Advanced Training Module in Perioperative Medicine
University Hospital of North Durham
Lead: Dr Alastair Duggie
The module offers opportunities in Post Operative Medicine/Colorectal /Urology & Gynae
Domain 1-Clinical Practice
At UHND, we perform over 200 major intra-abdominal operations a year, which include both open and laparoscopic work. These are largely for cancer (120+), inflammatory bowel (40+) and other pathology (40+). In addition, there are a small number of these that are combined cases with plastics (about 5-10/year) which require free flaps. All patients undergoing major abdominal surgery are seen in a high risk anaesthetic clinic (4/week) with cardiopulmonary exercise testing routinely performed as part of the preoperative assessment.
Domain 2-Team working
There are regular colorectal and Vascular MDTs every week at UHND. During the patient pathway, there are multiple opportunities to enhance their team working skills, which include but are not limited to participating in MDTs, Preoperative Assessment, Acute pain ward rounds. Trainees in the advanced module will also be in the second tier on call rota where they have further opportunities to develop their team working skills.
Domain 3- Leadership
At UHND, there is good precedent of senior trainees leading on patient care starting from the preoperative assessment all the way to postoperative care. Trainees towards the end of their training have also been given the opportunity to act up and work at Consultant level.
There are opportunities to participate and lead on patient improvement initiatives in Preoperative Assessment.
There are regular portfolio research projects running in UHND and trainees can choose to get involved in varying degrees to get a better understanding of conducting research in the NHS.
We have an agreement with the Care group director and Medical director to allow the candidates to shadow them during appropriate meetings/events. This will give the candidate an insight into higher level management styles and leadership skills.
There is a year round teaching programme for covering all the common exam topics. We get a regular intake of undergraduate students who have their own teaching programme as well. We also have regular teaching sessions for the nursing staff across various groups which include recovery and preoperative nurses. Candidates can choose to organise and deliver these teaching sessions to develop this aspect of their training.
Queen Elizabeth Hospital, Gateshead
Lead Clinician: Dr Andy Bracewell
This module offers the opportunity to advance your knowledge and skills in peri-operative medicine within a friendly and forward-thinking team. You will gain experience in leading care for patients undergoing high risk surgery and will be expected to lead quality improvement and service development in this area.
QEGateshead has an established pre-operative assessment system which includes nurse-led and Consultant-led pre-assessment clinics and a Cardiopulmonary Exercise Testing (CPET) service. The Trust is the regional tertiary-referral centre for gynae-oncology surgery and also performs major colorectal operations.
There are currently three CPET clinics per week. All patients over 50 years of age undergoing major intra-abdominal surgery, and selected other “high-risk” patients are CPET tested. All of the CPET clinics are Consultant led, “one-stop shop” clinics where patients undergo CPET testing, results are analysed, and the patient counselled about the risks of surgery. This feeds into the planning of peri-operative care for patients, including the use of critical care facilities. In addition to the CPET service there are three “High Risk” Anaesthetics Assessment Clinics per week, all of which are Consultant-led. A variety of patients are seen in these clinics, all of whom require some planning of peri-operative care.
In terms of theatre experience, trainees should expect to gain experience in anaesthesia for major surgery in colorectal (both laparoscopic and open), gynae-oncology surgery and major orthopaedics. QE Gateshead is the Tertiary referral centre for the North of England. Gynae-onc surgery performed includes major laparoscopic procedures as well as prolonged, extensive open intra-abdominal surgery, with bowel resection, splenectomy, diaphragmatic surgery and liver resection, in addition to the “gynaecological” component of the surgery. There is potential for massive blood loss and fluid shifts. Peri-operative management of these patients is challenging and requires careful planning and execution.
What trainees would be expected to achieve during Advanced module:
- Experience in CPET clinics, High-Risk pre-assessment clinics and enhanced recovery programmes.
- Development of skills in risk-assessment and patient counselling/shared decision-making.
- The ability to lead clinics and undertake CPET testing and interpretation of results, including decision-making regarding fitness for surgery.
- The ability to utilise results from pre-op assessment to optimise and pre-habilitate patients prior to surgery.
- Experience of management of major surgery cases including colorectal and gynae-onc surgery in supervised and “solo” capacity.
