Clinicians are taught to clinically assess patients, and combine this with the physiological parameters available to assess likely differential diagnoses. This is essentially pattern recognition which we build upon through clinical experience. So what happens when the cause does not fit the clinical picture?
Here we discuss the case of a healthy 57 year old male who had a significant intra-peritoneal haemorrhage following elective open inguino-scrotal hernia repair, yet did not display the typical signs or symptoms. The specific bleeding vessel and mechanism was likely to contribute to the unusual presentation.
The patient displayed no tachycardia, no abdominal pain, and there was no evidence of any haematoma in the abdomen, flanks or scrotum. His observations remained unremarkable except for intermittent episodes of hypotension that were responsive to minimal crystalloid resuscitation. Moreover, the patient himself felt well except for transient episodes of dizziness and nausea, caused by the hypotensive episodes. It was subsequently discovered that the patient was a regular marathon runner so his physiological reserve probably masked his signs.
At surgery the bleeding vessel was discovered to be the inferior epigastric artery which had bled directly into the abdominal cavity with no external signs. This was thought to be related to the complexity of the large hernia sack and subsequent dissection.
This demonstrates that life threatening haemorrhage can present in unusual ways, especially with patients who have altered physiology to begin with. The anatomy of the haemorrhage can also significantly effect the presentation and should be taken into consideration.
Introduction:
We present our experience of day surgery Greenlight XPS prostatectomy. Since 2013, there was a gradual reconfiguration of our service in order to enable this operation to be performed as day case.
Methods:
Retrospectively, relevant electronic medical entries for all the operations carried out between January 2013 and September 2016 were reviewed. We recorded the length of stay, readmission and complications rate, subdivided in yearly intervals. We also examined if the ASA score or preoperative retention had an effect on the length of stay. Finally, we looked at the rate of successful trials without catheter for each group.
Results:
Between 2013 and 2016 we performed 448 GreenLight XPS prostatectomies. The average age was 73.7. There was a gradual improvement in the rate of procedures performed as day case. In 2013 the percentage was 19% while in 2016 we achieved a rate of 78%. The readmission rate at 30 days was 6.8% for the day cases and 10.5% for the patients with longer stays.
The risk factors than may lead to longer duration of stay we identified that overall there was statistical significance in patients with age >80, ASA > 3 and prior retention.
Finaly from the 182 the " day case" patients 95% had a successful TWOC. This was 92% in the 238 patient that had a longer stay.
Conclussion:
Our study concludes that Greenlight XPS prostatectomy is a procedure that can be safely performed as a day case for the majority of the patients with a low readmission risk.
Introduction/Background: Intrathecal baclofen (ITB) and morphine (ITM) pumps improve pain, spasticity and QoL. Pump explantations due to complications is more expensive and traumatic for patients. Determining complication rates is beneficial from a biopsychosocial aspect.
Aims: Determine the perioperative complications post-primary pump implantation (1998-2016); perform a service evaluation.
Methods: A retrospective review of indications, dose changes over time, and the complications 14 days post-operatively.
Results: 48 adult patients were included. The overall perioperative complications rate was 24%. 10% were pump related (4 catheter blocks, 1 pump failure), 14% non-pump related (1 CSF leak, 3 haematomas, 2 superficial infections). The mean initial and current ITM doses were 4.27mg/day and 10.4mg/day, and 120.61 mcg/day and 215mcg/day for ITB. Patients rated the service as excellent. 73.4% ranked their QoL improvement moderate (2-4/5) to excellent (5/5). Moderate symptoms control satisfaction (3.70/5 (ITB), 3.82/5 (ITM)).
Conclusion: These results are comparable to those from the NHNN and current literature (level III evidence). There is a deficiency between the incidence of patients eligible for pump implantation and procedures performed per annum. Reviews across the UK including patient surveys are required to set a standard of care and support adequate resource allocation for the continuation of this service.
Introduction
Laparoscopic cholecystectomy (LC) has become a gold standard intervention with reduced post-operative pain and length of hospital stay. A practicable, safe anaesthetic approach conferring similar benefit would improve post-operative recovery. Studies have shown promise for the use of spinal instead of general anaesthesia.
Methods
Aim: compare the effects of LC under spinal anaesthesia with LC under general anaesthesia, looking primarily at post-operative pain scores (using median Visual Analogue Score [VAS] pain scores at 4, 8 and 24 hours post-op) but also with regards to length of stay, cost and patient satisfaction. Initially 40 trials were identified via computerised searches of Cochrane Central Register of Controlled Trials (CENTRAL), PubMed and MEDLINE (all up to December 2017). Selection criteria (using PRISMA) narrowed this to 8. Statistical comparisons were done using RevMan v5.3.
Results
Eight trials with 501 participants were included in the review. Results show with regards to:
Conclusions
Spinal anaesthesia for laparoscopic cholecystectomy results in reduced pain at all stages of a typical post-operative period compared to general, with a reduced length of stay and improved feasibility from reduced cost.
Background Compare the our trust day case rate for inguinal hernia repair and compare with national standard
Aim: What was the actual day case rate; Was coding accurate? ; Why were patients staying overnight? and Is there a need to extend Day Case unit opening hours?
Objectives
The aim of the audit was to see if we can improve a Day case rate for inguinal hernia
Method
Retrospective analysis for Day case inguinal hernia rates for our trust for the audit period 1-sep 2016 to 30th Sep 2017. Cases with day case intent was included and Cases done as emergency and Case with planned overnight stay/In patient stay was excluded
Results Summary
We identified 366 patients who underwent inguinal hernia repair as a day case intent . however we excluded 13 patients who were wrongly coded as it was not meant for day case . thereby our cohort of patient dropped to 353 patients.
Of these patients 327 patients went home same day ( True day case rate 92.5%) target was 95%
22 patients stayed overnight (6%)
4 patients stayed beyond overnight but less than 72 hours (1.1%)
0 patients stayed beyond 72 hours
We analysed the notes of patient who overstayed. The commonest reasons was acute urinary retention(n=10); social reasons(n=9); more complex surgery (n=4);concerns of bleeding(n=6)
Conclusion
In summary , clinical coding should be more accurate ; we are trying to develop a pathway for acute urinary retention who can be safely placed in that path.
Background
Compare the our trust day case rate for Umbilical hernia repair and compare with national standard
Aim : What was the actual day case rate; Was coding accurate?; Why were patients staying overnight? and Is there a need to extend Day Case unit opening hours?
