Anaesthesia and Perioperative Care PSP Protocol

Purpose

The purpose of this protocol is to set out the aims, objectives and commitments of the Anaesthesia and Perioperative Care Priority Setting Partnership (PSP) and the basic roles and responsibilities of the partners therein.

Steering Group

The Anaesthesia and Perioperative Care PSP will be led and managed by the following:
Patient representative/s:

• Marion Cumbers, Royal National Orthopaedic Hospital Patient Group
• Jacqui Gath, Independent Cancer Patients' Voice
• Emma Harris, Kangaroo Club (ileo-anal pouch following colorectal surgery)
• Tony Ingold, Oesphogeal Patients Association

Clinical representative/s:

• Mike Grocott, National Institute of Academic Anaesthesia & Royal College of Anaesthetists
• Simon Howell, NIAA Research Prioritisation Exercise legacy + NIAA specialist societies
• Mike Nathanson, Association of Anaesthetists of Great Britain and Ireland (+AAGBI research legacy)
• Tom Pinkney, Royal College of Surgeons of England

Perioperative practice representative:

• Ann Conquest, Association for Perioperative Practice

Project organisation:

• Oliver Boney, National Institute of Academic Anaesthesia & Royal College of Anaesthetists
• Sharon Drake, National Institute of Academic Anaesthesia & Royal College of Anaesthetists

The Partnership and the priority setting process will be supported and guided by:

• Leanne Metcalf*, James Lind Alliance

(*Note: Leanne Metcalf took over from the original JLA Adviser, Adrian Grant, in Jan 2014)

The Steering Group includes representation of patient/carer groups and clinicians.

The Steering Group will agree the resources, including time and expertise that they will be able to contribute to each stage of the process. The JLA will advise on this.

Background to the Anaesthesia and Perioperative Care PSP

The JLA is a project that is overseen by the National Institute for Health Research Evaluation, Trials and Studies Coordinating Centre (NETSCC). Its aim is to provide an infrastructure and process to help patients and clinicians work together to agree what the most important treatment uncertainties are, affecting their particular interest, in order to influence the prioritisation of future research in that area. The JLA defines an uncertainty as a “known unknown” – in this case relating to the effects of treatment.

How the PSP came together:

In 2009 the National Institute of Academic Anaesthesia (NIAA) conducted an internal research prioritisation exercise (RPE) with results published in 2011. In 2012, one of the NIAA’s partner organisations, the Association of Anaesthetists of Great Britain and Ireland, surveyed the research priorities of many of the NIAA’s Funding Partners (Specialist Societies within anaesthesia and anaesthesia-associated journals).

However, by late 2012, it was felt within the NIAA that a new and more comprehensive research prioritisation exercise needed to take place. Initial exploration of the James Lind Alliance model looked appealing as it strongly incorporated the patient and carer perspective, offered leadership of the process by an independent body, and brought with it the experience from about 20 similar exercises in the field of health research. At the National Institute of Academic Anaesthesia’s (NIAA) Board meeting on the 31 January 2013, it was decided to apply for an ‘Anaesthesia Priority Setting Partnership’ in collaboration with the James Lind Alliance (JLA) and funded by the funding partners of the NIAA.

The Health Services Research Centre (HSRC) of the NIAA submitted a “Readiness Questionnaire” to the JLA on 8 April 2013. On 24 April 2013, the JLA accepted the proposal and appointed Adrian Grant as Adviser to the Anaesthesia PSP. This later became, following discussions of scope, the “Anaesthesia and Perioperative Care” PSP. At this stage there was still no obvious patient representation body to pair with the clinical representation, so the first mission of the core team became to identify a broad spread of relevant patient representation bodies that would potentially be interested in partnering in such a project.

Potential patient and nursing representation partners were identified by multiple routes: 1) asking the representatives of the NIAA specialist societies for nominations, 2) asking for suggestions from INVOLVE, and 3) Google searching in domains that we felt had not been covered by nominations from 1) and 2).

Interested parties were invited to an initial Awareness Raising meeting/workshop on Friday 18 October at the Royal College of Anaesthetists. People representing some 28 organisations attended, including 12 patient representation bodies, (there were other organisations interested, but they were unable to send a representative), nursing bodies, the specialist societies of the NIAA, the Cochrane Anaesthesia Review Group, and the James Lind Alliance.

From the attendees and other interested partners, a Steering Group was formed according to the spread of expertise/representation and enthusiasm and capacity of individuals to engage in the running of the PSP.

The Steering Group was finalised and confirmed on 27 November 2013 and an initial Steering Group meeting was organised for 20 January 2014 at the Royal College of Anaesthetists.

Scope of the PSP

The Anaesthesia and Perioperative Care PSP will cover aspects of care during anaesthesia and the perioperative period, and the management of longer-term problems that have their origin during this period. Hence, the management of chronic pain will not be considered unless the pain originates around the time of anaesthesia. The scope was discussed and clarified as part of the first Steering Group meeting.

