IMPROVING THE QUALITY OF OPERATION NOTES

Improving the Quality of Transurethral Resection of Bladder Tumour (TURBT) Operative Notes Following the European Association of Urology Guidelines: A Completed Audit Loop Study

Background

The European Association of Urology (EAU) recommends that the operative steps and documentation necessary for successful and appropriate management of bladder cancer include identifying factors necessary to assign disease risk stratification, clinical stage, adequacy of resection and the presence of complications and immediate intravesical chemotherapy administration.

Aim

To assess and improve the adequacy of current transurethral resection of bladder tumour (TURBT) documentation at a district general hospital in the UK against the EAU 2022 guidelines.

Methods

Operative notes over a one-year period were assessed for the inclusion of key steps to achieve a comprehensive TURBT as outlined by EAU guidelines. Outcomes included documentation on the details of the operative findings and intervention as well as the perioperative assessment. A standardised template for TURBT procedures was created and surgical staff received training on its usage. The audit was subsequently repeated after six months to assess for improvements.

Results

TURBT documentation of 78 cases in the first cycle was compared to 37 cases from the second cycle. Significant improvements in the documentation of tumour size (46% to 89%; p<0.05), tumour description (59% to 89%; p <0.05), depth of resection (36% to 89%; p<0.05), administration of chemotherapy (21% to 46%; p<0.05) and assessment for perforation (22% to 68%; p=0.001) were demonstrated. Improvements in pre-operative and post-operative examination rates under anaesthesia also achieved statistical significance (47% & 14% respectively to 89%; p<0.05). There was an increase in the documentation of completeness of resection but this did not achieve statistical significance (59% to 68%; p=0.42).

Conclusion

The operative note template led to the improvement in the documentation, improving the risk stratification of bladder cancer in patients undergoing TURBT. The use of procedure-specific operative note templates should be adopted for all commonly performed procedures to improve the completeness of documentation.

Operation notes in orthopaedics: Beliefs and practices in a developing country

Maintaining accurate and complete operation notes is an essential metric of the quality of surgical care. While developed countries have implemented electronic health records to improve documentation, financial constraints prevent this realisation in the Caribbean. Somewhat paradoxically, previous studies in this area have focussed on 'process' while neglecting the key role of the surgeon. We conducted a 25-item Knowledge, Attitudes and Practices survey of orthopaedic doctors to identify any culturally unique health-related behaviours. Our results indicate that while most doctors understand the importance of operation notes, many are unaware of international note-keeping recommendations. Legibility was identified as a significant issue by 92% of doctors. A disturbing and previously unreported finding from the study revealed that 72% of surgeons would occasionally write the operation notes, although they were not scrubbed in for the procedure. We suggest that future studies examine this peculiar behaviour in greater detail.

Implementation of a checklist to enhance operation note quality at a UK burns centre

INTRODUCTION

Operation notes are fundamental for clinical, academic and medico-legal purposes. Good Surgical Practice (2014) provides guidelines to assist note completion but the literature suggests poor adherence to these. The aim of this study was to evaluate and improve operation note quality at a UK burns centre through implementation of a burns surgery-specific checklist.

METHODS

A 22-component burns surgery-specific checklist, modified from Good Surgical Practice (2014), was designed and implemented. The quality of 80 operation notes (40 pre and 40 post-implementation) was assessed against this checklist. Fisher's exact and Mann-Whitney U statistical tests were used to evaluate pre and post-intervention note quality.

RESULTS

Before checklist implementation, only 6/22 components (27.3%) were recorded on every note. 4/22 components (18.2%) were not recorded on any, including microbiology specimen and clinical photography, which are particularly important in burns. After implementation, 16/22 (72.7%) were recorded on every note, with a statistically significant improvement in all other components (p≤0.01), except venous thromboembolism prophylaxis (p=0.10). The median percentage score of components recorded improved from 78.2 to 100% (p<0.01).

CONCLUSION

To our knowledge, this is the first study in available literature to show that a burns surgery-specific checklist can significantly improve burns operation note quality. This presents a simple and cheap method to improve note quality and may enhance post-operative intra/inter-team communication and patient care. At our unit, we have now developed an electronic checklist format with mandatory field completion to facilitate total compliance.

Improving the documentation of flexible cystoscopy notes: Case for introduction of electronic patient records?

Introduction/Objective:

Good surgical practice dictates that comprehensive and legible records are maintained by surgeons of all their interactions with patients. Flexible cystoscopy (FC) notes should be no exception to this standard. Currently at our institution, for every cystoscopy, FC operators document the same information in two different locations: handwritten in patient notes and electronic discharge letter.

Methods:

A closed-loop audit of FC notes at our institution was undertaken and data were collected prospectively using patients’ notes. Notes were scrutinised against the Royal College of Surgeons (RCS)/British Association of Urological Surgeons (BAUS) standards. The first period was 13–17 October 2015, and the second period was 20–31 May 2016. A total of 73 patients were included (43+30).

Results:

The first cycle highlighted several areas requiring improvement. Eight of 15 parameters fell short of the 100% target compliance: time (5.9%), responsible consultant (32.4%), operator (50%), postoperative instructions (82.4%), indication for FC (85.3%), date (88.2%), procedure name (91.2%) and signature (97%). Subsequently, a new electronic FC proforma was designed using the RCS/BAUS criteria for data to be documented. A successive re-audit using identical criteria established 100% compliance in all fields.

Conclusion:

Adopting the new proforma significantly improved the quality of FC documentation. Subsequently, new online software incorporating our proforma was introduced as part of electronic patient records, allowing for data to be easily accessed and read. We discuss the relevance of this in the context of existing literature.