Objectives
The aim of the audit was to see if we can improve a Day case rate for Umbilical hernia
Method
Retrospective analysis of day case umbilical hernia repair for our trust for the period 1st Sep 2016 to 30th Sep 2017. Cases with day case intent was included; Cases done as emergency and Case with planned overnight stay/In patient stay was excluded
Results Summary We identified 113 patients who underwent Umbilical hernia repair as a day case intent. However we excluded 4 patients who were wrongly coded as it was not meant for day case.
Of these patients 109 patients; 96 patients went home same day ( True day case rate 88%) target was 85%. 12 patients stayed overnight (11%); 0 patients stayed beyond overnight but less than 72 hours (0%); 1 patient stayed beyond 72 hours
We analysed the notes of patient who overstayed. The commonest reasons was acute urinary retention(n=3); social reasons(n=1); more complex surgery (n=1);concerns of bleeding(n=3);lack of interpretor (n=1);unclear documentation(n=3)
Conclusion
In summary , clinical coding should be more accurate ; we are trying to develop a pathway for acute urinary retention who can be safely placed in that path.
Introduction:
Historically, patients were fasted from eight to twelve hours prior to anaesthesia to reduce the risk of aspiration pneumonitis. More recently there has been evidence that shortened pre-operative fasting periods do not increase the risk of harmful events. Current guidelines recommend fasting for six and two hours for food and clear fluids respectively prior to anaesthesia. This audit aims to compare our patient’s fasting times to the guideline.
Method:
This was a prospective study of 51 day-case surgical patients. Patients attending for morning or afternoon theatre lists were selected at random from the waiting room prior to admission and given a questionnaire regarding pre-operative fasting to complete.
Results:
Of the 51 patients, 19 had attended for the morning theatre list and 32 for the afternoon. All patients reported receiving an information leaflet on fasting. Overall 41/51 (80%) fasted from clear fluid for 2 hours. The remaining 10/51 (20%) had either started fasting too early (n=8), too late (n=1) or couldn’t remember (n=1). 43/51 (84%) fasted from food for 6 hours while 8/51 (16%) either started fasting too early (n=6) or too late (n=2).
Conclusion:
At COCH there was good overall adherence to current fasting guidelines. It was concerning that despite all the patients reporting to have received an information leaflet so many started fasting from either food or clear fluids too early. This can affect patient comfort and hydration. A targeted approach to these patients outlining the guidelines should be considered to prevent this.
Aims: 85% of tonsillectomies should be completed as day-case operations. This rate was 33% in the University Hospital of South Manchester (UHSM) in April 2015.This study will focus on identifying factors that could be contributing to this low rate, in order to decrease length of stay following tonsillectomy.
Methods: Tonsillectomies were accessed from April 2015, October 2014 and April 2014, with patient details recorded. The case notes were then requested and a pro forma made to include a variety of information regarding the patient and operation.
Results: A total of 62 patients had tonsillectomies done across the 3 months of the study. 8 were not included. The day-case rate was 31% in April 2015, 50% in October 2014, and 65% in April 2014. In total, 27 patients were managed as day cases (50%).
Patients under the age of 6 had a low day-case rate of 29%. 68% of bilateral tonsillectomies were completed as day cases, in contrast to 21% of adenotonsillectomies.
64% of operations done in the morning were completed as day cases, in comparison to 22% performed in the afternoon. Operations done as day-case averaged 25.6 minutes, while overnight stay averaged 31.4 minutes. 10% of patients with sleep apnoea, and 20% of patients with complications, were managed as day cases.
Conclusion: The day-case rate of tonsillectomies performed at UHSM are significantly below the required standards of 85%. Several contributing factors were identified: younger patients, afternoon operations, type of procedure (adenotonsillectomy), prolonged duration of surgery, sleep apnoea, and complications.
Approximately 25,000 transurethral resections of the prostate (TURP) are completed per year in the UK, with a total cost of £53 million. The British Association of Day Surgery has recommended that 15% of TURPs should be completed as day surgery.
We aimed to establish day case TURP at the Royal Hampshire County Hospital, a District General Hospital in the South of England. We analysed our current data as a baseline, and to understand which patients would be suitable for day case TURP. We put in place the necessary clinical, administrative and managerial structures to allow the hospital to run a day case TURP service, and present a framework for doing so.
We are currently completing the first Plan, Do, Study, Act Cycle as recommended by NHS Improvement. Our primary outcome measures are: percentage of planned day case conversion to inpatient stay; readmission rate; and patient feedback, to be analysed using qualitative thematic content analysis. Our secondary outcome measures will also analyse: complications related to readmission using the Clavien-Dindo classification; length of stay; financial impact of change in length of stay; percentage trial without catheter success rate; and prostatic resection weight.
We aim to complete multiple PDSA cycles to ultimately meet the 15% British Association of Day Surgery target.
Post-operative nausea and vomiting (PONV) is a barrier to successful day case surgery. However, the risk of this must be balanced against potential side effects of anti-emetic use. The preoperative assessment service at Torbay hospital calculates a PONV risk score and gives a recommendation for perioperative antiemetic use based on the Apfel score. This is available to the Anaesthetist on the day of surgery.
The aim of this project was to raise awareness of the predetermined risk score using a department-wide survey and a presentation at a local governance meeting. Data collection after each of these interventions aimed to determine if Anaesthetists are following the risk score’s recommendations and whether the interventions had an effect on anti-emetic strategy and incidence of PONV.
A total of 135 patient records were analysed. Prior to any intervention, baseline data showed compliance with recommendations in less than 50% of low to medium risk patients. After the survey, compliance improved to 63%. The survey also elicited a range of views regarding intraoperative anti-emetic practice. After the clinical governance presentation compliance remained above baseline but dropped to 55%. In each data collection period, only 1 patient required an anti-emetic in recovery.
We conclude that a simple survey may have been effective in raising awareness of the PONV risk score and may have changed practice. We recommend that patients receiving Total Intravenous Anaesthesia with low and medium risk scores for PONV undergoing low risk procedures do not require intra-operative anti-emetics.
Introduction: We focused on pre-operative testing NICE guideline NG45 compliance at University Hospital Lewisham in elective surgery patients between October 2017 and February 2018. Aims included increasing the number of pre-operative tests performed appropriately, reducing the number of tests performed unnecessarily, and improving staff awareness of guidelines.
Methods: Data was collected from 100 randomly-selected patients before, and 93 patients after, an intervention (comprising a poster displaying guidelines in a clear, staff-focused format) was implemented. The intervention was identified through patient shadowing and root-cause analysis and improved through sequential Plan-Do-Study-Act cycles.