- Involvement in the post-operative management of patients, including those on Critical Care.
- Involvement in the peri-operative care process for patients undergoing major emergency surgery.
- Service development within perioperative medicine, including, but not limited to:
- Quality improvement programme within pre-operative assessment, intra-operative or post-operative care.
- Guideline development within peri-operative medicine.
- Care pathway development for peri-operative care of major emergency surgery.
- Monitoring of service delivery and implementation using audit/QI methodology.
- Development of links with other specialties to ensure high-quality patient care.
- Involvement in teaching, including teaching anaesthetics trainees, medical students and nursing staff.
Royal Victoria Infirmary
This post is for 6 months, within the specialty training programme for anaesthesia in the Northern School of Anaesthesia and Intensive Care Medicine; as such the post holder will be an ST6 or ST7 trainee. By the end of the attachment, successful trainees will be expected to have achieved the competences for completion of advanced perioperative medicine training and furthered their completion of the advanced domains of training, as well as the competences contained within “Annex G,” in accordance with the Royal College of Anaesthetists curriculum 2010. The relevant competences and learning outcomes can be found here: http://www.rcoa.ac.uk/CCT/AnnexE; http://www.rcoa.ac.uk/CCT/AnnexG.
Trainees undertaking this unit of training should be conversant with the higher level competences in perioperative medicine.
Clinical commitments will primarily be to anaesthesia for major elective surgery (oesophagogastric surgery, colorectal surgery and major spinal surgery) and the pre-assessment service; it is expected that on average two sessions per week will be spent in pre-assessment. There is the opportunity for the post holder to learn to undertake and interpret cardiopulmonary exercise testing. Exposure to relevant medical specialties, such as through cardiology, respiratory medicine and assisted ventilation clinics, can be facilitated, as well as attendance at MDTs. On call commitments will involve participation in the “PINC” and “ORANGE” second on call rota at the RVI, offering a broad range of out of hours clinical and team leadership experience.
A significant component of this unit of training, in addition to the furthering of clinical knowledge and skills, will be the development of non clinical skills in preparation for independent consultant practice and we would hope to equip trainees to take a leadership role in perioperative medicine. The post holder will be expected to make a meaningful contribution to relevant service improvement, educational and research activities, taking a leadership role where appropriate. Non-clinical time will be made available to support this.
Educational supervision will be provided by either Dr R Sinclair, lead for the pre-assessment service, or Dr K Duffield, lead for perioperative medicine. Once appointed to this advanced module, trainees are encouraged to make early contact with the supervisors, before commencing in post, in order to maximise the opportunities available during the attachment. Clinical supervision will be by a number of consultants as indicated on the online rota.
Newcastle is at the forefront of advances in pre-assessment and perioperative medicine, and we work closely with colleagues at the Freeman Hospital. Our pre-assessment service at the RVI has expanded significantly over recent years, seeing over 7000 patients in 2015-16; patient and colleague satisfaction with our service is high. The Trust, combining both sites, hosts one of the largest cardiopulmonary exercise testing facilities in the country. Our pre-assessment service is predominantly nurse delivered, with approximately 30% of patients receiving consultant input (either by means of notes review or in person). Early anaesthetic assessment and optimisation are integral to our pathways for patients with gastrointestinal malignancy and inform overall cancer management decisions. We have well established relationships with a number of specialties, including cardiology, haematology and respiratory medicine.
The RVI offers a number of tertiary surgical services, including oesophagogastric surgery, neurosurgery, correction of spinal deformity, complex abdominal wall reconstruction, surgical management of locally advanced anorectal cancer and management of burns; we are a major trauma centre. The pre-assessment and anaesthesia teams are supported by excellent relationships with colleagues from critical care and pain. Both our surgical and critical care services, and indeed the overall Trust, have been rated as “Outstanding” by the Care Quality Commission. Our long established assisted ventilation service supports over 500 ventilated patients across the North.
The directorate of perioperative and critical care medicine is large, with approximately 70 consultants and a similar number of trainees/SAS doctors. We are an academic department and a number of consultants have interests in research and quality improvement, supported by our team of research nurses; Dr Rhona Sinclair and Dr Dave Saunders have particular research interests related to perioperative medicine. A number of innovative approaches to perioperative care have been adopted across the department, including the widespread use of regional anaesthesia/analgesia and a very successful pathway to facilitate day case breast surgery. As a department, we have committed to working towards anaesthesia clinical services accreditation (ACSA) by the Royal College of Anaesthetists.
