with Marfan Syndrome.

Louise Wyllie-Lau from Nottingham University Hospital to visit the Heart and Vascular Institute at Maimonides Medical Centre in New York, USA to learn more about patient treatment pathways and follow up processes for management of atrial fibrillation (AF) in designated AF clinics.

August 2019

17

Alison Woolley from Kings College Hospital to visit the Miller Family Heart & Vascular Institute in Cleveland USA to gain insight and ideas around patient education and support, sharing information between hospitals and workforce development.

Trudy Elliott from University Hospital Southampton to visit the North West Heart Centre at Manchester University NHS Foundation Trust to observe their scheme to detect early lung cancer.

I would urge readers to keep an eye out for future opportunities which will be emailed to all members and advertised on the SCTS website www.scts.org Please share notice of this opportunity with colleagues who might not yet be members of the Society. Associate membership is the only pre-requisite to applying for a travel fellowship.

Research Nursing and Allied Health Professional Research Group (NARG) A breakout session for the NARG was held during the annual meeting but unfortunately this was at the end of the day on the second day so was not well attended. The programme committee will aim to schedule this at a more accessible time next year. All associate members of the SCTS are invited to join the NARG, led

by Professor Julie Sanders (SCTS Nursing & AHP Research Lead). Its purpose is to support the development of nursing and AHP-led research, share expertise and highlight research and funding opportunities. There is a dedicated webpage (https://scts.org.narg/) for SCTS members to access a research support directory and an emerging resource library.

Cardiothoracic Interdisciplinary Research Network (CIRN) This research network was setup in 2019 by the SCTS Research Sub-Committee and is led by Professor Julie Sanders, Luke Rogers and Ricky Vaja (RCS Associate Surgical Specialty Leads). The CIRN aims to have a member in each cardiothoracic surgical unit in the UK, with a remit is to deliver a portfolio of multi-centre clinical trials, the first of which is to focus on surgical site infections. Work is on-going with the West

Tanya Usher from Barts Health Trustdiscussing rehabilitation in critical care and quality of life outcome measures

“The CT Forum followed a format that has proved successful and popular over the past few years with a practical, handson university day on the Sunday followed by a two-day programme of plenary speakers and abstract presentations.�

Midlands Research Collaborative to finalise Associate PI status for nurses and AHPs (and junior doctors) on CIRN trials.

3rd SCTS National Research Meeting: Glenfield Hospital Leicester, LE3 9QP Saturday 2nd November 2019 Planning for the 2019 SCTS national research meeting is underway and this is a fantastic opportunity for nurses and AHPs to showcase their research. Registration for the meeting is FREE - to register contact scts@le.ac.uk Structured abstracts (250 words) can be submitted by email to the address above before 31st August 2019.

The prize for the Thoracic Oral Session in 2018, was awarded to Zoe Barrett-Brown,

Team Leader Physiotherapist for Thoracic Surgery at Royal Papworth Hospital. Not only was this a fantastic achievement for Zoe, but it clearly illustrated the value and contribution from nurses and AHPs at research meetings.

Congratulations Zoe! n For more details about any of the above, or for more information about the SCTS, please do not hesitate to contact me, details below.

Helen Munday Matron - CT Surgery & Respiratory Medicine Barts Health NHS Trust Direct Line: 0203 465 6503 Mobile (Work): 07810 655 358 Email: Helen.Munday@bartshealth.nhs.uk Email: h.munday@nhs.net

the 18 bulletin

SCTS AHP Education portfolio Tara Bartley & Bhuvana Krishnamoorthy, SCTS Allied Health Professional Education Leads

SCTS Annual meeting CT Forum The morning began with a new venture.

In amalgamation with the Medical student day, for the first hour we welcomed fifty ‘would be’ cardiothoracic surgeons to experience the wetlab stations. They were very engaged with a lot of smiling faces and positive feedback.

Following this we had almost 150 nursing & AHPs attend the day with a faculty of 20 colleagues. The morning hands-on sessions were predominantly cardiac, followed by thoracic sessions in the afternoon. We would like to thank our colleagues in Industry for supporting the day, Ethicon, Abbott, Kevin Austin.

“Our two new courses, the non-medical prescription and theatre practitioner course have been the highlight of the year with very good feedback.”

Notable events in 2019 AHP Education courses The SCP Revision course, 27th and 28th January 2019 Surgical Skills course for SCP, 15th February 2019

Cardiothoracic surgical training courses

SCTS University Wetlabs, 10th March 2019

Our nursing and AHP portfolio consist of a variety of educational courses that run throughout the year. The majority of courses were held at Abbott teaching centre in Solihull. We have established a colligate working relation with Abbott and Kevin Austin, our thanks go to them for ensuring we are able to continue delivering the Allied Health Professionals Education portfolio.

The SCTS educational team also contributed to the programme Nurses & AHP at the European Association for Cardiothoracic surgery annual meeting in Milan 2018 and the Society of Thoracic Surgeons Annual Meeting in Florida, January 2019. Presenters from the UK and Ireland were able to showcase their work.

The 33rd EACTS 2019 meeting is to be held in Lisbon in October, with the Nurses and AHP Post graduate day on 5th October. The call for abstracts is currently open, closing on 31st July.

If you would like to submit your work with the opportunity to join us in Portugal go to the following link: https://www.eacts.org/annual-meeting/ education-meeting/alliedhealth/

SCTS Advanced Cardiothoracic two-day Course to run in Autumn 2019

SCTS Non-Medical Prescribing one day course, 13th April 2019 SCTS Core Skills three day Course to run in Autumn 2019 Theatre surgical course to run in August 2019 SCTS Educational input at EACTS, 3rd – 5th October 2019 Lisbon, Portugal SCTS Educational input at STS, January 2019 Joint RCSEd & SCTS SCP examination

Plans for 2019/20 Surgical skills course, January 2020 Revision course, January 2020 SCTS University Wetlab CT forum, March 2020 Further dates to be confirmed for our other AHP course: SCTS Advanced Practitioner course, SCTS Core skills course, SCTS Non Medical Prescribing course, SCTS Theatre course Our two new courses, the non-medical prescription and theatre practitioner course have been the highlight of the year with very good feedback. Both have proved interactive days with a high caliber of lectures that delegates have enjoyed and

stated has impacted on the care they deliver and knowledge they are able to share with their colleagues. If you would like to be involved in these or any of the other courses we deliver, then please contact Tara or Bhuvana via the SCTS office. n

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the 20 bulletin

SAC report Rajesh Shah, SAC Chair Cardiothoracic Surgery

I

am pleased to report the SAC has been granted conditional approval for the curriculum change by the GMC, which means we will be moving to the new curriculum in August 2020.

This is a significant achievement and reflects the hard work and commitment of the SAC. Below are some of the changes which are summarised.

Introduction The Cardiothoracic Surgery curriculum will provide Consultant Surgeons with the generic professional and specialty-specific capabilities needed to manage patients presenting with the full range of acute cardiothoracic conditions up to the point of operation, and to manage the full range of acute and elective conditions in the generality of their chosen special interest of Cardiac or Thoracic Surgery, including the operation.

Trainees will be entrusted to undertake the role of the general Cardiothoracic Registrar during training and will be qualified at certification to apply for consultant posts in Cardiothoracic Surgery in the United Kingdom or Republic of Ireland, with a special interest in Cardiac or Thoracic Surgery.

than time-based. It will, however, normally be completed in an indicative time of 7 years (3 years phase 1, and 2 years phase 2, and 2 years in phase 3 for those entering run through training (formerly 8 years in the 2015 curriculum).

For uncoupled trainees, who will have already spent 2 years as a core surgical trainee, it will normally be completed in an indicative time of 6 years (2 years in phase 1, and 2 years in phase 2, and 2 years in phase 3).

The programme will be divided into 3 phases (Figure 1): Phase 1 Phase 1 will take an indicative time of 3 years to complete for run through trainees, during which trainees will gain many of the GPCs and the knowledge, clinical and technical skills in both

trainees will demonstrate competencies in knowledge, clinical skills and professional behaviours commensurate with the CiPs and defined syllabus.

By the end of phase 1, trainees will follow a special interest in either Cardiac or Thoracic Surgery after discussion with their Training Programme Director (TPD). In exceptional cases, and with specific TPD and Deanery / LETB support, Cardiothoracic Surgery may be chosen as the special interest. Trainees will need careful counselling before following this route as it is likely to require extra training time.

Phase 2 Phase 2 will take an indicative time of 2 years to complete, during which trainees will train predominantly in either Cardiac or Thoracic Surgery with the exception of a small number who may train in Cardiothoracic Surgery to fulfil local requirements.

During phase 2 of training, it is expected that trainees will continue to be involved in the care of both cardiac and thoracic patients whilst on call to continue gaining the knowledge and clinical skills in the generality of Cardiothoracic Surgery.

To apply for a first sitting of the Joint Committee Intercollegiate Exam in Cardiothoracic Surgery, a trainee will need to have demonstrated the knowledge, clinical and professional skills equivalent of a day one consultant in Cardiothoracic Surgery as defined by the syllabus. It is anticipated that all trainees will reach this level by the end of phase 2.

“To perform a high level clinical task as a Consultant Surgeon requires trainees to be able to integrate areas of learning from all parts of the syllabus, including knowledge, clinical, professional and technical skills.�

Training Pathway Trainees will enter Cardiothoracic Surgery training via a national selection process following foundation training for run through or following core training for uncoupled programme. Cardiothoracic Surgery training is outcome-based rather

Cardiac and Thoracic Surgery, as defined in the CiPs and syllabus. Uncoupled trainees should have acquired generic skills, both technical and non-technical, during core training, and it is anticipated that an indicative time of 2 years after entry into cardiothoracic training will be required to achieve competencies required for completion of phase 1. At the end of phase 1, there is a critical progression point for phase 2 entry, assessed at the Annual Review of Competence Progression (ARCP), where

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Figure 1: Cardiothoracic Surgery training pathway

Training in Congenital Cardiac Surgery will be available after the end of phase 2 for a small number of trainees, who will be able to apply through a national selection process after passing the Intercollegiate Board Exam in Cardiothoracic Surgery.

Training in the subspecialty of Congenital Cardiac Surgery will take an indicative time of 2 years.

Phase 3 During phase 3 (indicative time 2 years) of training, it is expected that trainees will continue to be involved in the care of both cardiac and thoracic patients whilst on call to continue gaining the knowledge and clinical skills in the generality of Cardiothoracic Surgery. Trainees will continue to develop GPCs and knowledge, clinical and technical skills in their special interest as described in the CiPs and the syllabus. On successful completion of phase 3, including successful completion of the Intercollegiate Specialty Board Examination, trainees become eligible for Certification and for recommendation to enter the specialist register.

High level Outcomes or Capabilities in Practice (CiPs) Training is designed to produce a person capable of safely and effectively performing the role of a first day consultant surgeon. The role of a Consultant Surgeon can be thought of as

a sum of all the various tasks which need to be performed through a working week.

These tasks are the high level outcomes of the curriculum and grouping these together describe the role of a Consultant Surgeon. To perform a high level clinical task as a Consultant Surgeon requires trainees to be able to integrate areas of learning from all parts of the syllabus, including knowledge, clinical, professional and technical skills. In addition, a surgeon will need to have acquired the generic skills, behaviours and values shared by all doctors in order to perform this task safely and well. A capability is a set of skills that can be developed through training from novice to expert and therefore these high level clinical outcomes are known as Capabilities in Practice (CiPs). They are common across all surgical specialties and are delivered within the context of the Generic Professional Capabilities and the specialty syllabus.

6) Manages patients within the critical care area 7) Assesses surgical outcomes both at a personal and unit level The generic knowledge, skills, behaviours and values shared by all doctors are described in the Generic Professional Capabilities framework (GPCs). The GPCs are essential components and have equal weight to the CiPs in the training and assessment of clinical capabilities and responsibilities in the training programme.

The nine domains of the GPC framework are: l

Professional values and behaviours

l

Professional skills

l

Professional knowledge

l

Capabilities in health promotion and illness prevention

l

Capabilities in leadership and team working

1) Manages an outpatient clinic 2) Manages the unselected emergency take 3) Manages ward rounds and the ongoing care of inpatients 4) Manages an operating list 5) Manages a multi-disciplinary meeting

l

Capabilities in patient safety and quality improvement

l

Capabilities in safeguarding vulnerable groups

l

Capabilities in education and training

l

Capabilities in research and scholarship

In addition to these, the specialty-specific Cardiothoracic Surgery capabilities in practice are:

There are minor changes in the assessment process with the introduction of Multiple consultant reports. n

The 5 CiPs are:

the 22 bulletin

Cardiac audit update Uday Trivedi, Adult Cardiac Surgery Audit Lead

H

aving taken over the role of Adult Cardiac Audit Lead, my first task is to thank David Jenkins for all the hard work he has done over the past six years. He has overseen a difficult transition within NICOR and its relocation to the BARTS site. David’s legacy will be the next edition of the Blue Book of which he will continue to have oversight until completion. This edition of the Blue Book will be a 15-year review of outcome trends in adult cardiac surgery.

Looking forwards, there are a two areas of outcome reporting that will be implemented from April 2019.

Firstly, the change in methodology for measuring mortality outcomes and identifying outliers and second is the process of implementing Dual Consultant Operating (DCO) for very high-risk/complex cases.

Those of you who attended the annual meeting this year will have heard about the decision made to move away from the outcome data being presented as traditional funnel plots and to present the data as Forrest plots. The decision to make this change resulted from an external review carried out by Professor Spiegelhalter and this new methodology will apply not just to cardiac surgery, but all other cardiac analyses carried out by NICOR e.g. PCI outcomes. The decision to change was debated amongst the statisticians and clinical and patient representatives. NICOR wish to analyse the data using a random effects model

rather than the standard analysis. There are pros and cons to moving over to the random effects model. The SCTS and BCS are working with NICOR to produce a summary document to explain to our members the principles behind the change and how to interpret the Forrest plots.