Results: Baseline data demonstrated 65.8% concordance. ECG concordance was greatest (73.0%) followed by U&Es (65.0%), clotting (64.0%) and FBC (61.0%). Post-intervention, overall concordance increased to 69.6%. ECG testing saw a 19.3% improvement (87.1%) whilst U&Es and FBC testing displayed reductions (62.3% and 60.2% respectively). Clotting increased to 68.8%. Concordance was greatest for major surgery (72.8%) and lowest for minor surgery (55.0%). ASA-3 grades showed notably high concordance (93.0%).
Conclusion: A 5.9% concordance increase was achieved. Concordance was greatest for high ASA or surgery grades as more tests are justified at greater risk levels. Where concordance was low, the cause was inappropriately completed tests indicating over-testing. This demonstrates an area of unnecessary financial expense and the patient experience could be improved by reducing excessive testing. Further work is needed to educate staff on minor surgery guidelines and emphasise the negative sequelae of over-testing. Clinicians should be encouraged to question why they are ordering tests and evaluate patient benefit.
Aims
Our aim was to improve the care of patients with gallstones by providing emergency laparoscopic cholecystectomy within 14 days of presentation for suitable patients.
Methods
Patients were identified at diagnosis and entered onto our cholecystectomy pathway, and included patients with biliary colic, acute cholecystitis and gallstone pancreatitis. We obtained two theatre lists per week dedicated to emergency cholecystectomies giving us a capacity of 4 cases per week. Patients are assessed and, where possible, are discharged and return for day case surgery in order to reduced length of stay and associated costs. Patients are provided with a date of surgery prior to discharge and undergo a telephone pre-operative assessment.
Results
Over a 15 month period 216 patients presented with gallstone disease. 122 (56.4%) patients were fit for emergency surgery and 102 (83.6%) had this within 14 days of admission. 18% of these were patients with gallstone pancreatitis, the remaining 82% had biliary colic or acute cholecystitis. 43% were performed as a day case procedure.
Conclusions
Early laparoscopic cholecystectomy has been shown to be beneficial both for both patients and institutions. It reduces costs by removing the repeated admissions these patients often have whilst waiting for surgery, improves patient experience and has been shown in multiple studies to have no significant increase in complications. Through participating in this quality improvement project run by the RCS we have developed a pathway that enables us to achieve this efficiently and effectively and is being well received by patients and staff alike.
Introduction
A push towards day case surgery has been driven nationwide by fewer acute hospital beds, as well as improved patient recovery.
At Northumbria Healthcare NHS Foundation Trust an audit of day case total laparoscopic hysterectomy (DCTLH) outcomes and causes of unplanned admissions, showed a failure rate of 51% between July 2015 to June 2016. Following this, an anaesthetic protocol for DCTLH was introduced in January 2017. This audit looked at the compliance with the anaesthetic protocol and associated DCTLH failure rate.
Methods
A retrospective analysis of all DCTLH between March and August 2017, with 51 of the 58 notes available. A pro forma was used to collect data on admissions and compliance with DCTLH protocol.
Results
DCTLH failure rate was 37%, an improvement from 51% in 2016. Also, there were fewer admissions including pain (15.3% to 7.8%) and post-operative nausea and vomiting (20.3% to 2%) as factors. Of unplanned admission 75% had no recorded decision maker.
Compliance with individual items of the protocol varied from 100% to 29%.The use of magnesium intraoperatively having the lowest compliance. It was also found that the doses of magnesium and ketamine were largely sub-therapeutic.
Conclusions
There has been an increase in successful DCTLH since the protocol was introduced, with reduction in pain and PONV being a causal factor, however this protocol is not completely adhered to and better compliance could improve success further. Also there is ambiguity regarding the decision maker and reason for admitting failed DCTLH due to poor documentation.Introduction:
Traditional surgical treatment for subacromial impingement is an arthroscopic subacromial decompression (ASD) with bursectomy and acromioplasty. Acromioplasty aims to reduce compression from the acromial arch and bursectomy removes inflammation from degenerative tendinopathy. Bursectomy alone may be sufficient treatment1-3.
Method:
This was a single centre, four-surgeon retrospective study of patients who underwent an ASD between 2013-2017 with an intact rotator cuff. All failed conservative management and underwent a bursecomty, or bursecomty with acromioplasty. Pre and post-operative Oxford Shoulder Scores (OSS) were analysed using t-tests and effect size. Minimum clinically important difference was set at 4.5 points5.
Results:
17 underwent bursectomy alone and 20 underwent bursecomty with acromioplasty. The mean improvement in the bursectomy group was 15.53 (SD 9.3) (p<0.005, 95% CI -20.3 to -10.7) and 16.4 (SD 9.6) (p<0.005, 95% CI -20.9 to -11.9) in the bursectomy with acromioplasty group. The difference in the mean change score between the two treatments was 0.87 points (p=0.3998, 95% CI -9.7 to 3.9, effect size 0.0095). 88% achieved the minimum clinically important difference in the bursecomty group with 80% in the bursectomy with acromioplasty group.
Conclusion:
Statically significant improvements were seen with both treatments, with less than a point difference in the mean change scores. There was no statistically significant difference between the two treatments with a small effect size, highlighting no superior treatment. Regardless of the treatment more than 80% achieved a good clinical outcome. No increased clinical benefit was seen with acromioplasty suggesting bursectomy alone may be sufficient.
Introduction:
Consent in anaesthesia has become a topical issue following recent landmark legal rulings. In 2017 the Association of Anaesthetists of Great Britain and Ireland (AAGBI) updated their informed consent guidelines. We wished to evaluate how consent for anaesthesia is being undertaken in a major teaching hospital.
Methods:
A service evaluation of documented consent on anaesthetic charts was undertaken. Data were collected across two sites, from anaesthetic charts, in the post-operative recovery room.
Results:
74 sets of patient notes were reviewed with a mean patient age of 52 and median American Society of Anaesthetists (ASA) grade of 2. There was evidence of anaesthetic consent for 63 of the 74 patients. Of those patients consented for general anaesthesia (n= 45), 84% were warned of sore throat, 78% of post-operative nausea and vomiting and 47% of dental damage. Discussion regarding death and cardiorespiratory complications appeared on one chart. 26 patients were consented for neuraxial anaesthesia, of which; 77% were warned of potential for nerve damage, 69% for failure to give complete analgesia, 65% for post-dural puncture headache and 54% for potential conversion to general anaesthesia.
Conclusions:
The results show a large variation in consent for anaesthesia. 15% of patients had no evidence of documented anaesthetic consent and many common complications were not discussed prior to anaesthesia, contrary to AAGBI guidance. Documentation may not reflect verbal patient consent; however, failure to disclose and document material risk may be challenged legally. A difficult balance exists between legal-centred and patient-centred consent in anaesthesia.
Objective: Understanding patient perspective on healthcare is central to the evaluation of quality. SANP-11 study showed thirst was one of the three areas where patient experienced severe discomfort in postoperative period.