This is a 6 month training module based at the Freeman Hospital. The primary aim of the module is to provide a broad training based on the RCOA Perioperative Medicine Programme and is supervised by Dr James Prentis and Dr Chris Snowden (National Clinical Lead for Perioperative Medicine). The recent CQC report has highlighted the perioperative care team at the Freeman as national leaders in pre-operative assessment, cardiopulmonary exercise testing and outcome prediction after major intra-abdominal surgery (including shared decision making in the pre-operative counselling process)
The post will cover the competences listed in the CCT in Anaesthetics Higher Curriculum and Advanced Training in Perioperative Medicine.
The post will commence with a period of learning and acquisition of a broad knowledge base to underpin the delivery of the perioperative programme . This will involve collating the evidence base for best practice in one of a number of possible areas:
- Prehabilitation and patient optimisation
- Enhanced recovery pathways
- Risk modelling and measures of functional capacity
- Assessment of cardiorespiratory capacity and application to decision making
- The role of primary care and social care on modifying disease processes and optimising physiology perioperatively.
- Shared decision making in planning and modifying surgical approach and perioperative management.
- Multi-specialty and integrated multidisciplinary management pre- and post-operatively
- The use of goal directed therapy intra-and post- operatively
- Pain management strategies and their impact on perioperative outcomes.
- Long term follow up of post operative patients to evaluate morbidity, effectiveness of intervention and identification of key performance benchmarks.
We would hope the post holder will be able to support the implementation of a quality improvement programme at a local and possibly national level in their chosen area.
The post holder will then participate in and ultimately lead perioperative medicine clinics incorporating comprehensive preassessment including cardiopulmonary exercise testing, critical evaluation of the preoperative condition and suitability of patients for listed procedures, shared decision making, discussion of advantages and disadvantages of potential anaesthetic techniques, application of national and international guidelines and adopting an individual approach to the patient.
The post holder will deliver safe, effective and patient-centred care. There will be the opportunity to develop skills in
- communication, consent, consideration of alternative treatment plans,
- engaging the expertise of other specialties where appropriate.
- conducting and interpreting appropriate perioperative investigations including, but not limited to, cardiopulmonary exercise testing, coronary angiography, stress echocardiography, and blood investigations.
- Opportunistic health screening with referral to services to address modifiable lifestyle factors which affect perioperative outcomes.
- the management of anticoagulation and diabetes pathways
The post holder will work closely with their supervisors and also the nursing and surgical teams to support the delivery of the perioperative programme.
- This will require understanding of the current working practices and seek out and work with champions to effect change.
- There will be collaboration with the surgical teams to identify their priorities for implementation of the perioperative medicine programme and identify ways in which they can be supported to achieve this aim.
- There will also be wider collaboration with trainees with an interest in perioperative medicine (TRiPOM).
The post holder will become a key member of the perioperative research team. We currently have a number of research studies ongoing including a NIHR HTA sponsor study aimed at reducing alcohol intake preoperatively. We would hope that they will be a number of potential studies that the fellow could help develop including ethics applications,
There will be a significant teaching commitment during the post. This will take the form of:
- delivering teaching at workshops on the specific themes of the programme to the nursing staff
- organization of the audit meeting for senior medical team
Assessment of performance will take the form of workplace based assessments, production of reports, multisource feedback and reports from supervisors. We would also expect the trainee to be in a position to be accredited with the perioperative exercise testing and training society for CPeT by the end of their attachment.
James Cook University Hospital
Advanced year in Anaesthesia for Major Surgery, Pre-assessment and Peri-operative Medicine at South Tees.
An exciting opportunity is available for trainees within the department of Anaesthesia at South Tees Hospitals NHS Foundation Trust. In collaboration with the Northern School of Anaesthesia we have created advanced training positions combining clinical work in the Pre-assessment clinic, Major surgery in theatre and access to relevant aspects of peri-operative Medicine.