All consultants should have received the guidelines for DCO. The GIRFT report recommended that clinical outcomes for very high-risk and complex cases should be reported on a unit level. Based on the

Papworth model, the DCO guidance has been developed with the aim of providing a framework for units to develop their own systems to undertake high risk surgery, when it would be in the patient’s interest. All cases will have to be identified and discussed prior to surgery. There will be no retrospective allocation of a case to DCO. NICOR will monitor the percentage of cases being operated under this classification. It is expected that these operations will form a very small proportion of a unit’s caseload.

I cannot stress hard enough that the DCO system should not be abused as we risk having it pulled.

The rationale is to improve patient care by reducing riskaverse behaviour.

From April 2019, NICOR is able to capture the second consultant data, which will be the GMC number. There is also a new field relating to whether the case should be a unit case or not. All the database providers have been informed and are aware of the need to include these new fields into their datasets. This information has also been sent to all the respective unit audit leads along with the definitions relating to the additional data fields.

Having been in post for only a couple of months, I am still getting up to speed on many issues. Hence the short message. There is work to be done on publication of morbidity outcomes and the definition of ‘Emergency & Salvage’ cases. n

“Those of you who attended the annual meeting this year will have heard about the decision made to move away from the outcome data being presented as traditional funnel plots and to present the data as Forrest plots.”

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Thoracic surgery audit update Doug West, Thoracic Audit Lead and Audit Committee Chair

T

his year’s Society meeting in Westminster saw important personnel changes in the audit group. David Jenkins has completed his very successful tenure as adult cardiac surgery lead and audit chair, while David Barron stepped down after a similarly productive time as congenital cardiac lead.

The Society owes a debt to both for their leadership and hard work.

After a competitive interview process, Uday Trivedi has become the adult cardiac lead, while Carin Van Doorn is the new congenital lead. In addition, two new deputy roles have been created.

These new posts will allow for better SCTS representation in audit matters, Serban Stoica from Bristol and Ram Rammohan from Manchester have been appointed in the congenital and thoracic roles respectively.

In thoracic surgery, the LCCOP 2019 process is now well underway. After our annual review meeting with the National Lung Cancer Audit (NLCA) team, some changes have been agreed for this year’s report. 90-day survival will no longer be reported, leaving only 30 and 365-day survival. In recent reports, 30 and 90-day results have been highly correlated, weakening the argument for reporting both. Last year, 90-day all-cause readmission rates were reported for the first time. The rates reported were perhaps higher than expected, but a multicentre study, coordinated by the National Lung Cancer Forum for Nurses and presented at this year’s SCTS meeting provided some corroboration, also finding high readmission rates. This metric remains in for this year, and we encourage units to

reflect on the data and compare it to their internal data where possible. Reporting of resection rates will remain as last year, with a single summed rate for each unit.

LCCOP aims to improve outcomes for patients. In units with worse than expected outcomes, a process of formal reflection is required to identify areas for improvement.

At its conclusion, a formal outlier response is submitted to the SCTS and NLCA. Advice to outliers and a template for internal reviews and responses has been developed by the SCTS and NLCA to guide units through this process.

However, LCCOP also identifies results that are better than expected.

Identifying these high performing units and

Clinical Lead at Southampton, for his excellent talk at the SCTS thoracic audit session on how the Southampton team work together to achieve these outcomes.

The Society is keen to expand its role in disseminating best practice in future through LCCOP, GIRFT and similar quality improvement projects.

The Third Thoracic Database Report - the Blue Book - was circulated to members several months ago, and it key findings were presented at the SCTS thoracic audit session. It tells a positive story of innovation, increasing surgical activity and improved safety over the last three decades which Society members can take considerable pride in. We are currently working with the London College to disseminate the findings more widely.

Lastly, the Department of Health are increasingly interested in using routinely collected NHS to assess and report clinical quality. A foretaste of this approach can be seen in the Cardiothoracic Getting it Right First Time Programme. The SCTS itself has been a pioneer in this field; you can read about our collaboration with the RCSEng Clinical Evaluation Unit to report pneumothorax and pleural sepsis outcomes using routinely collected NHS data in the Blue Book. Representatives for the Society will be meeting with the Department of Health again in the next few months.

We hope that new resources beneficial to patients and the clinicians who serve them can be developed.

As always, please contact me directly if you have any questions or comments about the Society’s audit activities.

Email: doug.west@bristol.ac.uk n

“LCCOP aims to improve outcomes for patients. In units with worse than expected outcomes, a process of formal reflection is required to identify areas for improvement.” learning from them is potentially one of its most useful outcomes. Positive outlier status not only acknowledges outcomes significantly better than expected, but it allows other units to learn from them.

This year, teams in Norwich, Cambridge, Oxford and Coventry achieved positive outlier status in one or more of the LCCOP survival outcomes; congratulations to all on their achievements.

Although not one of the survival outcomes, the Southampton team have achieved unusually short lengths of stay in LCCOP since this metric was first reported. I’m grateful to Edwin Woo, the

the 24 bulletin

Congenital Cardiac Surgery Carin Van Doorn, Chair of the Congenital Committee

A

s I come to the end of my 3-year term as co-chair of the congenital cardiac subcommittee I take the opportunity to summarise the main events in congenital cardiac surgery over the last few years that will continue to influence the direction of travel of the speciality in the future.

After many years of political instability the dust about the national reorganisations of congenital cardiac services is finally starting to settle down. However, things have not yet been completely sorted.

Since 2016, we have an extensive set of National Standards for Service Delivery for Congenital Heart Disease, that need to be achieved latest by 2021.

One of these, the requirement for colocation with various other specialist services, has forced standalone congenital cardiac surgery specialist centres to relocate to multispeciality hospitals (or by now have advanced plans of doing so). This will particularly have an impact on the situation in London, where the Brompton Hospital is likely to move to the Guys and St Thomas’ site.

A standard that will be challenging to achieve for some units is a minimum of 125 Nicor reportable procedures/surgeon/ yr averaged over 3 years. By 2021, units are required to have at least 4 surgeons, and if all 10 current units were to remain open this would equate to a minimum of 5000 procedures/ yr for England only. However, Nicor reported total annual surgical activity combined for England (incl one private centre), Scotland and Ireland has been relatively static in recent times at between 5500 and 6000 procedures, and with some units doing well over 500 cases, it is difficult to see how every unit can meet this standard in the near future.

The number 125 is used as a (non-evidence based) measure of surgical expertise and there is on-going discussion about the suitability of this, as a simple ASD is given the same credit as a 4th time redo sternotomy for a multiple valve procedure.

Furthermore, newly appointed congenital surgeons nowadays will still have many months of double scrubbing with a senior colleague before they are independent operators, and currently the operation only counts towards one of the surgeons. As a result much discussion is going on about how exactly to count procedures. In this debate we should not forget, however, that the real question is about measurement of surgical expertise, and that we should continue to strive to develop better measures that reflect surgical dexterity, decision making and team working.

Over the last months a new programme of NHS England led clinical peer reviews has started to assess individual Congenital Cardiac Services, including their regional network. This is modelled on the cancer services where this has been in use for some years and has been defined as ‘a process for continuous quality improvement through self-assessment, enquiry and learning between teams of equivalent specialisation and knowledge’.

It is currently not clear how information gained from this process will be used in relation to achieving (or not achieving) compliance with the National Standards.

The national review of PICU and specialist surgical services is drawing to an end with further work to continue locally through newly established Regional Delivery Networks. From a congenital cardiac surgery perspective it had been hoped that the review would help to secure the necessary PICU beds required to deliver the required surgical throughput, but it has been disappointing in this respect. Instead paediatric cardiac surgical units will now need to make their own arrangements to

August 2019

ensure that adequate beds for cardiac surgery are available within their region.

The SCTS workforce report was published earlier this year, and showed that with regards to the congenital cardiac surgery consultant workforce it is estimated that approximately 15 to 20 new consultants will be required in the next decade based on expected retirement and centres expanding to 4 surgeons. However, over the last years, the take up of national trainees to subspecialise in congenital cardiac surgery has been low, with positions on the national training scheme remaining unfilled. Most consultant appointments over the last years have been overseas medical graduates who either were already fully trained abroad, or more often, had a period of fellowship in the UK prior to being appointed to an NHS consultant post. It is hoped that with more political stability and with larger congenital cardiac centres, congenital cardiac surgery will – once more – become an attractive career choice. In the meantime we also have to make sure that the overseas graduates that will continue to be needed for the NHS get adequate preparation and support to build on a successful career in the UK.

The theme for the Annual Meeting this year was congenital cardiac surgery – no

25

“It is hoped that with more political stability and with larger congenital cardiac centres, congenital cardiac surgery will – once more – become an attractive career choice.” doubt others will also reflect on this in other parts of this Bulletin. Compared to the other subspecialities in cardiothoracic surgery, congenital cardiac surgery is a life-time disease. The presentation by Adrian Chester, a patient and scientist with a single ventricle who initially underwent palliative surgery, followed later by transplantation illustrated this in a very powerful way. The presentation from Jo Quirck, cardiac liaison nurse, illustrated the very different and age-specific needs of patients throughout their life. Finally, we had the opportunity to honour Marc de Leval, one of the pioneering congenital cardiac surgeons, scientists, and trainers. It was an excellent session and inspiring session.

As said at the beginning of this article, I have come to the end of my three year term as the co-chair of the subcommittee. It has been a busy period with much work related to various national reviews and the Nicor database. I thank the many congenital cardiac surgical colleagues and the SCTS executive for the support given to me. There were many constructive discussion during conference calls and email conversations on challenging subjects. Rafael Guerrero from Liverpool will take over the job, supported by Andrew Parry and Chuck McClean. I will continue to serve the SCTS via the Executive Committee and as the newly appointed congenital representative on the Audit Committee. n

the 26 bulletin

SCTS Education tutors’ report Carol Tan, SCTS Thoracic Tutor Sunil K Bhudia, SCTS Cardiac Tutor

W

e are in our third year as Tutors.

Time has flown and many changes have occurred. We have learnt and keep learning.

Every report we thank the fantastic team we work with and this report is not going to deviate from that. Emma Ferris and Letty Mitchell do a fantastic job in ensuring that the courses run smoothly and funding is allocated appropriately. We are also indebted to the SCTS Executive Committee, Cardiothoracic Surgery Specialty Advisory Committee, and Training Programme Directors. There are no words to describe our gratitude to the dedication, commitment and innovation of the Course Directors and Faculty. This extended team comprises of over 60 Cardiac and Thoracic consultants, and several others from allied specialties.

Moving forward, we will be approaching other consultants to join the team as faculty members and hoping that in time will take on courses as directors. New ideas are always welcome.

Course dates and venues for 2019 are confirmed and we urge trainees to plan ahead and book their study leave as soon as possible. We are already in the process of finalising dates and venues for 2020. Emma and Letty will contact trainees via email prior to the course and need to confirm number of attendees and requirements for accommodation. Travel to UK based courses is organised by the individuals but Emma and Letty will organise travel to and from Hamburg for courses at The European Surgical Institute, Hamburg. We continue to run three courses in Hamburg which involve live animal operating. These courses are the ST3A, ST6AB and ST8A. We encourage trainees to respond to emails as soon as possible to assist with administration.

Funding for the courses comes from various industry partners. Sri Rathinam and Narain Moorjani have secured sponsorships

of varying amounts and support. The support has come from Ethicon (Johnson and Johnson), Abbott Medical, Medistim, Edwards, Atricure, LivaNova, Terumo Aortic (Vascutek), Medtronic and Cardiosolutions.

Trainees are asked for a deposit prior to a course. The deposit used to be refunded once the course was attended. However, we have taken to refunding the deposit only once the course feedback is completed.

Feedback is extremely important to not only improve but also to reinforce the positive aspects of the courses.

With the success of the first Multidisciplinary Team Simulation Course held last year, funds have been pledged by Mr Marian Ionescu to run two courses per year.

The next course is scheduled for 27th September 2019. We are extremely proud that following the last course, Ms Carin van Doorn, from Leeds Royal Infirmary, has convinced their leadership team to run regular courses in Leeds.

The SCTS Education Operative Video Prize drew in a high number of entries.

There were 13 entries for thoracic and

15 entries for cardiac surgery. This year again there were no entries for congenital cardiac surgery. The videos were reviewed by the SCTS Education Secretaries and SCTS Tutors. Shortlisted videos were viewed at the SCTS Trainee Forum. The winners, voted by the trainees at the SCTS Annual Meeting 2019 held in London, were Rini Vyas for Thoracic Surgery with Chest Wall Resection and Reconstruction with Latissimus Dorsi Flap and Split Thickness Skin Graft, and Mohamed Elsaegh for Cardiac Surgery with Pulmonary Thromboembolectomy. There is lots of exciting developments in congenital cardiac surgery and cardiothoracic transplantation surgery. We would like to see submissions from these two areas for not only the surgery but also to enthuse trainees to consider pursuing a career in congenital cardiac surgery and cardiothoracic transplantation.

Over the years we have accumulated a large bank of videos and intend to make them available for viewing to a wider audience. These videos are a valuable source of education. n

SCTS Education NTN Courses in 2019 • 28th September 2019 - Clinical Examination Course for FRCS(CTh) (ST7B) Royal Papworth Hospital

• 14th – 16th October 2019 - Introduction to Specialty Training in Cardiothoracic Surgery Course (ST3A) Ashorne Hill, Leamington Spa • 26th – 28th November 2019 - Core Cardiac Surgery Course (ST4A) Ashorne Hill, Leamington Spa

• 3rd – 4th December 2019 - Professional Development Course (ST8B) Ashorne Hill, Leamington Spa

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The Academic Cardiothoracic Trainees Group and the 3rd SCTS National Research Meeting Marius Roman, MD (Cantab), NIHR Academic Clinical Lecturer in Cardiac Surgery ST4 Cardiothoracic Surgery

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he SCTS Annual meeting in London was not only the highlight of the year on the calendar of our speciality, but an excellent opportunity for all the members of the heart team to be involved in research.

One of my personal highlights was the opportunity for all the academic trainees to be involved and engage with the SCTS Research Committee. We were fortunate to have a glimpse of the current national research initiatives, but as well to update the committee on our progress and receive its invaluable support and guidance.