Method: From October 2017 we began to offer 150 ml of water on arrival to the day surgery unit(DSU). A prospective patient survey was conducted specifically looking at postoperative thirst, sore throat and nausea vomiting in patients receiving water on arrival. Adult patients undergoing general anaesthesia in February 2018 in DSU filled in the questionnaire prior to their discharge.
Results: We analysed 99 out of 100 collected forms. 100% of our patients had read the information sheet given to them at pre-assessment. 82 patients drank water as per instruction and were subsequently offered it on arrival. Statistical analysis of these patients showed significant reduction in post operative thirst compared to patient surveys conducted in 2016 (19.66%; 95% CI 6.04 - 32.02, p =0.005) and 2017 (16.71%, 95% CI 3.21 - 29.04, p=0.01). There was reduction in post operative sore throat; 2016 (19.18%; 95% CI 7.55-29.27, p=0.002) and 2017 (11.05%, 95%CI -0.01 to 20.71, p=0.05).
Conclusion: We worked closely with our nursing staff to implement the change in our practice and it has shown to improve our patient experience. However we have identified that both patients and some staff are unsure of the new guidelines. We plan to discuss this further within the department.
BJA: British Journal of Anaesthesia, Volume 117, Issue 6, 1 December 2016, Pages 758–766
Consent was obtained from the patient for a follow up telephone call the day following surgery. Data collected showed the type of surgery, duration and the type and volume of local anaesthetic used, and was recorded on the day. The follow up call captured data relating to the time the patient experienced the return of motor function, the time the patient experienced pain over the operative site and what (if any) oral analgesics they self-administered. This was categorised according to when they took said analgesics, and whether or not the ABPB was supplemented with peripheral nerve blocks.
Introduction
Miscarriage is common, occurring in about 20% of pregnancies. Experiencing a miscarriage is incredibly distressing for both the patient and their family. Management of miscarriage can either be medical or surgical. Surgical management of miscarriage (SMM) is a common day-case emergency procedure, but there is no consensus on where these patients should be cared for perioperatively. NICE recommends tailoring healthcare services for each patient. We look at how the hospitals in our region care for these vulnerable patients.
Methods
We conducted a regional survey across the South West to investigate how these patients are managed, receiving a 70% response rate. Using the results, we targeted a variety of stake-holders to make some changes, both within our trust and across the region.
Results
Hospitals manage up to 40 SMM patients a month. 43% of patients have procedures in maternity theatre (alongside elective deliveries), 57% in gynaecology or general emergency theatres. 72% of clinicians feel these patients are not receiving care in an optimal environment, and no clinician believes these patients should be managed in maternity theatre. There is room for improvement!
Conclusions
The majority of SMM patients in the South West are managed in maternity theatres, where they are surrounded by audible and visual reminders of new-born babies. Our work demonstrates that clinicians feel this should change. We share the strategies we are currently using to improve this service including the challenges of change in a large teaching hospital that involves colleagues from a variety of different disciplines.Introduction
Hysterectomies are common procedures usually performed via an inpatient pathway. However, there is evidence that day-case surgery is safe and has a high level of patient satisfaction for a variety of gynaecological procedures, as well as providing a cost-effective, bed-saving service. This audit provides a review of patient outcomes and satisfaction following hysterectomy in our day surgery unit.
Methods
The routinely collected dataset for patients undergoing hysterectomies over a 24 month period was reviewed; fields of interest included admission rates, reason for admission and patient satisfaction.
Results
354 hysterectomies were performed of which 169 (48%) were via a day case pathway. 70 of 105 (75%) vaginal hysterectomies and 90 of 202 (45%) laparoscopic hysterectomies were planned as day case procedures.
44 (26%) day case patients required admission. The most common reasons for admission were pain and surgical complications. Of those who were discharged, 100% were satisfied or very satisfied with their experience.
Discussion
This audit has demonstrated that day-case hysterectomies can be successfully performed with an acceptable admission rate, minimal post-op morbidity and excellent patient satisfaction. Changes in anaesthetic technique and post-operative pain management could help reduce the admission rate and improve this service further.
Introduction
Performing operations as a day case can minimise morbidity, reduce waiting lists and
improve patient satisfaction. Cancelling operations, particularly on the day of surgery, can reduce theatre utilisation, impact on waiting lists and decrease patient satisfaction. We have reviewed the cancellation of operations in our Day Procedure Unit (DPU).
Methods
We retrospectively reviewed data from our hospital computer database on cancelled day case operations over a 4 month period. We recorded specialty, operation, number of days before surgery that the operation was cancelled and reason for cancellation (pre-set options).
Results
724 operations were cancelled, 38.3% of these occurred on the day of the planned
operation. Analysing initial data identified 2 specialties (urology and pain management)
which accounted for the highest proportions of cancellations. A high number of on the day cancellations occurring within urology are entered as ‘patient unfit, cancelled by hospital’, additional comments show just over half of these are due to the detection of a urinary tract infection (UTI) on arrival for surgery. We are reviewing our current processes and re-auditing a pre-assessment pathway that identifies UTIs in certain
elective urological surgical patients. Did not attend (DNA) and operation not needed are the commonest reasons for on the day cancellations for pain management.
Conclusions
A reduction in the number of cancelled operations would improve theatre utilisation and
patient satisfaction and reduce waiting lists. We have focussed on 2 specialties that contribute the highest proportion of cancellations and have identified areas where an intervention may reduce this number.
Introduction –
General guidance from RCSE states that consent should be taken as early as possible to allow patients time to reflect prior to surgery. In cases of acute cholecystitis/pancreatitis requiring urgent laparoscopic cholecystectomy, patients are often listed on a semi-emergency basis for theatre straight from acute admission and therefore miss an opportunity for consent discussions prior to day of surgery (DOS). We aim to improve the quality of this process in our unit.
Methods –
A retrospective audit of all semi-emergency laparoscopic cholecystectomies at a single centre was undertaken October to December 2017, using individual paper and electronic records. Date of listing for theatre, date of operation and of consent was collected along with evidence of documented discussion of procedural risks, if done, prior to DOS.
Results –
26 patients underwent semi-emergency laparoscopic cholecystectomy, all coordinated via the Emergency Surgery Department. The median time from listing to DOS was 28 days. 17 were listed straight from acute admission, 9 via interim Emergency Consultant clinic. 92% of patients were formally consented on DOS. 23% of patients had evidence of discussion of risks and complications documented prior to the DOS, all of whom were seen in clinic.