Level of evidence:

Not applicable for this multicentre audit.

Improving the quality of operation notes with electronic proformas

Introduction

Surgeons must ensure operative notes are legible and sufficiently detailed, outlined by 21 criteria in Good Surgical Practice guidelines (2014). Our aim was to introduce an electronic operating proforma to improve quality of operation notes.

Methods

Two audits were performed six months apart, after an education session and introduction of an electronic operating proforma, assessing adherence to the guidelines. Results were compared and analysed using Chi-square and Fisher’s exact tests.

Results

In both audits, notes for 187 operations performed over a two-week period were studied. In the first audit, six of the 21 criteria were recorded in ≥95% of operation notes, improving to nine in the second audit. In the second audit cycle, two subgroups were analysed, non-proforma (n = 30) and proforma (n = 157). In the proforma subgroup, 15 criteria were recorded in ≥95% of operation notes.

Conclusion

Quality of operation notes can be significantly improved by using a combination of education, electronic proformas and avoiding handwritten notes.

Quality of handwritten surgical operative notes from surgical trainees: a noteworthy issue

BACKGROUND

Surgical operation notes are crucial for medical record keeping and information flow in continued patient care. In addition to inherent medical implications, the quality of operative notes also has important economic and medico-legal ramifications. Further, well-documented records can also be useful for audit purposes and propagation of research, facilitating the improvement of delivery of care to patients. We aimed to assess the quality of surgical operation notes written by junior doctors and trainees against a set standard, to ascertain whether these standards were met.

METHOD

We undertook an audit of Urology and General Surgery operation notes handwritten by junior doctors and surgical trainees in a tertiary teaching hospital over a month period both in 2014 and 2015. Individual operative notes were assessed for quality based on parameters described by the Royal College of Surgeons of England guidelines.

RESULTS

Based on the Royal College of Surgeons of England guidelines, a significant proportion of analysed surgical operative notes were incomplete, with information pertaining to the time of surgery, name of anaesthetist and deep vein thrombosis prophylaxis in particular being recorded less than 50% of the time (22.42, 36.36 and 43.03%, respectively).Overall, 80% compliance was achieved in 14/20 standards and 100% compliance was attained in only one standard.

CONCLUSIONS

The quality of surgical operation notes written by junior doctors and trainees demonstrated significant deficiencies when compared against a set standard. There is a clear need to educate junior medical staff and to provide systems and ongoing education to improve quality. This would involve leadership from senior staff, ongoing audit and the development of systems that are part of the normal workflow to improve quality and compliance.

Improving the Standard of Orthopaedic Operation Documentation Using Typed Proforma Operation Notes: A Completed Audit Loop

Introduction

The Royal College of Surgeons (RCS) published Good Surgical Practice guidelines in 2008 and revised them in 2014. They outline the basic standard that all surgical operation notes should meet.

Objectives

To retrospectively audit 57 typed orthopaedic operation notes from St. James’s Hospital in Dublin (from August to November 2015) against the RCS Good Surgical Practice guidelines published in 2014. They were then compared with the department’s previous audit of handwritten notes to complete the audit loop.

Materials and methods

A total of 57 orthopaedic operation notes were audited by a single reviewer. They were prospectively collected between August and November 2015. All notes were typed on the standard St. James’s Hospital operation note proforma.

Results

Of the surgeries, 89.5% were emergencies with 77.2% of them being performed by trainees. All of the operation notes were typed and signed by trainees. The procedure name, incision and closure details, tourniquet time (when relevant), and postoperative instructions were documented in 100% of the notes. In total, 80.7% had an operative diagnosis included while only 26.9% of the documentation had prosthesis serial numbers. All of the typed notes were deemed to be legible.

Conclusion

The use of printed operation notes allows for improved legibility when compared to typed notes. Documentation standards remained very high in the same areas as the handwritten notes and a marked improvement was seen in areas that had been poorly documented.

The impact of an operative note proforma at a paediatric surgical centre

RATIONALE, AIMS AND OBJECTIVES

With expectations for standardization and evidence-based practice, the Royal College of Surgeons (RCS) published the 'Good Surgical Practice' in 2008. The document sets standards for operative records anticipating improved documentation, audits, medico-legal review and quality and safety of handover. We evaluated (1) documentation against RCS standards; (2) whether RCS standards are applicable to and adequate for paediatric surgery; and (3) the impact of a standardized operative proforma.

METHODS

All general surgery and urology admissions during July 2011 and August 2012 were retrospectively reviewed using 23 set criteria. An operative note proforma was introduced in February 2012. Results were compared and statistically analysed using two-tailed Fisher's exact test, with Bonferroni correction where appropriate (SPSS 20.0, IBM SPSS Statistics, Armonk, NY, USA).

RESULTS

There were 345 children admitted; 63.2% underwent an operation (119 in 2011 versus 99 in 2012); 55% of operations were day cases. The initial audit noted poor documentation in 7 of 23 criteria. Following introduction of the operative note proforma, documentation improved significantly: patient identifiers by 12.3%, procedure time 43.3%, assistant's name 31.9%, procedure type 21.4%, closure 6.2%, anaesthetist's name 15.9%, anaesthetic type 56.8% and surgeons grade 65.8% (P<0.05). Subgroup analysis in the latter cohort shows most of these effects to be related to the use of the proforma rather than education alone (P<0.05). Quality of documentation was better by consultants versus trainees in 2 of 23 criteria (P<0.05).

CONCLUSION

We have demonstrated a simple and cost-effective way of improving the quality of operative documentation, in line with guidelines set out by the RCS, in a climate of increasing economic austerity.