The academic trainees have now successfully set up an ACT WhatsApp group, where we can keep updated, share and discuss relevant topics to their research and challenges they face. Despite promising evidence on obtaining starter grants supporting their pilot work or MD/PhD degrees, the trainees have identified the need to organise a Grant writing workshop to further develop their skills. This has been recognised as an essential metric and as one of the major challenges in the successful

career progression in a highly competitive environment. This workshop was organised in Leicester on 8th June 2019 under the lead of BHF Prof. Gavin Murphy.

Following the previous success of the two SCTS National Research meetings, we have now confirmed the next edition of this meeting to be taking place in Leicester on 2nd November 2019.

Cardiothoracic Surgery. As in the previous meetings, the highest quality presentations and posters will be rewarded with highly sought after prizes.

The highlights of this meeting promise to address the development of the trainees and allied healthcare professionals as leaders and researchers in the field of Cardiothoracic Surgery. This will be an excellent opportunity to receive lectures from Senior Cardiothoracic Surgery Academics, who will address important and pragmatic topics to our speciality. As part of the meeting, we will receive updates and have popular satellite sessions from the national trainees collaborative, allied healthcare work group and attend the operative video presentations session. As we have recently exceeded the capacity of the previous venue, this meeting will be hosted in a larger venue at the University of Leicester, with the details circulated nearer to the date of the meeting.

The organising team, including Sue Page who is the event coordinator, are looking forward to your participation and contribution to this meeting. n

“We are looking forward to continuing the previous achievements in the high quality of the submissions received from doctors, nurses and allied healthcare professionals on topics relevant to Cardiothoracic Surgery.�

The aim of this meeting is to highlight the latest high impact research in our specialty and encourage networking between the members of the heart team. The abstract submission deadline is set for 31st August and we are looking forward to continuing the previous achievements in the high quality of the submissions received from doctors, nurses and allied healthcare professionals on all the topics relevant to

August 2019

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SCTS student engagement day -

Liverpool University -

Cindy Cleto, Medical Student Tom Eadington, Medical Student Aman Coonar, Consultant Thoracic Surgeon

T

his year the 6th annual SCTS student engagement day moves to the North West, hosted as a joint venture by a team from Liverpool and Manchester. The event will take place at Liverpool University on 9th November 2019 and medical students from our islands and beyond will be invited to attend, along with sixth form students from local schools. The team comprising of medical students and surgeons from Liverpool and Manchester hospitals will build on the success of previous years, after a very successful meeting in Birmingham in 2018. The local consultant leads are Mike Shackloth from Liverpool and Rammohan Kandadai from Manchester.

The day will start with a morning of talks and lectures to give delegates an overview of

the life of a cardiothoracic surgeon, and to give an insight into the various sub-specialties within the field. These will include talks given by experts in the fields of general thoracic and cardiac surgery, as well as more sub-specialised fields such as congenital, transplant, aortic and robotic surgery; areas that are well represented in the North West.

There will also be lectures on the recruitment process and requirements needed for a career in Cardiothoracic Surgery.

The afternoon will consist of a series of practical workshops for medical students dedicated to surgical skills which are tested in the recruitment interviews. These will cover basic suturing and chest drain placement, as well as more specific skills such as lung stapling, VATS and aortic anastomosis.

Sixth form students will receive guidance on a range of topics including the realities of life working as a doctor, applying to medical school and simulation of difficult multiple mini interview scenarios.

The day promises to be an exciting event for any students interested in learning more about the challenging and diverse career of cardiothoracic surgery. It also offers a good opportunity for students to network with consultant surgeons and cardiothoracic trainees. n

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SCTS Annual Meeting 2019: SCTS Student Day report Saad Khan, Medical Student & Aman Koonar, Consultant Thoracic Surgeon

T

he SCTS held this year’s annual meeting in the heart of London.

The event was very popular with medical and school students and we were very oversubscribed. Thanks to Clinton Lloyd & Maninder Kalkat and the SCTS Education for their flexibility and support in opening up more than 100 spaces.

Students came from all round the UK, Ireland and a few even further.

There was a great speaker line-up including our president Richard Page, a live ‘chest-opening’ (simulation!) by the Royal Papworth CALS team (Trudi Bircham, Tracey Senycia, Marius Berman, Kiran Salaunkey) and hands-on anatomy demonstrations courtesy of the cardiothoracic forum team. We also had careers talks from consultants and trainees (David Jenkins, Pedro Catarino, Elizabeth Belcher, Jason Ali, Sara Volpi, Tamara Ni hici, Kate Wallwork, Alex Shipolini, Natasha Khan). A big thank you to all for giving up your Sunday.

The day ended with some astonishingly good presentations from selected medical students on various areas of cardiothoracic research for the Pat Magee award.

The students left a packed day hopefully motivated and inspired toward pursuing a career in cardiothoracic surgery

medical school to both popularise our specialty and to get involved in multi-centre projects. The first of those projects MERITS which has already recruited >6k patients will report later this year www.royalpapworth. nhs.uk/merits

Next Student engagement day will be November 9th 2019 in Liverpool and

“The students left a packed day hopefully motivated and inspired toward pursuing a career in cardiothoracic surgery.” and school students better geared towards pursuing a career in medicine.

We also used this event to further the student network with the aim of having representatives in every GB & Ireland

organised by a team from Liverpool & Manchester medical schools.

We are very grateful for support of the Student programme and particularly the Ionescu foundation. n

August 2019

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My elective at Royal Papworth Hospital Bernard Badasu, Medical Student

R

oyal Papworth Hospital is the UK’s largest specialist cardiothoracic hospital and the country’s main heart and lung transplant centre. I am grateful and fortunate to have had the opportunity to spend two months with them, one month in the pulmonary department and the other in surgery.

My name is Bernard, and I am a final year medical student from Botswana. I have been studying in the Czech Republic at Charles University and will graduate in July 2019. My time in both departments far exceeded my expectations. I had an amazing experience and was well taken care of not only by the consultants but also by every member of staff. Everyone was open, friendly and willing to go the extra mile to assist me in anything I needed help with.

Initially, before I went there, my main interest was in Sports Medicine but after spending time in the surgery department under Mr Coonar and his team, surgery is now top of the list for me. I got to observe him perform many surgeries using all sorts of different tools and I was truly in awe of it all.

I had only read about the procedures being performed but being able to see it in person was an amazing experience that I will never forget. He also made it very easy for me to follow what was going on because he would explain the procedures and answer any questions I had for him.

There were also many opportunities for learning as his whole team were very friendly and willing to help. Whenever Mr Coonar was not in theatre, I would shadow one of his registrars, they were very helpful, giving

great tips and advice, both medical and nonmedical, and that was more than I could have ever asked for.

The nurses in the department were also some of the most competent nurses I have ever met. They added a lot to my learning experience, sharing their knowledge and helping me improve my practical skills. I had some of my most comprehensive suturing lessons from the Scrub Nurse in the team just to put things into perspective.

Overall, I had a truly amazing time in Papworth, and the experience as a whole was much more than I could have ever asked for.

As I plan to do my specialisation in England, based off my time there, I think Papworth would be a great place to do it. It has a great history, great infrastructure and most importantly, great people. n

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The view from the (far) North Keith Buchan, Cardiothoracic Surgeon

O

ne of the most rewarding aspects of my job is the understanding it gives me of the ways of life of my patients who hail from a wide hinterland, stretching from the Shetland Isles, 260 miles north of Aberdeen to the Outer Hebrides 210 miles to the west to Dundee, 65 miles south.

Despite being the smallest Cardiothoracic unit in the UK, we have by far the largest catchment area in terms of square miles.

Many of the localities in the north of Scotland have house prices that are amongst the lowest in the UK. For this reason, there is a constant inflow of English economic refugees who may find they are able to buy a detached family home with a garden for under £100K. When I see them in clinic I always like to ask about how they have found the transition.

Earlier this year I had a man who had lived in Blackpool all his working life but had retired with his wife to a coastal village near Wick. Being a wildlife enthusiast he was delighted with the situation he now found himself in. His cottage was in a waterfront position within a stone’s throw of the beach.

He told me that last summer he was amazed to find himself looking out from his breakfast table at a live walrus lying on the beach. He was one of the first on the scene but soon the other villagers had joined him. Within an hour the local police had arrived and had staked out a perimeter around the one ton mammal with a tape labelled “Police Line – Do not cross”. The same walrus was sighted at a number of other locations around the north of Scotland and became known locally as Wally the walrus. It was the first time in 50 years that an arctic walrus had been sighted on the UK mainland. https://www.pressandjournal.co.uk/fp/ news/islands/1483517/wheres-wallyinteractive-map-charts-walrussscottish-adventure/

I have a patient in the ward at present who has worked for 40 years as a harbour pilot on Shetland, principally at the Sullenvoe oil terminal. He knows the waters around the Shetland Isles very well. I asked him about the local killer whale population. He

explained that since the EU North Sea fishing quotas had been introduced, the killer whale population had been growing exponentially.

There are now 30 known families (or pods) of killer whales thriving in the waters around Shetland. Orcas are intelligent creatures and they have learnt to follow fishing boats. Apparently the fishermen still catch far above their quota limits for whitefish but the quotas do not relate to the amount of fish caught – only to the amount landed. The excess of fish caught are released back into the sea, constituting a free lunch for the Orcas. Nice to know that at least these apex predators are gaining a benefit from our country’s membership of the EU. https://www.youtube.com/ watch?v=GVB7ktBgI5g

It is not rare to have a patient who is a gamekeeper. They are invariably employed by an estate owner from whom they receive a small annual salary plus benefits. The benefits compensate to a large extent for

the usually poor salary and leaving aside the interest of the job include freedom to take fish from the rivers and game from the hill and forest as required for the sustenance of their families. They will also have the use of a tied house for as long as they hold the position of gamekeeper, possibly with free wood for fuel thrown in.

They do not necessarily retire at the age of 65 and may become close life-long friends of their (sometimes famous) patrons. When the gamekeeper dies his widow may have the prospect of eviction added to her woes. She may have to apply for council housing when the estate house is lost.

I had just such a patient a few years ago who needed coronary artery bypass surgery.

After her husband died, the landowner came to see her and explained that although she would have to vacate the gamekeepers cottage, he had another house in a nearby village which he wanted her to have, free of charge, for as long as she needed it. God bless him. n

“One patient told me that last summer he was amazed to find himself looking out from his breakfast table at a live walrus lying on the beach.”

SCTS ANNUAL MEETING 22nd -24th March 2020

CALL FOR ABSTRACTS 1st September: Submission Open

5th November: Submission Deadline 1st December: Registration Open #SCTS2020

www.scts.org

the 34 bulletin

Enoch Akowuah and Isaac Okyere performing a mitral valve operation

A heart surgery mission to Ghana: Enoch Akowuah, Joel Dunning, Mike Foley, Jan Spegar, Kim Thompson, Fiona Lougland, Alison Clark, Caroline Baldwin, Peter Hill, Nick Child, Andrew Turley, Puwalani Vidanapathirana.

August 2019

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Our team at the airport

Joel Dunning, Consultant Cardiothoracic Surgeon, James Cook University Hospital

I

n February 2019 a team of 12 from James Cook University Hospital went on a heart surgery mission to Kumasi, Ghana. It was our first mission and we want to share some of our experiences so that if you are sitting there right now wondering if your unit should or even could do a heart surgery mission, then this might be of some help to you.

Several things came together to make us want to go on a heart surgery mission.

I myself had been to see Dr Emily Farkas, an American heart surgeon (who spends half her career doing missions), do a heart surgery mission in Enugu, Nigeria in September 2017, after she set up a new www.CTSNet.org volunteerism portal.

I was shocked by the desperate need for such missions in Western Africa. Nigeria, with a population of 190 million people, has no functioning heart surgery unit at all anywhere in the country and this mission was confronted with lines of rheumatic patients aged in their 20s and 30s whose only chance of survival was heart surgery from an overseas mission.

I have honestly never performed an operation in my whole life that could not have been done a good deal better by someone else! But here if the operation is not performed by the visiting team then that patient will not survive. It is as basic as that.

The team on the post op ward round

When I came back to the UK, the natural choice to discuss this with was our own Enoch Akowuah. He grew up in Kumasi, Ghana before coming to the UK aged 15 to continue his education, which led to university, medical school, cardiothoracic training, and eventually his consultant position here at James Cook,

“I have honestly never performed an operation in my whole life that could not have been done a good deal better by someone else! But here if the operation is not performed by the visiting team then that patient will not survive. It is as basic as that.”

where he has been an outstanding colleague and a national leader in valve surgery, including the set-up of two RCTs in aortic and mitral surgery. But for him it had also been a lifelong ambition to go back to his home country, where he returns yearly to see his parents, but this time to help the Komfo Anokye Teaching Hospital.

Thus the decision was made to do the mission. That was the easy bit! The next easy bit was to form a team. Every single member of our team who we asked to come were just perfect and seemed to embrace the challenge beyond our wildest expectations.

And now for the hard bits! We had no idea what to expect. We didn’t know what was out there, we didn’t know what they had or didn’t have, or their level of training.

Luckily Enoch struck up a great relationship with Dr Isaac Okyere, the local surgeon and we also talked on the phone to missions who had been there before. Dr Farkas agreed to come and help us for the mission as a kind of ‘mission proctor’ which was great too. >>

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Enoch Akowuah operating

Mike Foley and Peter Hill

Participants are observed in action On the ward

The decision is made to proceed to sternotomy and the cardiac surgical team, including theatre and perfusion, attend

But as surgeons we truly didn’t appreciate the huge amount of preparation and equipment it actually takes to perform heart surgery which does sound a strange thing to say, but you will never understand this until you actually see 117 boxes meticulously put together by your fabulous team of scrub nurses, CICU nurses, intensivists, and by your perfusionist, all of which needed to be placed in a container on a 40 tonne truck and shipped 2 months before the mission.

I certainly feel silly now, thinking that all we needed were our loupes!