Conclusion –
The majority of patients that undergo semi-emergency laparoscopic cholecystectomy are still consented on the DOS. The quality of our consent process should improve with planned inclusion of unit complication rates in a specific information leaflet. This will be given out to every patient on their index admission prior to discharge and documented in the notes.
Introduction
Undergoing general anaesthesia involves a risk of aspirating gastric contents. This can be reduced through adequate preoperative fasting. However, prolonged starvation can be detrimental to patients’ health and experience. Therefore fasting times for patients presenting to Rotherham Hospital for elective surgery (including day surgery) were evaluated.
Method
Patients attending Rotherham Hospital Theatre Suite for elective surgery were asked when they had last 1 Eaten 2 Drank clear fluids. This was recorded with the time the patient arrived in theatre and the intended mode of anaesthesia. Data collection took place over one week in November 2017.
Results
Fasting times for food: (131 patients), 17 local anaesthetic only (LA); 114 non LA techniques.
Non LA patients: Starved 2-6hours-3%, 6-12hours -31%, 12-24hours -65%, > 24hours -2%.
LA patients: Starved < 2hours-6%, 2-6hours-47%, 6-12hours-18%, 12-24hours-29%.
Fasting times for clear fluids: (113 patients) 14 LA, 99 non LA techniques.
Non LA patients: Fasted <2hours -13%, 2-6hours-58%, 6-12hours-21%, 12-24hours-8%.
LA patients: Fasted <2hours 29%, 2-6hours - 64%, 6-12hours - 7%.
Conclusions
Many of our patients are undergoing prolonged starvation times. The reason for this is likely to be multifactorial but could influence patients’ health and recovery. We intend to introduce strategies to reduce excessive starvation times which include patient education to actively encourage eating and drinking until fasting should begin; consider allowing small amounts of milk in drinks up to 2 hours prior to admission and offering water on arrival.
Introduction
Patients requiring procedures should have them completed within 18 weeks of referral. The 92% target has not been met since February 2016. Waiting times for elective surgery may jeopardise patient’s safety due to likelihood of developing complications. Delays may be reduced by maximising theatre efficiency and minimising turnaround time with the view of expanding case lists.
Methods
This cross-sectional study looked at start and finish times of elective cases across all specialties during a working week period. The time of induction, knife to skin, closure and recovery were collected from the theatre database. The number, length and reasons for delay were identified. We subdivided into length of ‘golden patient’ delay and subsequent cases delay. Stages from patient’s check-in to recovery were assessed for delays. Strategies were developed to target this.
Results
During a 5 day period, 173 elective cases were completed in 10 theatres across 6 specialities. Seventy-one cases (41%) were delayed. During this period, 38 cases (first on each list) were due to commence at 0900. All cases were delayed by an average of 30.0 minutes (range 3 to 131 mins). The following cases on the lists (n=33) had a turnaround delay averaging 57.4 mins (range 10 to 217 minutes).
Conclusions
The high number of delayed cases with prolonged turnaround time is detrimental to the safety and well-being of patients and theatre staff. A number of strategies have been developed to minimise delays. The effects of these will be analysed in 3 months’ time.
Introduction
Following our switch from codeine to oral morphine solution for rescue analgesia for tonsillectomy, we wished to assess pain control at home. We trialled text messaging (SMS) to gather daily post-discharge data.
Methods
We recruited patients undergoing tonsillectomy ± adenoidectomy, and recorded their age, weight, gender, diagnostic indication for surgery and surgical technique. Parents consented to be texted with a series of questions for 10 evenings postoperatively, starting the day following surgery. Questions included the maximum pain score (0-10), the analgesic drugs administered and any nausea or vomiting (PONV) experienced that day. Responses were stored in a secure database for analysis.
Results
Data was gathered from 32 patients. 27/32 (84%) parents responded to texts on ≥5 days. 2 patients with poor responses were excluded. Of the 30 studied, 50% were male, with ages 10 months to 15 years, and weights 6.6kg to 64kg. 21 patients had sleep-disordered breathing (SDB) and 14 patients had experienced recurrent tonsillitis, including 5 who also had SDB. The average pain score ranged from 4.0 on Day 1 to a peak of 5.5 on Day 6 to a minimum of 2 on Day 10. 69.2% parents gave their children morphine on one or more days in addition to simple analgesia. The rate of PONV was 30%, unrelated to morphine use.
Conclusion
SMS proved very successful for data collection. We showed that pain is a significant problem for up to 10 days post-tonsillectomy and confirmed the requirement for opioid rescue medication after discharge.
Introduction
Since the Montgomery law was passed in 2016 new guidance regarding consent in day surgery have been released by the Royal College of Surgeons and the GMC. These guidelines suggest that consent should be relevant to the individual, should commence well in advance of the treatment and the discussion should be documented in the notes. It is important to assess the impact that these guidelines have had on clinical practice.
Methods
A prospective audit was performed between the time period 21/09/2017 – 19/12/2017 to assess the consenting process in the day surgery unit of a single centre. This was then repeated over a 2 week period 26/02/2018 – 09/03/2018.
Results
The notes of 89 patients were reviewed in the initial audit cycle. Of these patients 81% were consented on the day of surgery.
During the second cycle the notes of 34 patients were reviewed. Of these patients 85% were consented on the day of surgery. There was no significant difference in the consent process between the two groups (p=0.79). However, 76% of patients had the discussion regarding consent documented in their clinical record prior to attending for day surgery.
Conclusions
Despite recent guidelines the consenting process in day surgery is still poor. Further work needs to be done to assess how to improve this to meet the standards of the latest guidance.
Introduction: This audit aimed to review common anaesthetic strategies for day surgery knee arthroscopies, and to assess whether the different approaches to analgesia and anti-emesis influenced recovery time.
Methods: This retrospective audit looked at all patients admitted to the elective orthopaedic admissions lounge (THAL) for ambulatory knee arthroscopy +/- surgical intervention during a one month period in 2017.
Data collected included analgesia and anti-emetic administration – pre-operative and intra-operative strategies, and rescue requirements in recovery. Time in recovery was noted, prior to discharge back to THAL. Unplanned admissions were also noted.
Results: A total of 48 elective knee arthroscopies were performed, with 79% having arthroscopy with intervention. Multimodal analgesia was given in 100% cases (paracetamol, opioid, local anaesthetic infiltration by surgeons); 73% also received non-steroidal analgesia.
All but three patients received opioid analgesia intra-operatively – the vast majority receiving fentanyl, in the range of 50–300μg. 20% of patients were given intravenous morphine.
In recovery, rescue analgesia was needed in 35% cases – this rose to 58% in patients who received only 100μg fentanyl and who underwent arthroscopy and intervention. Intra-operative morphine appeared to reduce the need for rescue analgesia to 22%, with a slight reduction in time spent in recovery (96vs.103 minutes). Of those not given peri-operative anti-emetic(s), 75% needed rescue treatment.