Inclusion criteria:

The scope should include all the work of the anaesthetist (e.g. obstetrics and resuscitation), but also the wider perioperative team and the care pathway from initial intention to treat/operate onwards. “Onwards” is an open-ended word signifying that long-term problems attributable to this surgery/intervention and management period must also be considered. There is no age limit to the criteria and we actively encourage consideration of, and representation from, more vulnerable populations such as newborns, young children, the elderly and disabled.

Exclusion criteria:

As this priority setting partnership has its focus on “perioperative care”, we would wish to exclude commentary on surgery itself, or management (e.g. of pain) outside of secondary care that is unrelated to a hospital episode. We want to focus on the management of patients’ physical wellbeing within the hospital environment throughout all procedures and its impact on recovery thereafter. We acknowledge that there is another Priority Setting Partnership on Intensive Care, but do not wish to exclude commentary on this area so that we do not discourage feedback that may border with critical/intensive care but not be fully covered within the Intensive Care PSP remit.

Aims and objectives of the Anaesthesia and Perioperative Care PSP

The aim of the Anaesthesia and Perioperative Care PSP is to identify the unanswered questions about anaesthesia and perioperative care from both patient and clinical perspectives and then prioritise those that they agree are the most important.

The objectives of the Anaesthesia and Perioperative Care PSP are to:

• work with patients and clinicians to identify uncertainties about the effects of anaesthesia and perioperative management and care
• to agree, by consensus, a prioritised list of those uncertainties for research
• to publicise the results of the PSP and its process
• to take the results to research commissioning bodies to be considered for funding

Partners

These are those who agree to be called “partners” and provide access to groups for the survey. Organisations and individuals have been invited to take part in the PSP, which represent the following groups:

• people who have had personal experience with undergoing anaesthesia, surgery, in-hospital recovery and perioperative pain management.
• carers of people (esp. children/elderly) who have undergone surgery.
• medical doctors, nurses and professionals allied to medicine with clinical experience of anaesthesia and perioperative care.

It will be possible for other appropriate organisations to join the PSP. It is important that all organisations that can reach relevant people should be invited to become involved in the PSP. The JLA will take responsibility for ensuring the various stakeholder groups are able to contribute equally to the process.

Organisations wishing to participate in the PSP will be asked to affiliate to the JLA in order to demonstrate their commitment to the aims and values of the JLA. Details on the affiliation procedure can be found on our website.

Exclusion criteria

Some organisations may be judged by the JLA or the Steering Group to have conflicts of interest. These may be perceived to adversely affect those organisations’ views, causing unacceptable bias. As this is likely to affect the ultimate findings of the PSP, those organisations will not be invited to participate. It is possible, however, that interested parties may participate in a purely observational capacity when the Steering Group considers it may be helpful.

Methods

This section describes a schedule of proposed stages through which the PSP aims to fulfil its objectives. The process is iterative and dependent on the active participation and contribution of different groups. The methods adopted in any stage will be agreed by consulting the partners, guided by the PSP’s aims and objectives. More details and examples can be found in the JLA guidebook.

Identification and invitation of potential partners

As outlined above, potential partner organisations were identified through a process of peer knowledge and consultation; others are likely to join later. Potential partners were contacted and informed of the establishment and aims of the Anaesthesia and Perioperative Care PSP and invited to attend and participate in the initial stakeholder meeting.

In the case of the Anaesthesia and Perioperative Care PSP, the initial team at the Health Services Research Centre of the NIAA identified a broad range of potential partners, from which the Steering Group was formed. However, the Steering Group may wish to nominate more associations for partnership.

Initial stakeholder /awareness raising meeting

PSPs will need to raise awareness of their proposed activity among their patient and clinician communities, in order to secure support and participation. Depending on budget this may be done by way of a face to face meeting, or there may be other mechanisms by which the process can be launched.

The initial stakeholder/awareness raising meeting had several key objectives:

• to welcome and introduce potential members of the Anaesthesia and Perioperative Care PSP
• to present the proposed plan for the PSP
• to initiate discussion, answer questions and address concerns
• to identify potential partner organisations that would commit to the PSP and identify individuals to be representatives for those organisations and the PSP’s principal contacts
• to establish principles upon which an open, inclusive and transparent mechanism can be based for contributing to, reporting and recording the work and progress of the PSP
• to identify potential members of the Steering Group

The Awareness Raising meeting/workshop was held on Friday 18 October at the Royal College of Anaesthetists. The Steering Group was finalised and confirmed on 27 November 2013.

Identifying treatment uncertainties

Each partner will identify a method for soliciting from its members, questions and uncertainties of practical clinical importance relating to the treatment and management of Anaesthesia and Perioperative Care. The survey will be open for approximately 2 months. The time allocated to collate, analyse and categorise will be approximately 3 months.

The methods may be designed according to the nature and membership of each organisation, but must be as transparent, inclusive and representative as practicable. Methods may include membership meetings, email consultation, postal or web-based questionnaires, internet message boards and focus group work.

