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Adoption of electronic health record systems offers an opportunity to collate massive volumes of complex information about patient care. Healthcare data can inform performance management, enable predictive analytics and enhance strategic decision making. A data-driven approach to improving patient care is vital to address the growing burden of morbidity and mortality associated with major surgery. We describe our methodology for transforming and utilising process of care data in an electronic health record system to develop a registry for quality improvement purposes in patients undergoing major surgery at a single UK hospital. We highlight development of our data-driven vision, technical aspects of processing raw data into metrics relevant to clinical decision making, alongside challenges encountered. Finally, we outline how our data infrastructure supports clinical governance, quality improvement and research. In sharing our experiences, we hope to enable others to embed and access the transformative clinical insights that healthcare data can yield.

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We present the INSPIRE dataset, a publicly available research dataset in perioperative medicine, which includes approximately 130,000 surgical operations at an academic institution in South Korea over a ten-year period between 2011 and 2020. This comprehensive dataset includes patient characteristics such as age, sex, American Society of Anesthesiologists physical status classification, diagnosis, surgical procedure code, department, and type of anaesthesia. The dataset also includes vital signs in the operating theatre, general wards, and intensive care units (ICUs), laboratory results from six months before admission to six months after discharge, and medication during hospitalisation. Complications include total hospital and ICU length of stay and in-hospital death. We hope this dataset will inspire collaborative research and development in perioperative medicine and serve as a reproducible external validation dataset to improve surgical outcomes.

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Throughout its 100-yr history, a key ambition of the British Journal of Anaesthesia has been to foster our academic community by addressing the needs of individuals in the early stages of their independent clinical and research careers. Longitudinal mentoring and peer networking are critical for establishing a community of like-minded peers and mentor-advisors required to navigate the challenges of academic medicine. In 2019, the Journal launched an Editorial Fellowship scheme, aimed at comprehensively demystifying the process of peer review, editing, and publishing through guided mentorship and experiential learning.

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Failure, ubiquitous in life and medical practice, offers myriad opportunities for learning and growth alongside challenges to overall well-being. In this article, we explore the nature of failure, it's sources and impacts in perioperative medicine, and the specific challenges it brings to trainee well-being. With a deeper understanding of the societal, psychological and cognitive determinants and effects of failure, we propose solutions in order to harness the opportunities inherent in failures to create brave and supportive learning environments conducive to both education and well-being.

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BACKGROUND: The international scale and spread of evidence-based perioperative medicine for older people undergoing surgery (POPS) services has not yet been fully realised. Implementation science provides a structured approach to understanding factors that act as barriers and facilitators to the implementation of POPS services. In this study, we aimed to identify factors that influence the implementation of POPS services in the UK. METHODS: A qualitative case study at three UK health services was undertaken. The health services differed across contextual factors (population, workforce, size) and stages of POPS service implementation maturity. Semi-structured interviews with purposively sampled clinicians (perioperative medical, nursing, allied health, and pharmacy) and managers (n = 56) were conducted. Data were inductively coded, then thematically analysed using the Consolidated Framework for Implementation Research (CFIR). RESULTS: Fourteen factors across all five CFIR domains were relevant to the implementation of POPS services. Key shared facilitators included stakeholders understanding the rationale of the POPS service, with support from their networks, POPS champions, and POPS clinical leads. We found substantial variation and flexibility in the way that health services responded to these shared facilitators and this was relevant to the implementation of POPS services. CONCLUSIONS: Health services planning to implement a POPS service should use health service-specific strategies to respond flexibly to local factors that are acting as barriers or facilitators to implementation. To support implementation of a POPS service, we recommend health services prioritise understanding local networks, identifying POPS champions, and ensuring that stakeholders understand the rationale for the POPS service. Our study also provides a structure for future research to understand the factors associated with 'unsuccessful' implementation of a POPS service, which can inform ongoing efforts to implement evidence-based perioperative models of care for older people.

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Over time, the focus of evidence-based acute pain medicine has shifted, from a focus on drugs and interventions (characterized by numbers needed to treat), to an appreciation of procedure-specific factors (characterized by guidelines and meta-analyses), and now anesthesiologists face the challenge to integrate our current approach with the concept of precision medicine. Psychometric and biopsychosocial markers can potentially guide clinicians on who may need more aggressive perioperative pain management, or who would respond particularly well to a given analgesic intervention. The challenge will be to identify an easily assessable set of parameters that will guide perioperative physicians in tailoring the analgesic strategy to procedure and patient.

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Perioperative care in the United States is largely based on current fee-for-service models. Fee-for-service models are not based on the true cost of services provided, charges do not equal costs, and reimbursement varies based on insurer. Value-based health care is defined as patient-centered outcomes over cost of providing these services. Process mapping and time-driven activity-based costing can be used to define actual cost of services provided. Outcomes after discharge can be measured, so that the overall value of care provided can be assessed and improved based on the outcomes and costs identified.

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A closed-loop automatically controls a variable using the principle of feedback. Automation within anesthesia typically aims to improve the stability of a controlled variable and reduce workload associated with simple repetitive tasks. This approach attempts to limit errors due to distractions or fatigue while simultaneously increasing compliance to evidence based perioperative protocols. The ultimate goal is to use these advantages over manual care to improve patient outcome. For more than twenty years, clinical studies in anesthesia have demonstrated the superiority of closed-loop systems compared to manual control for stabilizing a single variable, reducing practitioner workload, and safely administering therapies. This research has focused on various closed-loops that coupled inputs and outputs such as the processed electroencephalogram with propofol, blood pressure with vasopressors, and dynamic predictors of fluid responsiveness with fluid therapy. Recently, multiple simultaneous independent closed-loop systems have been tested in practice and one study has demonstrated a clinical benefit on postoperative cognitive dysfunction. Despite their advantages, these tools still require that a well-trained practitioner maintains situation awareness, understands how closed-loop systems react to each variable, and is ready to retake control if the closed-loop systems fail. In the future, multiple input multiple output closed-loop systems will control anesthetic, fluid and vasopressor titration and may perhaps integrate other key systems, such as the anesthesia machine. Human supervision will nonetheless always be indispensable as situation awareness, communication, and prediction of events remain irreplaceable human factors.

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Guidelines provide a framework to take better care of our patients. They are published by different professional groups and are based on all the research done for us by hardworking colleagues. Compiling a guideline is an enormous amount of work and is generally done with the utmost care. However, recommendations often require a subjective interpretation of published research, where personal and academic interests can influence the outcome. We discuss two recently published guidelines on perioperative cardiovascular assessment that led to different conclusions on some important areas of patient care.

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