The next thing was funding. It cost us £30,000 to put on this mission, and that was with many generous donations of bypass equipment, echo machines, valves and ICU equipment. We were very pleased to receive £11,000 from LivaNova, but again our team raised £20,000 by local events and fundraisers which was beyond our wildest expectations. We found that new missions and adult heart surgery missions are not as easy to fund as children’s congenital missions by established groups and large companies often take a year to make decisions!

So then we went on the mission!

The travel was easy. The welcome was warm, but walking into an empty room where our ICU was to be located was the first eye opener, shortly topped by air coming out of the wall in theatres when our perfusionist was expecting oxygen!

We basically created a whole ICU from an empty room in 12 hours and Kim resuscitated their perfusion machine to run off gas cylinders, and survive the daily power-cuts in a similar time. So many other things happened that we don’t have space here to tell you but that is why we recorded a daily blog of the mission so that you can see what it is like to go on a mission. You can see it all here: https://www.ctsnet.org/article/dailyvideo-blog-medical-mission-ghanafebruary-23-march-1-2019

So every patient survived. We also performed pacemakers which was a great bonus and we all want to go back on the 19th October 2019 to do it all again!

I personally think this was the most valuable and rewarding week of my life in surgery (and yes a better person than me did do all the operations out there and I just watched!) There is no other opportunity as stark as offering treatment to those without any other options.

August 2019

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The team from James Cook University Hospital

Enoch Akowuah interview

Pre-op brief

“I personally think this was the most valuable and rewarding week of my life in surgery.”

I also think that every unit in the country should strongly consider doing at least one mission a year, although having been on this mission I am delighted to hear that many units do indeed do many missions, but perhaps do not tell the world about it, and thus we should consider reporting this nationally every year via the SCTS and being proud of all this work that is being done charitably.

Furthermore, the SCTS has 11 committees but not a single person on any committee with a role to promote, assist or coordinate overseas charitable missions which surely must be a mistake that is very easy to rectify, and could be paired with a regular SCTS annual meeting multidisciplinary session on mission experiences.

We at James Cook also strongly believe in the Cape Town Declaration1, which states that the ‘fly-in’ single missions are not the way to address the scourge of rheumatic heart disease but we must build up the capacity of the local units towards independent practise, which is why we are attempting to build a group of 4-5 mission groups to be able to perform a series of quick-fire missions at Kumasi with the sole intention of bringing the local unit up to

speed in order to perform their own safe surgery in the future.

I believe the time is right for us all to get together through the SCTS to build a united mission base in the UK that we can be truly proud of and that can be used to set up units in areas of the greatest need to provide their own independent heart surgery. I hope you agree! n

References 1. Zilla P, Bolman RM, Yacoub MH, Beyersdorf F, Sliwa K, Zühlke L, Higgins RS, Mayosi BM, Carpentier A, Williams D The Cape Town Declaration on Access to Cardiac Surgery in the Developing World. Cardiovasc J Afr. 2018 Jul/Aug 23;29(4):256-259

Three of our patients One week post surgery

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The Heart Surgery PSP Second Survey: Updates on success and looking to the future Bethany Tabberer, Cardiac Surgery Clinical Trials Administrator

T

he SCTS Annual Meeting, in London March 2019, hosted the launch of the Heart Surgery Priority Setting Partnership (PSP) Second Survey. Following on from the success of the Initial Survey, the project has transitioned into the Prioritisation stage to establish the Top 10 priorities for cardiac surgery research over the next decade.

In November 2018, closure of the Initial Survey resulted in the submission of 1,082 questions from 629 respondents.

During the intermediate analysis stage, duplicate submissions were combined and any questions previously/currently addressed by research were eliminated from the question bank. The remaining 45 questions were grouped into the categories of anaesthesia, bypass surgery (CABG), intraoperative management, longerterm outcomes, patient selection/risk stratification, post-operative management and complications, pre- and post-operative care, specific diseases and conditions, valve surgery and other themes. The Second Survey was launched to ask participants to vote for their Top 10 questions across all categories, prioritising questions they wished to see addressed by future research.

To observe trends in recruitment, we compared the response rates between the Initial and Second Surveys. The Initial Survey was open between March – October 2018, resulting in just over 600 responses in eight months; this averaged at 75 responses per month. Comparably, the Second Survey recruited 200 responses in less than one month since launching (at the time of writing). This is a dramatic improvement in recruitment rate, although the Second Survey was only running March – June 2019 (4 months). Based on the launch month statistics, it was predicted that the Second

Survey would result in 800 responses by the time of Survey closure. This is a 33% increase on the Initial Survey submissions despite the Second Survey being open for half the duration of the Initial Survey.

We believe there are several factors responsible for the improved response rate.

At the launch of the Initial Survey, the Heart Surgery PSP had not yet established a network of connections to disseminate the survey. We were required to build our reputation and share our aims. Our Second Survey has been vastly more popular due to pre-established awareness and contingency (many participants remarked they had already completed our Initial Survey and had been anticipating the follow-up). Secondly, we have hugely expanded our marketing strategy.

Initially we had limited responses from the UK only until we broadened our reach to international audiences. For the Second Survey we have a global reach and have contacted every known heart surgery patient support group across the United Kingdom, in addition to disseminating amongst outpatient clinics and attending academic conferences.

Another possible explanation is the differences in the presentation of the Initial and Second Surveys. Completion of the Initial Survey was perceived as a daunting task by many. Participants were requested to provide us with a research question, rather than vote for their preferred answer as seen in traditional survey formats. The purpose of this was to observe the research themes important to those dealing with frontline surgical issues; by requesting their thoughts and ideas, we wanted to objectively observe what individuals felt was most important to contribute to the research agenda. However, many patients were satisfied with their care and therefore did not feel the need to identify areas they wished to see improved. Although

this is an excellent reflection on the standard of care they received during their treatment, we still aimed to identify gaps in the current clinical knowledge or patient care. Many people declined to participate because they did not feel they had a question to contribute.

In contrast, the Second Survey adopted a traditional tick-box format in which the questions were presented to respondents. The Second Survey took less time to complete than the Initial Survey, and is more user-friendly.

There are various benefits to the outcomes of the Heart Surgery Priority Setting Partnership. By giving influence to those dealing with the frontline of heart surgery we are raising awareness of clinical research, thereby potentially generating interest for future involvement by patients and clinicians. This will help the progression of modern medicine and improve the outcomes for future cardiac surgery patients. Another benefit of the project is that the research agenda for the next decade will be established; as a scientific community, we will observe the gaps in current clinical knowledge and begin to address these with clinical research.

The next stages following the Second Survey is the final prioritisation; on 11th July 2019, a workshop will be held attended by independent delegates to establish the Top 10 priorities. The decision will be made by representatives from the clinician and patient demographics, and delegates will rank the questions according to those voted for in the Second Survey and those which they best feel reflects the research interests of individuals dealing with the frontline of cardiac surgery.

By the time this article has reached print, the Second Survey will have closed. To keep up to date with Survey results and future publications, including a collaboration with the Cochrane Heart Group, please follow our Twitter handle @HeartSurgeryPSP. n

So you can seal pulmonary veins and arteries — up to and including 7 mm in diameter — with confidence1–6 Comparing the LigaSure™ Maryland jaw thoracic sealer/divider to our original LigaSure™ Maryland jaw device

Compared to systemic vasculature, pulmonary vessels are:

PHYSIOLOGICALLY DIFFERENT Significantly lower blood pressure7

Thinner, less muscular, and more elastic walls8,9

Based on preclinical test results, we narrowed the specifications of two proprietary jaw parameters for the LigaSure™ Maryland jaw thoracic device.

These changes significantly improve the reliability of pulmonary sealing performance compared to the original LigaSure™ Maryland device (See Figure 1).11 Figure 1. The Maryland jaw thoracic device delivers statistically significant higher burst pressures on pulmonary veins and arteries than the original Maryland device (p < 0.05; n ≥ 304 per group).11

800

Burst Pressure (mmHg)

DIFFERENT. BECAUSE IT HAS TO BE.

EVIDENCE-BASED TECHNOLOGY. PROVEN PERFORMANCE.11

Burst Pressures of Pulmonary Vessels Burst pressure for individual seal

600

400

200

90 0 Original LigaSure™ Maryland Jaw Device

LigaSure™ Maryland Jaw Thoracic Device

INHERENTLY COMPLEX Vascular morphology and elasticity of pulmonary arteries varies throughout the pulmonary system10

Pulmonary veins have more collagen content than pulmonary arteries9

These variations highlighted the need to evaluate our devices differently, which led to design changes to our LigaSure™ Maryland jaw thoracic device.11

4.4%

of seals have burst pressures that don’t meet the LigaSure™ technology performance standard on pulmonary vasculature11

3X

normal pulmonary systolic blood pressure (30 mmHg)7

the 40 bulletin

Day of surgical admission (DOSA) - One year on Cathy Walters, Lead ANP for Cardiothoracic Surgery

D

ay of Surgical Admission (DOSA) is accepted practice in many surgical specialties. GIRFT noted that whilst itâ&#x20AC;&#x2122;s commonplace in thoracic surgery, for patients undergoing cardiac surgery this was not so and that it should be a panacea of good practice.

At Harefield in April 2018 we were tasked with launching a pilot scheme that was to see patients admitted for

cardiothoracic surgery on the morning of, rather than the night before their surgery.

Whilst this was a familiar pathway for many of the thoracic patients, it was a road less travelled for those undergoing cardiac surgery.

In the time running up to the launch we set about devising protocols and criteria that would allow direct admission to the DOSA hub on the morning of surgery.

Initial concerns The benefits for the organisation are clear.

Length of stay will reduce as the patientâ&#x20AC;&#x2122;s pathway is streamlined. This will result in significant financial savings. Most patients do not need inpatient care the night before surgery. The fiscal benefits were obvious from the outset. What was less clear was how this would be of benefit to patients.

Initial concerns were that the geographic areas covered by Harefield are vast. Patients are referred to Harefield from all over the country, but our routine referrals come from a radius of 100km. We were concerned about patients travelling long distances to numerous clinic appointments and on the morning of their surgery. Other concerns were around the morbidity of our patients, many are having redo procedures, many are octogenarians with significant comorbidities. How would they feel about navigating the complex journey to hospital for admission on day of surgery? Other concerns were about the availability of ward beds to discharge the patients out of high dependency areas early in the morning. Historically the first case going to theatre frees up ward beds to allow discharge from critical care, if they arenâ&#x20AC;&#x2122;t inpatient would that impact on flow?

It was necessary to evaluate the whole patients journey to see what would be needed to make DOSA a success.

The Cardiac Pathway What was clear from the outset was that a robust pre-operative assessment process was essential if DOSA was to succeed.

At Harefield all cardiac surgery patients are referred to a fitness for surgery clinic appointment which forms part of their preassessment process. At this appointment the patients are clerked, have protocol dictated

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41

Second cases If the patient is second on the list they are asked to arrive between 8-9am. Their second group and save is taken. The patient is clipped and showered.

The Thoracic Pathway

tests and see an anaesthetist if necessary to assess the complex patient. Following the appointment, when they are declared fit for surgery and if they meet the criteria for DOSA, a red ‘DOSA’ sticker is put on the front of their notes.

The scheduling team use the electronic IMPAX scheduler and when a date is given for surgery providing the patient has a DOSA sticker on their notes, it will appear on the operation list. As soon as this is done the DOSA team pick it up and book the patient in for a PORAC (pre-op reassessment clinic) appointment. At this clinic the patient is seen by an ANP, a brief clerking and physical examination takes place, any expired tests are repeated, and the patients are consented and see the anaesthetist. They are given an

information leaflet with where to go, fasting instructions and what medication they need to stop. Both first and second cases are accepted as DOSA.

First cases If the patient is first on the list, national blood transfusion guidelines require that the patient has a 2nd group and save sample sent within 3 days of surgery. The patient either attends the hospital or a home care sister will visit the patient and take the blood. First cases are then asked to arrive at the hospital at 6:30 where they are prepped for theatre and showered. All patients are given the choice of whether they would like to walk to theatre. Almost all of them do.

Previously there was no provision at Harefield for a thoracic pre assessment process. So, with one consultant committed to DOSA we set one up. The POAC is the thoracic equivalent of PORAC but as it’s the first time that the patients have been seen, the title is slightly altered. The patients are clerked and examined by an ANP, they are consented, see an anaesthetist and a pharmacist and the nurses on DOSA will complete a nursing assessment. The patients are sent for relevant investigations. The ANP collates the information and checks that all the results are safe to proceed. Any issues are discussed with the consultant directly. As many of the thoracic patients are on the 2 week cancer target pathway they are seen and processed as quickly as is possible so there is no delay to treatment.

“At Harefield in April 2018 we were tasked with launching a pilot scheme that was to see patients admitted for cardiothoracic surgery on the morning of, rather than the night before their surgery.” >>

the 42 bulletin

The patients experience of DOSA There has been overwhelming positive support and praise from patients for DOSA. They tell us that they want to sleep in their own bed, that they want to enjoy a meal with family the night before major surgery. They enjoy the process of coming to the place that they will have their surgery before the date.

Of being able to ask questions and meet the staff that will be looking after them. To familiarise themselves with the staff and environment is extremely important. Where patients are cancelled they ask to be a DOSA patient again. 97% of patients report being very satisfied with their care in DOSA.

Organisation progress and successes Current data has surpassed all expectation. In March 70% of all elective patients were admitted through DOSA. This figure is steadily rising. The criteria now only excludes those patient who require IV fluids, or those with very poor clinical conditions pre operatively.

The length of pre op in patient stay has reduced from 1.7 to 1.3 days.

Using 17/18 activity as a comparison patients were spending on average 1.7 days in hospital pre-op equivalent to 3 beds per day. For November with this new mix the average was below 1 day pre-op with an average of 1.3 beds per day so more than a 50% reduction in capacity requirement.

DOSA has undoubtedly been successful here at Harefield. The fiscal, economic and financial benefits are clear. The cost saving for the first year is approximately a million pounds. I estimate that as the process only really began seeing significant numbers in October, that this figure will be doubled when we see a full year of DOSA working at capacity.