Conclusion:For patients undergoing ambulatory knee surgery, use multimodal analgesia, and consider using morphine, or higher doses of intra-operative fentanyl in order to reduce the need for rescue analgesia in recovery. Use at least one anti-emetic for all patients.
Safe, cost effective and patient-centred care is essential in current financial climate. Day case procedures are more cost effective compared to inpatient stay while allowing patients to recover in the comfort of their home. Mastectomy is a common procedure in the treatment of breast cancer. British Association of Day Surgery (BADS) sets a target of 50% mastectomies to be day case procedures. If done as day case, mastectomy attracts £195 higher tariff while mastectomy with node procedure attracts £274 higher tariff. There is additional £306/day hospital bed cost saving. The aim was to ascertain the percentage of mastectomies done as day case and determine contributing/complicating factors for those Length of stay (LOS) >0.
MethodsPatients who underwent mastectomies at QEH, from 1/4/2017 to 31/10/2017, were identified retrospectively using theatre programme, operation notes and GP handover documents.
Results106 mastectomies were done (age 28-88 and mean 61.76). Only 35% cases were done as day case (versus 50% BADS target). Reason for inpatient stay were not documented in 55% of in-patients. Other reasons include post-operative intravenous antibiotics and other complications. Nodal procedures did not affect LOS.
ConclusionQEH did not achieve the BADS target. Only 35% of cases were done as day case.
Findings and importance of day case mastectomies were presented at surgical safecare meeting to ensure relevant staff promote and encourage patients for same day discharge, and if not possible, to documents reasons.
An re-audit will be performed in 6 months' time.
Introduction
Identifying factors that increase the length of stay (LOS) in day case operations can improve patient flow through the day case pathway and potentially increase patient throughput. We aimed to look at if anaesthetic technique, analgesic and anti-emetic management affected LOS on the day surgery unit (DSU).
Methods
A single centre, retrospective review of data collected on all planned adult general anaesthesia day case operations over 1 week. Data were collected by manual review of the anaesthetic chart and recovery notes.
Results
A total of 65 cases were recorded, 1 of these cases was abandoned after induction due to aspiration and so was excluded from analysis. A range of specialties were covered, general surgery (6, 9.2%), gynaecology (12, 18.5%), ENT (8, 12.3%) orthopaedics (16, 24.6%), dental (10, 15.4%), breast (3, 4.6%) and urology (10, 15.4%). Pre-operative paracetamol was given to all but 1 patient and 43 patients (66%) received modified release ibuprofen. Anaesthetic maintenance seemed to have some effect on mean LOS; Desflurane 136 minutes (4, 6.3%), Propofol 138 minutes (10, 15.6%), Sevoflurane 179 minutes (48, 75%), Isoflurane 238 minutes (2, 3.1%). The biggest factor seemed to be surgical procedure performed with surface and less invasive surgery generally spending less time on DSU and more invasive surgery such as laparoscopic abdominal surgery generally spending longer.
Conclusions
Maintenance with Isoflurane was associated with longer LOS but this may not be the only factor in these cases. Prolonged stay on DSU seemed to be mainly associated with the surgical procedure performed.
Introduction: Laparoscopic cholecystectomy is regarded as the gold standard treatment for benign biliary pathology. It is estimated that 66,000 cholecystectomies are performed each year across the United Kingdom. Ample evidence exists in the literature that advocates that laparoscopic cholecystectomy is both safe and a suitable operation to be undertaken as a day case procedure. This audit reviewed our current practice and assessed whether the best standard of practice was being achieved for our patients that undergo laparoscopic cholecystectomy.
Methods: A retrospective case note review was conducted evaluating all elective laparoscopic cholecystectomies being performed in a district general hospital over a 6 month time period.
Results: 193 laparoscopic cholecystectomies were performed during the 6 month time period. The gender split was 145 Females / 48 Males. The mean age was 54 (range18-86). 6 cases (3%) were converted to an open procedure. 106 patients (55%) were successfully discharged as a day case procedure. Only 7 patients had a documented reason for an overnight stay. There was a 4.7% complicaton rate observed, of which only 1 patient needed a return to theatre.
Conclusions:The data highlights a low conversion rate and a low post operative complication rate. However only 55% of patients were successfully discharged as a day case. Further assessment is required to identify the specific causes for delayed discharges. Obtaining this information will enable a revision of the current day case pathway in order to achieve best standard of care.
Introduction
All patients undergoing a surgical procedure in the UK should have documentation of the operative details in the medical notes. The Royal College of Surgeons of England (RCSEng) “Good Surgical Practice” document details 21 standards that should be met. This audit aimed to measure how accurately these guidelines are followed in our trust within a defined patient group.
Methods
We identified all patients undergoing day-case laparoscopic cholecystectomy between 1.11.2017 and 31.11.2017 from the electronic operative database ‘Theatreman. Operative records filed in the patient notes were analysed to see how many of the 21 criteria described in the ‘Good Surgical Practice’ document were adhered to. For each criterion, adherence was deemed good if met in >50% patients and was deemed poor if met in <50% patients.
Results
29 patients were identified. One set of notes could not be obtained, leaving 28 for the final analysis. One criterion was deemed not applicable in this patient group. 9 of the 20 remaining criteria had a 100% adherence rate. 6 of 20 criteria were deemed good and 5 were poor.
Conclusions
Standards for operative note documentation are not being consistently met. Results will be presented in a departmental clinical governance meeting. The authors recommend: 1. all notes should be typed on a proforma that includes all RCSEng guidelines; 2. all surgeons should familiarise themselves with RCSEng guidelines and 3. a laminated copy of the guidelines should be displayed in every theatre. Following these interventions, re-audit will take place in 3 months’ time.
Introduction:
Incidence of renal stones is increasing worldwide and varies from 58 to 900 per 100,000, whilst there is a 9% lifetime risk of having renal stone related symptoms. Increasingly ureteroscopy (URS) coupled with laser fragmentation is being used for ureteral and renal stone management, with associated high stone-free levels and patient satisfaction. However 5% of patients require an additional procedure for residual fragments and 25% readmission for pain management.
Method:
Retrospective analysis of 57 patients admitted under Urology between November 2016 –17, undergoing URS guided laser fragmentation for ureteric and renal calculi. Compared against national intercollegiate guidelines.
