Surgeons and neonatologists views about surgical decision making in necrotising enterocolitis

Objective To understand why surgical decision-making in necrotising enterocolitis (NEC) is challenging and to explore what is required to optimise this. Design Three semi-structured in person focus groups exploring surgical decision-making in NEC. Reflexive thematic analysis of focus group transcript was undertaken. Participants Twenty-two consultant participants (15 paediatric surgeons and 7 neonatologists). Main outcome measures Themes addressing what informs, the challenges of, and how to improve surgical decision making in NEC. Results Ten themes addressed what informs decision-making in NEC, six themes addressed why this is challenging and five themes explained what is required to address the challenges of decisionmaking. Themes regarding challenges of decision-making were: diagnostic uncertainty, variable threshold for referral/transfer, lack of continuity of care, absence of clear criteria for surgery, uncertainty surrounding surgery and fear. Subthemes regarding fear were fear of i) poor clinical outcome, ii) criticism from colleagues and iii) undertaking unnecessary surgery. Themes in all three areas were related to infant, clinician and system-based factors. These included themes regarding indications for surgical intervention, indications for referral and transfer of infants, and reducing variability in practice. Conclusions This study identified themes that illuminate the difficulties experienced by neonatologists and surgeons regarding surgical decision-making in NEC. Clinicians of both specialties would welcome changes to current practice focussed particularly around standardisation of practice and greater objectivity around several aspects of surgical decision-making. These insights can be used to focus further research and implement practice change around surgical decision-making in NEC with the ultimate aim of facilitating early and accurate decision-making.