These benefits are important but what drives us is that the patients are so positive about what we do, their feedback demonstrates that this is the right thing for the patients not just the organisation. n

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Glenfield Part II Cardiac Surgical Wetlab 27 March 2019, Leicester Ahmed Abbas, Clinical Fellow

F

ollowing our first successful basic cardiac surgery wetlab on the last day of May 2018 we, as a coherent team in Glenfield hospital in Leicester, were determined and managed to organise our second advanced specialty wetllab on 27th March 2019. The excellent and coherent team work spirit at Glenfield cardiac centre has ameliorated the challenges this wet lab faced before its success get witnessed.

This event, like the one before, was a great success and highly praised by both junior and senior delegates. The attendance was more than expected with 30 delegates both local and nationwide. It was not only attended by registrars but also theatre staff, anaesthetists and perfusionists as observers.

The wetlab was a whole day event split into four parts, Anatomy, Mitral, Focused ECHO and Aortic Root sessions. Mr Zlocha, a mitral surgeon from Glenfield and course director, opened the course and introduced the faculty. Unexpectedly from anatomy, this session by Mr Fananpazir,

our senior encyclopaedic anatomist from University of Leicester, was one of the most interesting and enjoyable part of the course according to the delegates feedback.

This year, we introduced for the first time an ECHO session presented by two experienced Cardiac ITU consultants in Glenfield, Dr Schupp and Dr Srivastava, who both took the delegates into a one hour journey of detailed cardiac echocardiography of real case scenarios from Glenfield theatres.

The event was divided into two parts; the first part was the mitral session with visualizer aided demonstration of mitral repair by Mr Zlocha, followed by troubleshooting and tips from Mr Al-Sarraf.

The second part was the valve sparing aortic root replacement strategies guided by our experienced Aortic surgeon Prof Mariscalco and our experienced guest from Wolverhampton, Mr Matuszewski, who made this challenging technique simple, achievable and learnable.

The event closed with excellent feedback from the attendees and certificates, with 6 CPD points granted from the Royal College of Surgeons of Edinburgh.

Our aim at Glenfield hospital is to maintain these two annual activities, both basic and advanced, as part of our training and educational program. This wetlab is the arena where skills and expertise transferred in a controlled enjoyable manor from Glenfield cardiac theatres and experienced team to the junior registrars. n

the 44 bulletin

Cardiothoracics and Cashmere A sub-internship in cardiothoracic surgery Andrew Hudson, Medical Student

F

riday midnight. Downtown Chicago.

9th floor up. Guns N’ Roses are pumping over the operating room sound system. I have just stepped off the transplant jet with the newly procured heart and this is the second transplant today.

I’m loving every second. This is surreal.

I’d pinch myself but I don’t want to break scrub. I quickly recall how I actually made it to this very moment...

Deciding which specialty to complete my sub-internship in for my final year of Medicine was a no-brainer. Once I had my first taste of cardiothoracic surgery back in 2nd year Medicine it was love at first sight. I have never once let my eyes wander or flirted with another specialty since. However the issue of location is what threw me a curve ball. Should I complete my sub-internship in the hospital that I hope to be an intern in next

year and get ahead of the curve? Or should I throw caution to the wind and look further abroad? Decisions, decisions. My Professor kindly agreed to meet up with me and have a quick coffee on the go. In her sagacity she advised me that international experience always looks good on a CV and a change of scenery with different surgeons in a different setting could do me a world of good. OK; decision made - I was off!

Through my Medical School I was able to secure a competitive collaborative elective in North America. When I scrolled through the options that were available to me, I quickly jumped at the chance for a 6 week elective in cardiac surgery in Chicago. With a North American elective came the additional paperwork of securing a Visa, HIPPA training, a patch quilt of my vaccination history and the all-important letters of

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45

“In lieu of giving lengthy presentations of patients’ post-operative course, the Fellows afforded me a lot of their time and taught me how to refine my presentation skills. I was learning to give the most amount of information with using the least amount of words.” recommendation. At the time it seemed insurmountable whilst on my General Practice rotation in a tiny, remote village in the West of Ireland however when the email of confirmation appeared on my phone email I was ecstatic that it was all becoming all very real.

After a long summer of working in the cardiothoracic surgery research lab, I was delighted to finally be back on the wards when September rolled around. Within three hours of my flight touching down in O’Hare International Airport, I was already being guided around the Feinberg School of Medicine and Northwestern Memorial Hospital. I was awestruck by the sheer magnitude, efficiency and sleekness of their establishment. Between the automatic glass doors and touch screen computers at every corner I felt like I was on the Starship Enterprise – learning here would be a phenomenal experience.

I was thrown in at the deep end. The next morning I met the cardiac surgery team outside the CT-ICU at 5:30am. I was immediately struck by the diversity of the team. It was a beautiful, cardiothoracic cultural kaleidoscope. Attendings, Fellows and Residents hailed from all parts of the world; Japan, Greece, Vietnam, Poland, Egypt, Belarus, Thailand, Nigeria and Canada to name just a few. Initially the learning curve was steep. I struggled with different units and esoteric clinical nomenclature. Instead of using end of bed early warning score charts, kardexes and chasing down patients’ charts everything was electronic and could be easily manipulated with a few clicks of ones fingers. Pre-rounds were thorough but succinct. In lieu of giving lengthy presentations of patients’ post-operative course, the Fellows afforded

me a lot of their time and taught me how to refine my presentation skills. I was learning to give the most amount of information with using the least amount of words. I had the opportunity to work alongside allied healthcare professionals such as respiratory therapists and physician associates that we don’t have back home yet. Their collaborative approach and input into the cardiac multidisciplinary team was invaluable.

Through the tutelage of the amazing CT advanced nurse practitioners I can officially put my hand on my heart and say that I can preform a slick cardiac and respiratory exam.

Like most medical students wishing to pursue a career in surgery I was happiest when scrubbed up and at the operating table.

I was encouraged to scrub in everyday and multiple times per day. I participated in all aspects of cardiac surgery and surprised myself that I had undiscovered passion for minimally invasive cardiac surgery, and TAVI. As Northwestern Hospital is a tertiary referral centre for cardiac surgery I had the opportunity to help operate on some incredibly complex cases; with each suture and knot I felt myself growing more confident in my operative abilities. Initially I was nervous in my abilities starting off on

my sub-internship however I quickly learned that no matter what corner of the world one is in, core knowledge and clinical skills will readily translate anywhere. Furthermore the wellbeing of the patient will always will be the key factor that influences a doctors’ practise and decision-making.

I would like to thank the Royal College of Surgeons in Ireland for allowing me to partake in this collaborative agreement. And the most heartfelt thanks to all of the staff and patients in Northwestern Hospital who taught me so much over the best six weeks of my life.

A very special thanks to Bart for my goodbye cashmere “CT MD-to-be” hoodie – I hardly ever take it off!

To any medical student reading this and considering a North American elective in cardiothoracic surgery I recommend it 100%.

Start the preparation early; stay organized with the paperwork and jump in with both feet. I have gained a new set of values and technical skills that I can now bring with me into my intern year in the coming months. I am so grateful and have learned so much from this opportunity. It has crystallized my passion for a career in cardiothoracic surgery. Was it tough? Yes - sometimes. Would I do it all over again? Absolutely - in a heartbeat! n

the 46 bulletin

RESOLVE PPI Group Helen Shackleford, Thoracic Research Nurse

O

nce again SCTS welcomed the RESOLVE PPI Group to its Annual general meeting. This is the fourth year that the group has been in attendance.

The ThoRacic surgEry reSearch cOllaborative patient and pubLic involVEment (RESOLVE) is a way by which people with Thoracic surgery conditions, their families, carers or members of the general public can influence research carried out on this topic. The purpose of the group is to help make our research more relevant and acceptable to people with thoracic conditions, clinicians and researchers.

The Thoracic Surgery patient collaborative is based at Birmingham Heartlands Hospital (as part of the University Hospitals Birmingham NHS Foundation Trust) and has been set up to provide patient and public involvement to support research activity nationally and internationally. In order to fulfil this objective, the group have committed to attend the annual SCTS meeting to review and appraise prospective research projects.

This year’s program was opened by Dr Sadeesh Sirinathan one of our Canadian colleagues. He provided the group with an update on the interim findings of his TORCH project, which is exploring health outcomes following major surgery. This was the product of a previous presentation that the group had participated in last November.

He recognized that the groups’ input had generated some interesting and insightful opinions that he and his team had not

previously considered and thanked them for their involvement.

Professor Eric Lim from the Royal Brompton Hospital followed this with a presentation on his upcoming RAMON project – a randomised controlled trial examining outcomes following surgery for advanced (stage IV) lung cancer. The RESOLVE members supported the premise that patients would consider the opportunity for surgery favourably, and gave written feedback offering their views and opinions.

This culminated with a member of the group imparting their experience and knowledge by joining the study protocol production team.

The next presentation was from Dr Akshay Patel, one of our research fellows, whose subject matter was the role of functional B cells on patient outcomes following surgery. This generated a lot of positive discussion and the group have since reviewed the patient information sheets and consent forms for this project providing constructive criticism on how to make them more patient appropriate.

Mr Aman Coonar from the Royal Papworth Hospital and his team gave the final two presentations. The first from Mr Steve Bloor was on the subject of novel and innovative techniques for the treatment of broncho-pleural fistulas (BPF). Although rare, BPFs represent a challenging management problem and are associated with high morbidity and mortality.

The second talk was

by Dr Brianna Ripoll on the challenges of Lung Volume Reduction Surgery. This was a subject that resonated

with several of our members and they were keen to offer their support to further develop and generate these concepts.

As always, this meeting generated very positive feedback, from both its members and the presenters. We would like to thank our PPI Members for their professionalism and the effort they go to in supporting us every year. We would also like to thank the SCTS for allowing us to attend and look forward to Wales in 2020.

We run a series of events throughout the year at Birmingham Heartlands Hospital for anyone who would like PPI involvement for future research projects or who require patient representation for upcoming grant proposals. The group are also willing to participate in conference calls or give written feedback as appropriate. If you wish to get in touch you can email Amy Kerr at amy.kerr@heartofengland.nhs.uk. or Helen Shackleford at helen.shackleford@ heartofengland.nhs.uk n

August 2019

47

My first SCTS Annual Meeting Abbie Mae Bolus - Student Nurse

W

hen being asked to participate as a student volunteer for the SCTS Annual Meeting, I was very excited to jump at the chance. Having previously been on placements relating to Cardiothoracic practice at St. Bartholomew’s, and deciding it was the field I’d like to specialise in, I knew that this could only enhance my learning experience. Moreover giving me so much more knowledge and understanding on the subject - perfect timing as I am due to become a newly qualified nurse in September.

The volunteer team were all other students - mainly medical and were all approachable and interesting to talk to about their array of experiences thus far. I was surprised to find that some of the other students had flown into London to attend SCTS 2019! Living in London myself, I tend to forget that it could be busy and interesting anywhere else. The team was well led by two students that had volunteered at the annual meeting in previous years and so were familiar with the itinerary and how the conference is run.

I was lucky enough to spend the first day ticket scanning in the wet lab, which

was extremely intriguing. I hadn’t had the chance to take part in anything similar since being at school, carrying out dissections in biology class. I was privileged to have the opportunity to practice some skills that would not usually be within the job description of a nurse, such as inserting chest drains, mini trachys and performing bypasses. The staff leading the wet labs were extremely knowledgeable and open to questioning as well as encouraging all to engage. Having dabbled in being a seamstress in the past and becoming quite skilled, when watching CT surgery, I had often, ignorantly, found myself wondering how difficult it would really be to stitch cardiac muscle.

I was shocked at how tough it actually is after it being made to look so simple and easy by the surgeons within St Bart’s.

Having nearly finished my nurses training, I would be quite comfortable looking after most level 1 patients and making sure their daily needs are met.

However, I really do believe in the importance of nurses thoroughly knowing and understanding what is going on with their patients. With better knowledge and understanding, comes better delivery of

empathy and care. For this reason, I was so impressed to see the amount of nurses and other professionals (including a student nurse) presenting their own research they had conducted at the nurses forum held at SCTS 2019. I found it inspirational how every speaker in the nurses forum was so passionate about the research they had carried out and about their findings. I hope that I will at some point have the opportunity to be able to do the same, as well as being so confident as to present to a full room of other professionals. Furthermore, I would like to comment on the support and welcoming attitude shown for the speakers by the other professionals in the room.

Overall I was extremely impressed with SCTS 2019! There was so much to learn and absorb from so many people that I would never usually have the chance to speak to. I would recommend any student coming into the medical profession that is interested in Cardiothoracics to volunteer. It is great fun to get to know the other students from all over the country and to hear about their experiences. I am very excited to be beginning my career in nursing as a part of such a professional and learned society. n

the 48 bulletin

Team training in Transcatheter Aortic Valve Implantation (TAVI)

The patient is cannulated for institution of cardiopulmonary bypass following sternotomy

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49

Gillian Hardman, ST7 Cardiothoracic Surgery, Health Education England, Northwest Ranjit More, Consultant Cardiologist, Lancashire Cardiac Centre, Blackpool Victoria Hospital Antony H Walker, Consultant Cardiac Surgeon, Lancashire Cardiac Centre, Blackpool Victoria Hospital

S

imulation at the Lancashire Cardiac Centre (LCC) has been regularly employed for education and training since 2015. More recently, monthly in situ team training in emergency post-operative scenarios has been held for all surgical, theatre, anaesthetic and cardiac intensive care unit (CICU) team members.

Emergencies in the catheter lab present particular challenges for the teams involved. They require the attendance of a secondary (Cardiothoracic or Vascular) surgical team, necessitating a level of communication and coordination beyond that routinely encountered in day-to-day practice. Barriers to this coordination are often only identified during the emergency.

Once the team arrives, they are required to perform in a foreign environment with unfamiliar team mates. In addition, further specialist equipment may be brought which members of the cath lab team are not familiar with and may not be easily adapted for use in a different environment.

Transcatheter Aortic Valve Implantation (TAVI) at the LCC has been performed since 2008. A review of data from 2014 to April 2019 identified 341 procedures performed, with 8 cases (2%) resulting in serious complications requiring surgical intervention immediately or within 24-hours of procedure. Once a serious complication has occurred, mortality was 75%. These complications therefore represent rare but potentially catastrophic events for both patients and staff.