Existing sources of information about treatment uncertainties for patients and clinicians will be searched. These can include question-answering services for patients and carers and for clinicians; research recommendations in systematic reviews and clinical guidelines; protocols for systematic reviews being prepared and registers of ongoing research.

The starting point for identifying sources of uncertainties and research recommendations is NHS Evidence.

Refining questions and uncertainties

The consultation process will produce “raw” unanswered questions. These raw questions will be assembled and categorised and refined by the PSP Coordinator (with assistance from a subgroup of the Steering Group) into “collated indicative questions” that are clear, addressable by research and understandable to all. Similar or duplicate questions will be combined where appropriate. The JLA will participate in this process as an observer, to ensure accountability and transparency.

The existing literature will be researched by a team to be decided (hopefully in partnership with the Cochrane Anaesthesia Review Group) to see to what extent these refined questions have, or have not, been answered by previous research.

Sometimes, uncertainties are expressed that can in fact be resolved with reference to existing research evidence - i.e. they are "unrecognised knowns" and not uncertainties. If a question about treatment effects can be answered with existing information but this is not known, it suggests that information is not being communicated effectively to those who need it. Accordingly, the JLA recommends strongly that PSPs keep a record of these 'answerable questions' and deal with them separately from the 'true uncertainties' considered during the research priority setting process.

Uncertainties that are not adequately addressed by previous research will be collated and prepared for entry into the “Surgery, anaesthesia, perioperative and critical care” section within the UK Database of Uncertainties about the Effects of Treatments (UKDUETs - www.library.nhs.uk/duets) by another team. This will ensure that the uncertainties have actually been checked to be uncertainties. This is the responsibility of the Steering Group, which will need to have agreed personnel and resources to carry this accountability. The data should be entered into UKDUETs on completion of the priority setting exercise, in order to ensure any updates or changes to the data have been incorporated beforehand.

(Please note the UK DUETs database was discontinued in 2015. All PSP uncertainties now appear on the JLA website.)

Prioritisation – interim and final stages

The aim of the final stage of the priority setting process is to prioritise, through consensus, the identified uncertainties relating to the treatment or management of Anaesthesia and Perioperative Care. This will be carried out by members of the Steering Group and the wider partnership that represents patients and clinicians.

The interim stage, to proceed from a long list of uncertainties to a shorter list (e.g. up to 20), may be carried out over email, whereby organisations consult their membership and choose and rank their top 10 most important uncertainties.

The final stage, to reach, for example, 10 prioritised uncertainties, is likely to be conducted in a face-to-face meeting, using group discussions and plenary sessions.

The methods used for this prioritisation process will be determined by consulting the partner organisations of the PSP and with the advice of the JLA. Methods that have been identified as potentially useful in this process include: adapted Delphi techniques; expert panels or nominal group techniques; consensus development conference; electronic nominal group and online voting; interactive research agenda setting and focus groups.

The JLA will facilitate this process and ensure transparency, accountability and fairness. Participants will be expected to declare their interests in advance of this meeting.

Findings and research

It is anticipated that the findings of the Anaesthesia and Perioperative Care PSP will be reported to funding and research agenda setting organisations such as the NIHR Evaluation, Trials and Studies Coordinating Centre (NETSCC), which includes the HTA Programme, and the MRC, as well as the major relevant research funding charities. Steering Group members and partners are encouraged to develop the prioritised uncertainties into research questions and to work to establish the research needs of those unanswered questions to use when approaching potential funders, or when allocating funding for research themselves, if applicable.

Publicity

As well as alerting funders, partners and Steering Group members are encouraged to publish the findings of the Anaesthesia and Perioperative Care PSP using both internal and external communication mechanisms. The JLA may also capture and publicise the results, through descriptive reports of the process itself. This exercise will be distinct from the production of an academic paper, which the partners are also encouraged to do. However, production of an academic paper should not take precedence over publicising the final results.

Signed by the Steering Group

• Oliver Boney, National Institute of Academic Anaesthesia & Royal College of Anaesthetists
• Ann Conquest, Association for Perioperative Practice
• Marion Cumbers, Royal National Orthopaedic Hospital Patient Group
• Sharon Drake, National Institute of Academic Anaesthesia & Royal College of Anaesthetists
• Jacqui Gath, Independent Cancer Patients' Voice
• Mike Grocott, National Institute of Academic Anaesthesia & Royal College of Anaesthetists
• Emma Harris, Kangaroo Club (ileo-anal pouch following colorectal surgery)
• Simon Howell, NIAA Research Prioritisation Exercise legacy + NIAA specialist societies
• Tony Ingold, Oesphogeal Patients Association
• Leanne Metcalf, James Lind Alliance
• Mike Nathanson, Association of Anaesthetists of Great Britain and Ireland (+AAGBI research legacy)
• Tom Pinkney, Royal College of Surgeons of England