Results:
Of 57 Patients, average patient age was 55 years old and a 38:19 male:female ratio. Of stones treated 71% were ureteric (73% upper, 8% middle and 19% distal ureter), and 29% renal (11% upper pole, 28% middle pole and 61% lower pole). Average stone size was 9.7mm, with 52% of stones ‹1cm, 43% 1-2cm and 5% › 2cm. Average stone burden treated was 10.9mm and an average 0.961 Watts of energy used. 89% of patients following URS guided stone fragmentation were stone-free, with a 7% additional procedure rate.
Conclusion:
The increasing prevalence of renal stones globally, associated with factors such as dietary changes and global warming, emphasises the need to develop effective management strategies. A high level of patients can be made stone-free via URS guided stone fragmentation, which can be further enhanced with intraoperative retrieval of fragments › 2mm.
A patient fell in the toilet a couple of hours after a general anaesthetic hernia repair and fractured their ankle. They stated that their leg gave way. The surgeon had infiltrated wound with local anaesthetic(LA) but had not requested testing for leg weakness before mobilisation. The patient had been assisted to the toilet door but then left alone and had not expressed any concerns about leg weakness prior to their fall. Root Cause Analysis(RCA) of this fall highlighted the potential risk of leg weakness due to femoral nerve block after LA infiltration in groin . A large study demonstrating this complication and use of straight leg raise test to detect it, was carried out in our Day unit 20 years ago[1]. Most of the day unit staff are familiar with the risks of LA infiltration in the groin and would routinely test for leg weakness before mobilising. However, many new staff had recently joined and not been made aware of this requirement.
The outcome of the RCA was production of a poster describing when leg weakness might occur post op and how to use a straight leg raise test. This is now displayed prominently in recovery and ward areas to remind staff to test for leg weakness before allowing patients to mobilise unaided.
[1] Leg weakness is a complication of ilio‐inguinal nerve block in children. A K Lipp, J Woodcock, B Hensman, K Wilkinson. British Journal of Anaesthesia, Volume 92, Issue 2, 1 February 2004, P 273
Introduction
Patients with abscesses often wait many hours for surgery due to more urgent cases on the emergency list. This can result in blockage of inpatient beds and poor patient experience. Our surgeons suggested creating a slot at the beginning of their elective list to operate on these patients, similar to the existing priority slot on the emergency list for evacuation of retained products of conception patients.
Methods
Patients with a surgically appropriate abscess and who met local day surgery criteria were deemed suitable for this pathway. Phase 1 (July-Sep 2017) to establish any impact on the elective list - addition of suitable patients to general surgical list but via their inpatient surgical bed. Phase 2 (Nov-Jan 2018) pilot through DSU (Day Surgery Unit). Patients were discharged home, admitted to DSU the following day for their operation at the beginning of the elective operating list and discharged via DSU ward.
Results
Pre pathway
Phase 1
Phase 2
There were no late finishes or cancellations on the elective lists with an abscess patient added in either phase.
Conclusions
Although our numbers are small we have shown this pathway to be effective in reducing the time these patients wait and to free up inpatient beds without any negative impact to the elective list.
Introduction:
Research has shown that daycase laparoscopic fundoplication can be feasible and safe in carefully selected patients. Despite laparoscopic fundoplication being on the The British Association of Day Surgery Directory of Procedures we found some resistance to this approach within our trust. Within a 4-year period we have successfully increased the rate of laparoscopic fundoplication being performed as a daycase procedure.
Methods:
We retrospectively reviewed prospectively maintained data from all the fundoplications performed by a single surgeon from 2013 to 2017. Demographic details, length of stay, complications and re-admissions were obtained from trust electronic records. Data was analysed using Windows Excel.
Results:
From 2013-2017 a total of 159 patients underwent laparoscopic fundoplication. 88 patients were female (55.3%) and 71 male (44.7%). Average age of patients was 49.4. Average length of stay was 1.8 days and 61 patients were discharged the same day (38.3%). The rate of successful daycase procedures increased across the 4-year period. In 2013 15.4% of patients (n=2) required no overnight stay post-op; in 2014 this was 25% (n=10), in 2015 32.5% (n=13), in 2016 45% (n=31), and in 2017 62.8% (n=22). Overall readmission rate was 12 patients (8.1%) within 90 days. The rate of readmissions for daycase patients was 4.9% (n=3) and for non- daycase patients was 10% (n=10).
Conclusion:
Across a 4-year period we have been able to increase the number of laparoscopic fundoplications performed as daycase procedures. There was no increase in readmission rates for patients undergoing laparoscopic fundoplication as a daycase.Our day surgery centre (DSC) has excellent staff who work hard in pressured times for the NHS. However, in spring 2017, staff turnover and study budget cuts had taken their toll on our team-working, skills and morale. Staff development and morale scored badly in a trust-wide staff survey, and our clinical service lead received feedback from some surgeons that they were reluctant to work in our unit.
Method
We instigated a program of simulation-based training, held in daycase theatres and recovery on surgical ‘audit’ mornings. The scenarios written were based on incident forms received from DSC as well as perceived training needs. Focus was on constructive feedback, examining our processes and maintaining a supportive learning environment.
Results
After initial concerns, staff became more relaxed about the process and engaged well. We found that it streamlined our processes, opened a dialogue about quality improvement and broke down the silo mentality between theatres, recovery and ward. Surgeons have noted improved team-working and feedback from staff has been positive.
Conclusion
We are instigating a series of brief in-situ simulations at the start of occasional operating lists to focus on potential complications and kit required for each speciality. We intend to run a whole unit simulation to include administration staff as well as clinical staff.
Aims
We aimed to complete a local database of patients undergoing cholecystectomies, and compare complication data to those of the CholeS collaborative national study.
Methods
Retrospective study of consecutive patients undergoing cholecystectomies between July 2015 and June 2016 at local district general hospital. Discharge summaries, radiological investigations, and a subset of case notes were analysed to identify patients with postoperative complications and readmissions.
Results
239 patients underwent cholecystectomies in the time period analysed: 70% females with an average age of 54 years (21-89 years). Cases were almost equally divided into emergency (110) and elective (129). The majority of cases were laparoscopic (227, 95%), 6 were planned open cases, and 6 were converted to open (2.6%). The overall length of stay was 5 days, with 48% (63/129) of elective patients and 6%(7/110) of emergency patients discharged on day one postoperative. The majority of patients listed as day cases were discharged on the same day (19 out of 20, 95%), whilst 27% (30/110) of emergency patients stayed 10 days or more. In total 15 patients (6.3%) were readmitted within 30 days, with no statistically significant difference (p = 0.4) in the rate of readmission between emergency and elective cases. The most common readmission diagnosis was non specific abdominal pain (10), and one recorded bile leak.
Our patient population and complication rates were comparable to the national CholeS data. We highlighted that bile leaks are under reported on electronic and paper documentation, and will organise a local intervention to improve this.