In situ Cath lab simulation.

SimMan prepared for Transfemoral TAVI

Our experience is not unique. In 2015, Tam et al recognised that a “well organised regularly-rehearsed emergency rescue plan that pre-assigns resuscitative roles may shorten the duration of patient instability and resuscitation and improve patient outcomes when catastrophe occurs in TAVI” 1. Many surgical teams now employ regular simulation based team training in the operating theatre, and there is evidence to support its efficacy in improving performance and patient safety. 2, 3

We recently extended our regular in situ team training in Cardiac Surgery to

“Transcatheter Aortic Valve Implantation (TAVI) at the LCC has been performed since 2008. A review of data from 2014 to April 2019 identified 341 procedures performed, with 8 cases (2%) resulting in serious complications requiring surgical intervention immediately or within 24-hours of procedure.”

post-TAVI procedure emergencies for the cath lab, theatre and cardiac surgical teams.

Why we did it The session was organised in response to a Serious Untoward Incident (SUI) following TAVI. The report outlined that: “at the end of the TAVI procedure, the patient suffered a cardiac arrest and the decision was made for sternotomy and the patient was put onto cardiopulmonary bypass”.

Investigation identified 4-key areas for development. These were used to inform the session learning objectives. The aim was to improve team performance during cath lab emergency scenarios, using interprofessional learning, in situ simulation and deliberate practice4 with a Human Factors (HF) and non-technical skills (NTS) approach to debriefing.

What we did An introduction to the session, with background information and key HF and NTS themes, was followed by a 40-minute simulated scenario of cardiac arrest in a patient at the end of a trans-femoral TAVI procedure was used. This was performed >>

the 50 bulletin

in situ in the cardiac catheter lab. An emergency theatre, perfusion and surgical team were made aware of the session and briefed that they should attend if contacted.

The learning objectives for the session were: 1. To understand the working environment and equipment needs for emergency situations in the cath lab 2. To understand and identify team roles in emergency situations, to improve team working and provide mutual support

3. To recognise the importance of key human factors and non-technical skills relevant to this case including equipment/environment, team work and communication, situational awareness and leadership/followership Twenty-four people attended the session along with faculty from the LCC cardiac simulation team. Fourteen team members, representative of the cath lab, cardiology, theatre, anaesthetic, surgical and perfusion staff, participated in the scenario. The remaining 10 learners observed (the cath

lab is ideally suited to this) and actively contributed to the debrief.

The simulation was followed by a one hour facilitated debrief. The NOTSS5 behavioural rating system was used to assess participants and the learning points were framed in the context of the SHEEP Human Factors model6.

The final 30 minutes of the session was used by team members to familiarise themselves with the cath lab environment, team members and surgical equipment facilitated by the participating learners.

How we did it

Participants are observed in action

A working group was formed, representative of all members of the participating teams. Matron and members of the theatre and cath lab management teams were consulted. This was essential to ensure availability of staff members and to add credibility to the session, allowing learning points identified through the simulation to be quickly actioned.

A frequently identified barrier to team training and interprofessional education is the availability for participation of all team members. This is complicated during in situ simulation when the working environment must be empty, without impacting on service and patient safety.

We used time allocated to our 3-monthly joint cardiology/cardiac surgery audit meeting to schedule this event.

The required level of fidelity for effective simulation is often debated.

We used the Laerdal SimManÂŽ adult simulation manikin placed in the cath lab and controlled remotely, with monitoring, by the simulation and skills team. Funding for refreshments for the session was provided by industry. All other costs for equipment and consumables were met by the participating departments.

Evaluation

The decision is made to proceed to sternotomy and the cardiac surgical team, including theatre and perfusion, attend

As a result of the session, 4-key learning points have been addressed with development plans actioned.

A post session online questionnaire using a 5-part Likert scale was used to evaluate the session. The questionnaire was completed by 19 individuals (response rate 79%). Results of the questionnaire are outlined in table 1.

All individuals expressed a desire for more simulation based team training, with

August 2019

1. Strongly disagree %

2. Disagree %

3. Neither agree nor disagree %

4. Agree %

5. Strongly agree %

Weighted Mean

After taking part in the in situ simulation session, I feel better equipped to handle emergency situations following TAVI

0

0

5.26

47.37

47.37

4.42

The session identified and helped to resolve equipment issues that can arise during patient management following complications of TAVI

0

0

5.26

42.11

52.63

4.47

The session helped to identify issues of environment that arise during patient management following complications of TAVI

0

0

0

52.63

47.37

4.47

The simulation session helped to develop my teamworking skills

0

0

5.26

57.89

36.84

4.32

The simulation session helped to develop my communication skills

0

0

21.05

47.37

31.58

4.11

51

Table 1: Results

95% of respondents requesting monthly to annual sessions. All respondents stated that the session was useful and that they would recommend it to colleagues and friends.

Further work is required to assess the impact of this session on behaviour, patient safety and outcomes following emergency complications after TAVI.

In-situ simulation based team training is now well established within our CICU and theatre teams at LCC. An SUI has prompted us to extend this education approach and successfully adapt it to a related working environment, providing real-time identification of practice development areas, fostering improved team working across disciplines and improving departmental patient safety culture.

Special thanks to the Lancashire Cardiac Centre Simulation team Neil Berrigan, Practice Development Nurse, Cardiac Theatres Gillian Liddle, Practice Development Nurse, Cardiac Intensive Care Matthew Stagg, Consultant Cardiac Anaesthetists, Education Lead for Cardiac Anaesthesia Mark Hatch, Clinical Skills Facilitator and Simulation Lead, Simulation and Clinical Skills Unit, Blackpool Victoria Hospital Mike Dickinson, Manager, Simulation and Clinical Skills Unit, Blackpool Victoria Hospital n

“The simulation was followed by a one hour facilitated debrief. The NOTSS behavioural rating system was used to assess participants and the learning points were framed in the context of the SHEEP Human Factors model.”

References 1. Tam DY, Jones PM, Kiaii B, Diamantouros P, Teefy P, Bainbridge D, Cleland A, Fernanded P, Chu M. Salvaging catastrophe in Transcatheter Aortic Valve Implantations: rehearsal, preassigned roles, and emergency preparedness. Can J Anesth 2015;62:918-926 2. Neily, J. et al. Association Between Implementation of a Medical Team Training Program and Surgical Mortality. JAMA 2010; 304(15): 1693 3. Amore Forse R, Bramble JD, McQuillan R. Team training can improve operating team performance. Surgery 2011;150(4): 771-778 4. Ericcson KA. Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Academic Medicine 2004;79:S70-81 5. Yule S. et al. Development of a rating system for surgeons’ non-technical skills’.

Medical Education 2006; 40(11): 1098–1104 6. Rosenorn-Lanng D. Human Factors in Healthcare. Level One. Oxford University Press, Oxford, UK. 2014

the 52 bulletin

Aortic Dissection: A UK Strategy Christina Bannister, Patient Lead – Nursing & AHP Committee

P

atient association Aortic Dissection Awareness UK & Ireland has launched a consultation to produce a UK national strategy for Aortic Dissection.

Hosted by SCTS President, Mr. Richard Page, at a satellite meeting of the main SCTS conference in Westminster on 12th March, over 40 distinguished professionals from Cardiac Surgery, Vascular Surgery, Emergency Medicine, Cardiology, Radiology, Pathology and Genetics participated in the consultation launch.

A stimulating and positive discussion ensued with Aortic Dissection patients, family members and a Member of Parliament interested in the condition, who had crossed the road from the House of Commons to attend despite an important Brexit debate that day.

Chair of Aortic Dissection Awareness UK & Ireland, Mr. Gareth Owens, reminded

those attending that the first documented case of death from Aortic Dissection was King George II of England in 1760. “In the 260 years since then, no-one has assembled the kind of senior, multi-disciplinary team we have here today and asked them to tackle the UK’s challenges with Aortic Dissection” he said, adding: “I think we will look back on today as an historic day.” Mr. Owens is co-leading this strategic initiative with Mr. Graham Cooper, Medical Advisor to the patient association and immediate past-President of SCTS. Their leadership embodies the spirit of partnership between clinicians and patients and indeed between the various clinical disciplines that the assembled company was encouraged to adopt.

So far, the consultation has identified six key themes and a list of strategic questions to address under each theme. The six themes and examples of the strategic questions are:

Emergency Medicine What if every UK ED implemented the ‘Bristol Model’ for improving diagnosis of AD? Radiology What if every AD patient had a CT Aortagram within an hour of presentation? l

What if the Royal College of Radiologists published a professional standard for Imaging in Aortic Dissection, like it does for Trauma? l

Surgery What if every UK Cardiac and Vascular Surgery centre implemented the new draft NHS England TAD service specification by the end of 2020? l

Education What if every UK Medical Degree programme included a module on Aortovascular medicine? l

Genetics & Genomics What if all families in the UK affected by AD knew about and could access Genetics and Inherited Cardiac Conditions services? l

What if the UK had a national screening programme for AD risk? l

What if, in future, everyone has their genome sequenced at birth, their AD risk is identified and Genomics allows us to mitigate this risk? l

Research & Innovation What if we had a national research agenda for Aortic Dissection? l

What if we prioritise and support the best innovations for treating AD? l

Mr. Gareth Owens and his team from Aortic Dissection Awareness (UK & Ireland), with consultant Aortic surgeon Miss Deborah Harrington from Liverpool Heart & Chest Hospital, at their stand in the SCTS Annual Meeting in Westminster

August 2019

This patient-led initiative to produce a national AD strategy in partnership with the medical profession has attracted widespread senior support. The Presidents of SCTS, the Vascular Society and the British Cardiovascular Society all attended the launch and the Presidents of the Royal College of Emergency Medicine and the Royal College of Radiologists sent senior representatives. Representatives of NHS England and Genomics England were also present and these organisations will all play an important role in the consultation process.

In a briefing note to consultation stakeholders after the meeting, Mr. Owens

53

shared further news of support from an unexpected senior source.

writing as you did and in return has asked me to send her warm good wishes to you all.’”

“It is my honour to convey to you all today the following message of support for our work, from a descendant of King George II, which I was privileged to receive on 23rd March:

In view of her ancestral connection with the disease, AD Awareness UK & Ireland intends to present Her Majesty with a copy of the UK AD strategy when it is completed.

Clearly, SCTS members have a major role to play in this strategy, by implementing the forthcoming TAD service specification; by optimising the pathway for AD patients from their referring EDs; by continuing to develop Aortic surgery as a specialist capability across the UK; and by conducting research into Aortic Dissection. n

‘Dear Mr. Owens, The Queen has asked me to thank you for your kind letter of 15th March on behalf of all those associated with Aortic Dissection Awareness, sent on the occasion of your Consultation Launch Event held on 12th March at the Queen Elizabeth II Centre in London.

Her Majesty appreciated your thoughtfulness in

Aortic Dissection diagnosis Graham Cooper, immediate Past-President, SCTS

S

tatistics show that a diagnosis of Aortic Dissection is considered in only half of patients who present with this fatal condition. One-third of patients with an Aortic Dissection are actively treated in Emergency Medicine for an incorrect diagnosis such as a heart attack or gastritis.

Aortic Dissection is not a difficult condition to diagnose when you have a heightened suspicion and are aware enough to THINK AORTA in the first instance.

Experience shows that if Emergency Departments educate staff about Aortic Dissection and lower the barriers to CT scanning, lives will be saved.

Omar Nawaytou of Liverpool Heart & Chest Hospital was inspired by the THINK AORTA campaign and came up with the concept of an Aortic Dissection educational film that could be embedded into every induction within Emergency Departments across the UK.

Taking the idea into action, Catherine Fowler of Aortic Dissection Awareness (UK & Ireland) took on the initiative to create and lead a collaboration between SCTS, Royal College of Emergency Medicine & Royal Collage of Radiology to develop a learning experience for Emergency Medicine providing valuable perspectives across the

patient pathway. Pamela Struthers (patient of Deborah Harrington LHCH) shares her personal story, where she survived an acute aortic dissection following a delayed diagnosis.

The learning material will be released on the RCEM eLeaning platform in May 2019.

As it is an open access platform, materials

are available for you to access, share and encourage your colleagues in radiology and emergency medicine to adopt and embed.

Together we can make a difference to inspire and accelerate the needed change to save lives. For more information visit www.thinkaorta.org n

Pictured left to right our collaborative team: Chris Walsh Head of RCEM eLearning, Pamela Struthers Survivor of Aortic Dissection, Catherine Fowler Vice Chair Aortic Dissection Awareness UK & Ireland, Emma Redfurn Consultant in Emergency Medicine, Associate Medical Director for Patient Safety BUH, Miss Deborah Harrington Consultant Cardiac and Aortic Surgeon LHCH, Professor Mark Callaway Medical Director, Royal College of Radiology

the 54 bulletin

Cardiothoracic Interdisciplinary Research Network (CIRN) Luke J. Rogers (Associate Surgical Speciality Lead) Ricky Vaja (Associate Surgical Speciality Lead) Professor Julie Sanders (SCTS Nursing & AHP Academic & Research Lead) Professor Gavin Murphy (Surgical Speciality Lead)

T

he Cardiothoracic Interdisciplinary Research Network (CIRN) is gaining momentum in developing the network infrastructure necessary to deliver a portfolio of trainee, nursing & allied health professional (NAHP) led clinical trials.

Enthusiastic individuals have continued to express an interest in getting involved with the network and we continue to encourage anyone interested to get in touch (contact details on the next page). The initial pieces of work are well underway and we anticipate being able to submit a research grant for an adult cardiac surgery care bundle to reduce surgical site infection (SSI) towards the end of this year.

Earlier this month (1st May) marked the pilot launch of the national survey into the variation of practise for interventions implemented to prevent SSI. Furthermore, Cochrane have accepted the protocol for a systematic review of interventions already in use to prevent SSI in cardiac surgery.

In this article we review the progress of this work and highlight the numerous

areas in which you can get involved in Cardiothoracic Surgery research, whether directly through the work of the interdisciplinary research network or standalone trials the network is supporting.