The intention of this attachment is to provide a year of clinical training that can be mapped to the RCOA advanced curriculum and the opportunity to participate in research/academic projects as a senior trainee. The post is designed to incorporate teaching and solo lists in complex major surgeries, pre-assessment and commitment to out-of-hours service provision in a Major Trauma Centre. There will also be timetabled opportunities to access research/academic activities and relevant aspects of peri-operative Medical care.
The year is divided into 4 blocks of 3 months designed to fulfil the core learning outcomes for Advanced training with in built pre-assessment sessions to enable the individual to gain experience in both pre-assessment clinic and CPEX. In the table below we have suggested the blocks that we feel are likely to “best fit” with pre-assessment and peri-operative Medicine, however it should be noted that any of the subspecialties in the General Duties module (such as Obstetrics if desired) can be accommodated. Successful candidates will:
- Deliver anaesthesia and pre-assessment sessions involving a wide range of surgical cases demonstrating understanding of the problems encountered
- Show the decision making and organisational skills required of an anaesthetist to manage busy clinics and operating sessions that involve major surgery and ensure the care that is delivered is safe and timely
- Assist colleagues in decisions about the suitability of surgery in difficult situations
- Provide teaching to less experienced colleagues of all grades
|Suggested Blocks||Case Mix||Specific Module Learning outcomes|
|Vascular Surgery with vPAC & CPET||EVARs, Carotid surgery, Open aneurysm surgery, peripheral revascularisation procedures. Opportunities to attend vascular PAC.||WBAs as per 2010 curriculum (1x A-CEX, ALMAT and CBD)
|Major Abdominal Surgery with general PAC||Cystectomy, major colorectal surgery, Upper GI, Bariatrics and Gynae oncology with general PAC sessions||WBAs as per 2010 curriculum (1x ALMAT)|
|Major Head and Neck Surgery with general PAC||Major Maxillofacial, ENT and Plastic reconstructive head and neck procedures with general PAC sessions||WBAs as per 2010 curriculum (1x A-CEX, ALMAT, DOPS)|
|Option block||This may involve academic/research endeavours, but could be spent visiting the Cardiology or Respiratory departments. It is assumed that most candidates will complete the CPX international course (or equivalent) in this time.||WBAs as per 2010 curriculum if further clinical attachment undertaken.|
The clinical expectation on which competence will be assessed is that the trainee will complete a minimum of 10 sessions in each subspecialty module of clinical work, allowing a minimum of 10 sessions per 3 months to be spent in peri-operative medicine/pre-assessment activities such as clinic.
The department has an expanding research base with several exciting trials. These trials encompass research in anaesthesia, critical care and Obstetrics. Recent studies include assessing the benefits of preoperative exercise training prior to major vascular surgery. Other examples include trauma research with the Ministry of Defence and cutting-edge studies involving pre-operative assessment and cardiopulmonary exercise testing. The research team comprises a number of research active consultants, 1 academic foundation programme doctor, a critical care research fellow and 2.3 FTE research nurses. We also have accessible OAA/AAGBI money available to work with our Professor in Obstetric anaesthesia in developing critical care services for the Maternity Unit.
Previous ‘research fellowship’ positions have demonstrated an excellent track record facilitating several international/national presentations (8 prize winners) and peer-reviewed publications over the last 8 years. Successful individuals will have a fantastic opportunity to be involved with on-going projects in addition to developing research ideas of their own.
Other opportunities include:
- Presentation of work at international / national conferences and future publications (financially supported where possible)
- Opportunity to undertake higher degree qualification e.g. MPhil, MSc, MD (not mandatory)
- Undertake statistical and research methodology training at Teesside University to enhance research training/knowledge
- Become accomplished at high-risk pre-operative assessment and cardiopulmonary exercise testing (CPET) through direct involvement in the pre-operative assessment clinic.
- Attend national/international CPET training course
- Involvement in undergraduate teaching curriculum (HBP) and postgraduate crammer courses.
The trainees will be given an Educational Supervisor who has an interest in both Clinical work and pre-assessment to maximise the potential of this placement.
Please contact Dr Matt Cheesman or Dr David Booth for further information.
It is anticipated that these positions will be circulated through the Northern School of Anaesthesia. Date for interviews will be set following an agreed closing date with the Northern School.