Introduction:
We noted a spike in unplanned admissions in late 2017 and found that most were from patients undergoing Laparoscopic Cholecystectomy (LC). This combined with feedback from local General Practitioners about inadequate take home analgesia prompted us to improve our process.
Method:
We retrospectively audited 3 months of LC procedures, analgesia received, timing of surgery and admission rates.
Based on our findings, we made 4 changes to our process: Guidelines for anaesthetists and ward staff on perioperative analgesic regimes, improved drug charts to enable timely intervention, continuity of usage of numerical pain rating scales throughout, improved written and verbal instructions (and take home medication chart) for patients to manage their own post-operative analgesia.
Results:
Prior to intervention, patients weren’t given adequate multimodal analgesia or ‘rescue’ medication post operatively. We weren’t scoring and treating pain promptly, and patients weren’t routinely given opiate analgesia to take home.
With small changes in all 4 areas in December, our admission rate fell back from a peak of 4.2% in September to 2.3% in February. This rate continues to fall, despite some resistance to change from staff.
Conclusion:
Whilst we know that protocolizing anaesthetic management of LC improves outcome and multimodal analgesia delivers better results (1), the real challenge lies with change management and a slow cultural shift.
References:
Day Case and Short Stay Surgery. The Association of Anaesthetists of Great Britain & Ireland, The British Association of Day Surgery, May 2011The Mater Hospital Belfast performs approximately 300 cholecystectomies annually, with the majority undertaken as day cases. Our practice includes nurse-led telephone review one month following surgery, however with recent pressures and staff shortages this has become inconsistent. There is much debate over the optimum timing for telephone review, so our primary aim was to determine when patients felt they would have most appreciated a phone call.
Methods
A telephone questionnaire was constructed with ten questions regarding: information provided upon discharge; complications encountered; follow-up received; merits of telephone reviews, and optimal timing of calls. A final open ended question invited general feedback. All patients who underwent laparoscopic cholecystectomy between August and November 2017 were included.
Results
Of 71 eligible patients, 52 (73%) responded and participated. Median age was 50 (range 20-82) and 69% were female. Our day case rate was 86.5%. Eighteen patients (34.6%) sought advice regarding analgesia, gastrointestinal upset or wound problems, and three (5.7%) were readmitted to hospital. There were no biliary complications. Seven patients had been reviewed by telephone and two at clinic. Nine deemed telephone reviews unnecessary but 43 (82.6%) thought a call would have been useful. The most popular time suggested was one week (46%), with a further 30% suggesting follow-up within a month. General feedback was overwhelmingly positive, however two patients felt routine outpatient reviews should be offered.
Conclusion
Patients find telephone review an acceptable method of follow-up, and their preferred timing is one-week post discharge.
Introduction
NICE (National Institute for Health and Care Excellence) guideline 65 provides guidance on hypothermia prevention and management. We assessed compliance to this guideline at Nottingham University City Hospital's Day Surgery Unit.
Method
Retrospective data collection for all patients having day surgery in a one week period in January 2018. Data collected on pre, intra, post operative body temperature and warming method.
Results
64 patients were identified. 38 (59%) had general anaesthesia and 26 (41%) had regional or local anaesthesia. 7 (11%) had their body temperature measured in the immediate one hour period prior to surgery. 30 (47%) had a pre-operative body temperature less than 36 oC.
Intra-operatively 9 (14%) were actively warmed. 32 (50%) were kept warm with a blanket or a pre-heated blanket. 11 (17%) were covered by surgical drapes. In 12 (19%) of cases documentation of the warming method was omitted. Of the patients having general anaesthesia 9 (24%) had an endotracheal tube and 26 (76%) had a supraglottic airway device. 4 (6%) of patients had their body temperature documented during their operation.
48 (75%) had temperature measured in recovery. 16 (25%) performed under local or regional anaesthetic did not have body temperature recordings. 27 (42%) had a temperature of 360C or greater.
Conclusion
Missing or poorly completed data for example nonstandard responses limited the audit. Findings will be presented to all staff in day surgery theatres along with a poster highlighting the importance of using all possible warming methods and a re-audit performed in 6 months.
Introduction:
Finding a specific item in a patients’ medical records often requires patience. Searching for an operation note can be very frustrating and time consuming. Colour coded paper has long been used for handwritten proformas, but typed documents are often printed on plain white paper.
The hypothesis that colour-coded operation notes help identification and reduce the time to locate was explored to justify the money spent on paper bearing a pre-printed coloured edge.
Methods:
Thirty health care professionals participated. Two sets of notes; 15cm and 2cm deep, each had a typed operation note with a coloured edge and one without, inserted into the notes. Each health care professional was timed to find each operation note in each set of notes.
Results:
When comparing the 60 plain notes with the 60 coloured edge notes, a paired T test revealed statistical significance (p=0.0001). The mean time to find the plain note was 82 seconds, and the coloured-edge note 20 seconds. The mean difference was 62 seconds.
A paired T test revealed that there was no statistical difference between the size of the notes used for either finding either paper.
Conclusion:
Identifiable paper saves time when searching through a set of notes. Using pre-printed coloured edge paper saves over 1-minute searching for the note. This has a real, yet small impact on the efficiency of all healthcare professionals looking after the patient. Although marginal, the potential gains to patient safety should not be overlooked.
Introduction:
Advances in patient record systems mean that typed, electronic operation notes are possible. The Royal College of Surgeons of England (RCS) suggests this as a preferred method incorporating a list of 18 minimum standards that should be present on each note to avoid compromising patient safety.
Methods:
A sample of 30 hand written notes was audited across a 1-week retrospective period.
A database was then created on Microsoft Access which linked patient administration system Medway to enable an operation note pre-populated with basic data such as patient details and date/time. The completed note was then automatically uploaded to Medway.
A second retrospective audit of 27 notes was conducted 3 months after the introduction of the “E-op Note Database”.
Results:
Of the first audit 1/10 notes were entirely illegible. Few notes were entirely legible. Overall compliance to mandatory details was 59%. Important details were surprisingly poorly recorded: Time (12%), Estimated bloodloss (3%), Surgeon (82%), Venous-thromboembolism (57%), Further antibiotics (58%) to detail a few.
Post-intervention audit revealed that every electronic operation note was entirely legible. Overall compliance improved to 96%. Comparative important details had all improved to 100%. Average time to amend, upload and print a template compared favourably against handwriting, meaning this is an efficient solution between daycase
Conclusion:
Electronic operation notes prove to be a quick, legible and consistently reliable. RCS 18 minimum details were radically improved due to prompting and easy selection of information using a template solution. Notes are instantly available when a patient reattends.