Ongoing Projects The background work underpinning the proposed research grant for a clinical trial to test the impact of a cardiac specific care bundle to reduce SSI has involved two related pieces of work: 1. A Systematic Review of Interventions to Prevent Surgical Site Infection (SSI) in Cardiac Surgery The protocol for this work has recently been accepted by Cochrane following prior publication on Prospero1. A steering committee are now working through the data analysis of over 200 articles to describe the findings of randomised control trials that have assessed the benefit of interventions to reduce SSI in adult

â&#x20AC;&#x153;In collaboration with the National Cardiac Benchmarking Collaboration (NCBC) and Public Health England (PHE) a national survey of practise has been launched in 6 centres across the United Kingdom to assess the variation that exists in the prevention of SSI in adult cardiac surgery.â&#x20AC;?

cardiac surgery. We unfortunately must state that Cochrane do not yet accept the Cardiothoracic Interdisciplinary Research Networks position on corporate authorship but this is still under negotiation and yet to be conclusively decided. They have however invited us to write an editorial discussing the networks background, ambition and corporate authorship.

2. National Survey of the Variation in Practise in the Prevention of Surgical Site Infections in UK Cardiothoracic Surgery Centres (ViP Survey) In collaboration with the National Cardiac Benchmarking Collaboration (NCBC) and Public Health England (PHE) a national survey of practise has been launched in 6 centres across the United Kingdom to assess the variation that exists in the prevention of SSI in adult cardiac surgery. Following completion of this pilot we expect to launch this survey across all other Trusts/ Health Boards this summer. We are therefore very keen for individuals who want to be involved as local leads to come forward as representatives for the centre in which they are working. If this is something that interests you please email us (contact details on the next page).

This survey will focus on the delivery of care in the majority of routine cases and is broadly still split into two distinct parts; a section relating to Trust/Health Board initiatives and a section that relates to the practises of individual surgeons working at that centre. This will need completing for each operating adult cardiac surgeon. No patient identifiable data will be collected and all information will be anonymised,

August 2019

both in terms of operating surgeon and Trust/Health Board.

All subsequent publications and presentations resulting from these pieces of work will be disseminated under the Cardiothoracic Interdisciplinary Research Network as part of our policy on corporate authorship. Detailed appendices outlining the contributions of individuals involved will be submitted alongside this work as per our Terms of Reference2 and the recently published guidelines for standardising reporting authorship in collaborative research3.

3. Grant application We envisage that the above work will provide the background information necessary to develop a research proposal to assess the benefit of an adult cardiac surgery specific care bundle to reduce surgical site infection.

This presents further opportunities for those wishing to explore cardiothoracic surgery research as we expect to form a steering committee to develop this proposal and then if successful to oversee delivery of the subsequent trial. In addition, local principle investigators will be required from representatives of the CIRN to ensure this work is delivered in a timely fashion.

Supporting Studies Alongside the principle work of CIRN outlined above the network is also facilitating the delivery of a number of other trials.

UK Mini-Mitral Trial Facilitation and identification of interested trainees in centres recruiting for an NIHR

funded clinical trial. In this trial trainees who aid the recruitment of substantial numbers of patients will be accredited as associate principle investigators in any publications resulting from the trial data. Positions still remain in the following Trusts: l

Essex Cardiothoracic Centre, Basildon

l

Edinburgh Royal Infirmary

l

Hammersmith Hospital, London

l

Kings College Hospital, London

Multicentre Evaluation of Renal Impairment in Thoracic Surgery (MERITS) Facilitation and recruitment of centres to assist Mr Aman Coonar, Mr Vinci Naruka and SCTS Students in the delivery of a Multi-centre Evaluation of Renal Impairment in Thoracic Surgery (www.royalpapworth.nhs.uk/merits/).

This is a multicentre investigation which seeks to bring thoracic surgery centres together to identify rates of AKI and from there, improve outcomes.

Evaluation of Postoperative Atrial Fibrillation in Thoracic Surgery (EPAFT) Facilitation and recruitment of centres to assist Professor Loubani, Dr Emmanuel Isaac and Vassili Crispi in the delivery of an evaluation of the incidence of postoperative AF in thoracic surgery. The study period coincides with that of the MERITS trial and therefore allows efficient data collection.

55

How Can You Get involved?

If you are interested in getting involved whether in one of the specific projects outlined or you have ideas about future research questions do not hesitate to get in touch. Email us at CIRNetwork@outlook. com stating your place of work and interest, question or idea. Keep your eyes on the SCTS website too as we expect in the not too distant future to be able to publish appropriate network documents (such as the networks Terms of Reference, NIHR Associate Principle Investigator Scheme and project protocols). You can also follow the group on Twitter @CIRNetwork. n

References 1. A Systematic Review & Meta-Analysis of Interventions to Prevent Surgical Site Infection (SSI) in Cardiac Surgery Protocol. 20th July 2018. https://www. crd.york.ac.uk/PROSPERO/display_ record.php?RecordID=104219 2. Terms of Reference. Cardiothoracic Surgery Interdisciplinary Research Network (CIRN). Society for Cardiothoracic Surgery (SCTS) in Great Britain & Ireland. Dec 2018.

3. National Research Collaborative & Association of Surgeons in Training Collaborative Consensus Group.

Recognising contributions to work in research collaboratives: Guidelines for standardising reporting of authorship in collaborative research. International Journal of Surgery 2018 Apr; 52: 355-360.

the 56 bulletin

SCTS Education report July 2019

Sri Rathinam, SCTS Education Secretary

T

he Education Team have streamlined the various sections in terms of courses, fellowships and restructured the team. It has been an exciting six months and just as we thought we had organised everything there are new challenges to face and new ventures to explore. The annual meeting was busy as ever with various sub-committee meetings, fellowship interviews, video prize finals and seeking funding from industry.

The wheels of life have been turning at a rapid pace, it is unbelievable that the first batch of trainees who started with the bootcamp (ST3) have completed the whole portfolio with the pre consultant course (ST8) in Hamburg. The NTN portfolio under the tutors Carol Tan and Sunil Bhudia and the AHP Portfolio led by Bhuvana Krishnamoorthy and Tara Bartley have gone from strength to strength.

The SCTS-Ionescu University proceedings of 2018 have been published as the Perspectives in Cardiothoracic Surgery Volume 4. Paul Modi, after executing an excellent role as Editor, is handing the reins over to Bil Kirmani.

SCTS-Ionescu Collaboration Mr Ionescu’s support has allowed the SCTS to offer various fellowships to the multi-disciplinary team. The annual awards were announced at the annual meeting in London. We offered the first SCTS-Ionescu Oscars to the award winning videos in the trainees’ operative video prize competition.

Mohamed Elsaegh from Royal Papworth Hospital was voted the best cardiac video (Pulmonary thromboembolectomy) and Rini Vyas from Leicester was chosen as best thoracic video (chest wall reconstruction).

We had a very positive meeting with Mr Ionescu updating him of the educational activities of the SCTS and the fellowships in April 2019.

SCTS-Ionescu Fellowships We are delighted to inform the members Mr Ionescu has offered support to another round of additional exceptional fellowships in summer 2019 and will replicate the same categories for the Annual meeting in 2020. We urge members to make robust applications to benefit from this

opportunity. We encourage members to highlight their experience, achievements and motivation in their applications.

SCTS-Ionescu Foundation Courses We highlighted the challenges facing the society in maintaining the same level of funding from industry as previous years to offer our educational courses free to our membership. Mr Ionescu has agreed to extend his support to some of the training courses to enable us to continue the same level of standard without the trainees incurring any costs. These courses will be offered under the title SCTS-Ionescu Foundation Courses.

Fellowship winners We had a record number of applications to the SCTS-Ionescu fellowships and Ethicon NTN fellowship applications.

SCTS Education judged applications on the merits of the individual track record as well as the impact of the proposed fellowship in a structured process. Each application was judged and scored by a panel depending on the category.

The Marian and Christina Ionescu Travelling Fellowship for a consultant: Mr Kulvinder Lall, St Bartholomew’s Hospital to visit Dr Manchandi in Houston Methodist Hospital and Dr Chu’s Unit in Western University London Canada to learn minimally invasive aortic valve replacement techniques.

SCTS-Ionescu Travelling Fellowship for Consultants:

Paul Modi

Bil Kirmani

Mr Marius Berman, Royal Papworth Hospital to visit Prof Nil Uriel’s unit on Heart Failure and transplantation in

August 2019

the University of Chicago, USA, to learn about integrated approaches in heart failure and shock management.

SCTS-Ionescu NTN Trainee Travelling Fellowship: Mr Edward Caruana, East Midlands Training Programme to visit Dominique Gossot, Institut Mutualiste Montsouris, Paris, France (Minimally invasive segmental resections), and Prof Spaggiari Istituto Europeo di Oncologia, Milan Italy (Advance lung resections and Robotic thoracic surgery).

SCTS-Ionescu Non-NTN Surgical Fellowships: Mr P Korah Oommen, University Hospitals of South Manchester towards visits to Cerfolio’s unit Langone Lung Centre New York University to learn about Robotic Thoracic Surgery. This is a part of robotic programme introduction in Manchester.

Mr Philemon Gukop, St George’s Hospital to visit Prof El Khoury’s unit in St. Luc Hospital Bruxelles Belgium to learn valvular repair techniques.

SCTS-Ionescu Non-NTN small travel awards: Pradeep Kaul, Royal Papworth Hospital to visit Prof Keshavjee’s unit in Toronto General Hospital to get experience in Ex-Vivo Lung Perfusion (EVLP) program.

for research and create collaborative opportunities for the newly established SCTS Cardiothoracic Interdisciplinary Research Network.

Rosalie Rena Magboo, St Bartholomew’s Hospital London to visit Prof S Hendricks to learn about surgery as well as HRQoL and psychosocial aspects of care in comprehensive care pathways for Marfan FS patients.

Trudy Elliott, Southampton University Hospitals to visit the Manchester Hospitals to understand pathways and policies in implementation of lung cancer screening and centralised lung cancer surgical pathway as part of optimal national lung cancer pathway.

SCTS-Ionescu Medical Student Fellowships: Madhivanan Elango, Cambridge University to go to The Mayo Clinic Rochester (M Stulak) to gain thorough exposure to the evaluation and treatment of patients with congenital or acquired heart disease.

Sashini Iddawela, University of Birmingham to visit Kandy Teaching Hospital, Kandy, Sri Lanka (Dr Muditha Lansakara) to focus on Cardiac surgery and perform systematic review on mitral valve repair of infective endocarditis.

Zoya Rashid, University of Bristol to visit the Royal Prince Alfred Hospital (Professor Paul Bannon) with a focus on cardiac surgery as well as aiming to do research on ASDs.

“We had a record number of applications to the SCTSIonescu fellowships and Ethicon NTN fellowship applications. SCTS Education judged applications on the merits of the individual track record as well as the impact of the proposed fellowship in a structured process.”

Andrew Selvaraj, St Bartholomew’s Hospital London to visit Prof El-Khoury in Cliniques Universitaries, Saint Luc to learn aortic valve repair.

Alison Woolley, King’s College Hospital, London to visit the Cleveland clinic to learn nurse led preoperative work-up, patient education and implementation of pathways.

SCTS-Ionescu Nursing & Allied Health Professional Fellowships:

Louise Wyllie-Lau, Nottingham University Hospitals, Nottingham to visit Dr Mintz’s unit in Heart and Vascular Institute, Maimonides Medical Centre New York and to experience the patient treatment pathway and follow up process for their surgical AF patients, both concomitant and lone AF and shadow the AF navigator nurse.

Prof Julie Sanders, St Bartholomew’s Hospital London to visit Prof S Fredericks Ryerson University Toronto to learn about nursing research, pathways and promote collaborative working. It also aims to understand the clinical opportunities

Manveer Rahi, University of Edinburgh to visit Auckland City Hospital (Dr Haydock) to have clinical immersion in Cardiothoracic Surgery.

SCTS Ethicon NTN Fellowship Winners:

Rizwan Attia, London Deanery for an advanced operative clinical fellowship at Massachusetts General Hospital affiliated to Harvard University focusing on major aortic cases, minimally invasive approaches and surgical heart failure therapies.

Izanne Mydin, North East Programme to visit Toronto General Hospital for Lung transplantation and lung preservation techniques.

Mobi Rehman, Wessex deanery to focus on minimally invasive cardiac surgery in the OLV Clinic in Aalst.

Azhgar Nawaz, Northwest deanery to visit New York for clinical immersion in Robotic surgery.

57

the 58 bulletin

The 2nd Consultant masterclass

25th anniversary meeting of the Egyptian Society of Cardiothoracic Surgery

SCTS - ESCTS Collaboration The 2nd Consultant masterclass The 2nd Consultant masterclass was held on the Saturday on the theme â&#x20AC;&#x153;Introduction of Innovation and New Techniques into clinical practiceâ&#x20AC;?. We had a great attendance with the programme addressing all aspects of innovation, regulation, credentialing including a live link to Johnson & Johnson innovation centre in Cincinnati Ohio. Dr P Wall Director, ISCA Healthcare gave an overview on taking a concept to a formal product. This included intellectual property rights, regulation as well as tips on engagement with NIHR, MHRA and Ethics committees. Ms Jessica Todd - Global Strategic Marketing, Thoracic, Ethicon via a live link to Johnson & Johnson innovation centre in Cincinnati Ohio explained the process of innovation to development and design. Mr R Steyn, Deputy Medical Director, University Hospitals of Birmingham discussed the regulatory and governance structure to introduce into clinical practice.

Finally Mr S Bhudia gave top tips on writing a good business case and securing funding.

We have co-hosted the 25th anniversary meeting of the Egyptian Society of Cardiothoracic Surgery with a pre-course masterclass. The meeting and discussions around future collaborations were very positive including training opportunities for our trainees. There were mutually beneficial areas of interest agreed. The Suez Canal University has offered to be the host unit for SCTS courses which would incorporate SCTS principles but aimed

at international trainees enabling us to disseminate our educational model outside the United Kingdom for wider benefits.

SCTS Education started in 2013 with a boot camp and a dream, it has now progressed and blossomed to become a proud achievement of SCTS. We have been successful because our society and our members have the passion, motivation and commitment. We are grateful to our benefactors for allowing us to realise that dream and offer this portfolio of educational opportunities to our membership. n

August 2019

59

SCTS-Ionescu

Additional Exceptional Fellowships 2019

T

he Society for Cardiothoracic Surgery in Great Britain & Ireland (SCTS) is pleased to invite applications for the Additional Exceptional Fellowships for 2019 sponsored by Mr Marian Ionescu. The broad range of the Fellowships allows all SCTS members to benefit - Consultants, all grades of Trainees, Nurses, Allied Health Professionals and Medical Students.

Mr Ionescu has supported the SCTS with his donations to the society for educational activities for many years. As a surgeon, educator and trainer Mr Ionescu has seen the value of helping in the development of trainees, consultants and the teams they work in.

In view of the great success of last year’s additional fellowship round and Mr Ionescu’s continued support, we are privileged to announce the following fellowships for the wider cardiothoracic multidisciplinary community.

SCTS-Ionescu Consultant Team Fellowships: 2 awards, £15,000 each Eligible applicants include all members of the multi professional team which should include a Consultant Cardiothoracic Surgeon currently working in Great Britain & Ireland in all sub-specialties, including adult cardiac surgery, thoracic surgery, congenital cardiac surgery and transplantation surgery. The fellowship is awarded to support a visit of a team to a cardiothoracic surgery centre, which may be in the UK, Ireland or elsewhere in the world.

SCTS-Ionescu NTN Trainee Travelling Fellowship: 1 award, £10,000 Eligible applicants include nationallyappointed cardiothoracic surgical trainees in Great Britain & Ireland, who have not yet secured a consultant post. The fellowship is awarded to support a visit to a cardiothoracic surgery centre, which may be in the UK, Ireland or elsewhere in the world. It is designed to enhance the experience of the applicant in preparation for a career as a Consultant Cardiothoracic Surgeon.

SCTS-Ionescu Non-NTN Surgical Fellowships: 2 awards, £10,000 each Eligible applicants will be cardiothoracic surgical trainees currently without a National Training Number. Examples would be clinical fellows, specialty doctors, associate specialists and staff grade doctors, currently working within cardiothoracic surgery in Great Britain & Ireland. The Fellowships will be awarded to support a visit to a cardiothoracic surgery centre in the UK, Ireland or elsewhere in the world, although applications will be considered for other educational opportunities to enhance the experience of the applicant in furthering their career in cardiothoracic surgery. The applicant should be able to describe how their Fellowship will enhance the specialty of cardiothoracic surgery and the wider NHS. SCTS-Ionescu Non-NTN small travel awards: 2 awards, £5,000 each Eligible applicants will be cardiothoracic surgical trainees currently without a National Training Number. Examples would be clinical fellows, specialty doctors, associate specialists and staff grade doctors, currently working within cardiothoracic surgery in Great Britain & Ireland. The Fellowships will be awarded to support a visit to a cardiothoracic surgery centre in the UK, Ireland or elsewhere in the world to enhance the experience of the applicant in furthering their career in cardiothoracic surgery.

SCTS-Ionescu Nursing & Allied Health Professional Fellowships: 3 awards, £5,000 each Eligible applicants include Cardiothoracic Nurses, Advanced Nurse Practitioners, Surgical Care Practitioners, Physician Assistants, Physiotherapists, Pharmacists and Perfusionists, currently working within Cardiothoracic Surgery in Great Britain & Ireland and professionally registered with the NMC or HCPC. The Fellowships will be awarded to support a visit to a cardiothoracic surgery centre in the UK, Ireland or elsewhere in the world, or other educational opportunities which enhance the experience of the applicant to further their career in cardiothoracic surgery.

SCTS-Ionescu Medical Student Fellowships: 4 awards, £500 each Eligible applicants include medical students at a University in the UK & Ireland. The Fellowships will be awarded to support a visit to a cardiothoracic surgery centre which may be in the UK, Ireland or elsewhere in the world. It is designed to enhance the educational experience of an aspiring cardiothoracic surgeon. It is likely that the successful applicant will have already shown an interest in cardiothoracic surgery, identified a UK consultant mentor and will be seeking an immersive experience during an elective typically at least 4 weeks in duration.

How to apply...

Prior to applying, please contact Letty Mitchell at education@scts.org for the application form and further information about required documentation.

the 60 bulletin

New Consultant Appointments - August 2019 to December 2019 Name

Hospital

Specialty

Starting Date

Jayanta Nandi

Hammersmith Hospital, London

Thoracic

June 2017

Steve Livesey

St George’s Hospital, London

Cardiac

December 2018

Mindaugas Rackauskas

Mater Misericordiae Hospital, Dublin

Locum Thoracic & Lung Transplant Consultant

January 2019

Michail Koutentakis

University Hospital of Wales, Cardiff

Locum Cardiac Surgeon

February 2019

Lawrence Okiror

Guy’s Hospital, London

Thoracic

February 2019

Giuseppe Rescigno

New Cross Hospital, Wolverhampton

Locum Cardiac Surgeon

March 2019

Ahmed Habib

New Cross Hospital, Wolverhampton

Thoracic

May 2019

David Rose

Blackpool Victoria Hospital

Cardiac

April 2019

Gerard Fitzmaurice

St James’s Hospital, Dublin

Locum Thoracic Surgeon

May 2019

Caroline Chenu

Royal Brompton Hospital, London

Congenital

July 2019

Incoming/Outgoing Officers Incoming Officers

Title

Amal Bose

Honorary Treasurer

Maninder Kalkat

Meeting Secretary

Mobi Chaudhry

Elected Trustee

Carin Van Doorn

Elected Trustee/ Congenital Cardiac Surgery Audit Lead

Doug West

Audit Sub-Committee Co-Chair

Serban Stoica

Congenital Cardiac Surgery Deputy Audit Lead

Uday Trivedi

Adult Cardiac Surgery Audit Lead

Steve Woolley

Thoracic Surgery Sub-Committee Co-Chair

Rafael Guerrero

Congenital Cardiac Surgery Sub-Committee Co-chair

Daisy Sandeman

CT Nursing & AHP Forum Lead

Chris Efthymiou

Perfusion Representative

Duncan Steele

Senior Trainee Representative

Abdul Badran

Junior Trainee Representative

Outgoing Officers

Title

Kulvinder Lall

Honorary Treasurer

Prakash Punjabi

Elected Trustee

Shyam Kolvekar

Elected Trustee

David Jenkins

Audit Sub-Committee Co-Chair / Adult Cardiac Surgery Audit Lead

Juliet King

Thoracic Surgery Sub-Committee Co-Chair

Carin Van Doorn

Congenital Cardiac Surgery Sub-Committee Co-chair

Clinton Lloyd

Meeting Secretary

Ahmed Al-Adhami

Senior Trainee Representative

Jacob Chacko

Junior Trainee Representative

August 2019

61

Obituary:

Leonard Bailey 1942-2019

John Dark & Asif Hasan, Newcastle University and Freeman Hospital, Newcastle

L

en Bailey, the father of paediatric cardiac transplantation, has died of cancer at the age of 76.

Although born in Marland, Bailey graduated from Loma Linda University medical school in 1969. He spent some time as senior Resident at the Hospital for Sick Children in Toronto, at a time when the speciality was evolving at a huge rate – Bill Mustard, George Trusler and Bill Williams were the leading surgeons. Bailey also noted that for a number of conditions, there was no surgical option, and the infants often died early after birth.

He returned to a paediatric practice at Loma Linda in 1976, staying on the staff for the next 42 years. Over a number of years, his laboratory devised successful xenotransplants in immature animals. In 1984 he was in the world’s headlines for transplanting a baboon heart into a baby with hypoplastic left heart syndrome – the “Baby Fae” case.

The child survived for only four weeks, and that particular field went quiet. But the work laid the ground for the first series of successful paediatric cardiac transplants, and Loma Linda became the leading centre in the world.

A number of us visited him in 1990, and again in 1994, to see a programme which was the model of how to organise successful cardiac transplants in infants and children. We also had the chance to see his wonderful

manner with patients and their parents.

He has been described as “one of the kindest people you could meet”, “a real gentleman” and a “gentle giant”.

Bailey had a wide repertoire in congenital surgery, and made significant contributions, but is best known for his influence in transplantation. He received the “Pioneer Award” from the International Society for Heart and Lung Transplantation in Madrid in 2006.

A revealing interview with him can be found in the ISHLT Archives at https:// ishlt.org/about-ishlt/ishlt-historyproject/video-interviews?viewmode=0

He also had links with a number of centres and surgeons in the UK. In 2008 he gave the Rutherford Morrison lecture in Newcastle, and spent several days as the guest at a combined Newcastle/ Great Ormond Street clinical meeting.

His talk began memorably with a video of the helicopter approach to the roof of the Loma Linda Medical Centre when returning with a donor heart.

Leonard Bailey is remembered with huge affection by all those who knew him; his legacy in paediatric cardiac transplantation is with us in every day of our clinical practice. n

“A number of us visited him in 1990, and again in 1994, to see a programme which was the model of how to organise successful cardiac transplants in infants and children. We also had the chance to see his wonderful manner with patients and their parents. He has been described as “one of the kindest people you could meet”, “a real gentleman” and a “gentle giant”.”

the 62 bulletin

Crossword

Set by Samer Nashef

Across

1/5 Monarch surrounded by cheap stuff left in

accommodation for 29 (8, 6)

9 Pollster gets stylish villain (8)

10 Discharge once covered loud complaint (6)

12 15 5 to a fault (9)

13 See 23 Down

14 See 21 Across

16/20 What music is playing round church? Double that (5, 2, 4)

19 Loose woman admits greeting without considering

the consequences (2, 1, 4)

21/14 Exposed triumph by theologian over conflict (8)

24/27 Gerry hit station where 5 lived (5, 6)

25 Nice area initially cleared up and razed to ground (4, 5)

27 See 24 Across

28 One learned from Harvard course offered by institute

of higher education (8)

29

Transaction state, not as tracker (6)

30

An individual present: a slice of meat, tenderised (8)

Down

1

Please email solutions by 30/09/19 to: sctsadmin@scts.org or send to Isabelle Ferner, SCTS, 35-43, Lincoln’s Inn Fields, London WC2A 3PE A bottle of champagne or fine olive oil will be sent to the winner of the competition Congratulations to Chris Blauth for winning the January 2019 bulletin crossword competition (right) for which he received a bottle of fine olive oil.

Look pleased to welcome one, as pleased as Punch perhaps? (6)

2 Hearing problem? Perhaps wear a cross (6) 3 ...or restraint (5) 4 Tom needs this act of God not to begin reforming (3, 4) 6 Naked holy sect making sense (9) 7 Somewhat abnormal in Germany to shirk responsibilities (8) 8 Allure of sixes and sevens, not half confused (8) 11/21 In rewriting tune, how idiot lacked! (4, 7) 15 Repulsive brother an abomination (9) 17 Fail as Eliot rants (8) 18 Rider almost mixed sandwiches: initially lemon jelly (8) 20 See 16 Across 21 See 11 Down 22 Eddie’s last letter (6) 23/13/26 Author crashed the only car around (6, 5, 5)

Upcoming SCTS Courses in 2019 Date/s

Course

26th – 27th September 2019

SCTS Essential skills for Cardiothoracic Surgery

27th September 2019

Multidisciplinary Course – Harefield Hospital

28th September 2019

ST7B – Clinical examination course for FRCS (C-Th), Papworth Hospital, Cambridge

14th – 16th October 2019

ST3A – Introduction to Specialty Training in Cardiothoracic Surgery Course – Ashorne Hill, Leamington Spa

26th – 28th November 2019

ST4A – Core Cardiac Surgery Course – Ashorne Hill, Leamington Spa

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LivaNova Canada Corp.

5005 North Fraser Way Burnaby BC V5J5M1 - Canada Tel: 1-604-412-5650

INDICATIONS: The Perceval Plus prosthesis is indicated for the replacement of diseased native or a malfunctioning prosthetic aortic valve via open heart surgery. The prosthesis is indicated for use in adult patients who are diagnosed to have aortic valve stenosis or steno-insufficiency.

TOP POTENTIAL SIDE EFFECTS: central and paravalvular leak, cardiac disorders, structural valve deterioration, thromboembolism, reoperation.

The decision of using Perceval Plus in patients should be based on a careful individual assessment and limited to cases in which the benefits of using Perceval Plus justify the risks. The available clinical data indicate that using Perceval Plus in patients with other prostheses may result in intraoperative valve misplacement or insufficient leaflet coaptation leading to valve replacement, due to possible interference with the other prostheses.

The decision of performing Valve-in-Valve procedures is at the discretion of the cardiologist and/or hospital’s heart team, following careful assessment of the individual circumstances of each patient. Currently, no long-term data exists to support the efficacy of the procedure.

MRI conditional.

For professional use. Please contact us through our website to receive instructions for use containing full prescribing information, including indications, contraindications, warnings, precautions and adverse events. Not approved in all geographies. Consult your labeling.

© 2019 LivaNova all rights reserved.

IM-01985 D

available to a wide patient population

TRIFECTA™ GT VALVE

Be c a u se yo ur p a t i ent s ’ live s matte r.

HEMODYNAMICS MATTER.

Abbott Vascular International BVBA Park Lane, Culliganlaan 2b, 1831 Diegem, Belgium Products intended for use by or under the direction of a physician. Prior to use, reference the Instructions for Use provided inside the product carton (when available), at eifu.abbottvascular.com or at manuals.sjm.com for more detailed information on Indications, Contraindications, Warnings, Precautions and Adverse Events. Photo(s) on file at Abbott. Information contained herein is for distribution for Europe, Middle East and Africa ONLY. Please check the regulatory status of the device before distribution in areas where CE marking is not the regulation in force.

For more information, visit our website at www.abbott.com Trifecta and Trifecta GT are all trademarks of Abbott Corporation. © 2018 Abbott. All Rights Reserved. 9-EH-3-7621-01 02-2018