Assessing the quality of operative notes meeting the current standards

Background: Operative notes are an important element of documentation based quality management for clinical practice. Often narrated by surgeons, they are usually penned by hand and are crucial in case of medical and legal consequences

Objective: To assess the operative notes at a tertiary care hospital and compare them to the standards set by Royal College of Surgeons of England

Methods: An observational prospective study carried out in the department of general surgery over a time period of one month from June to July, 2014. Sixty operative notes including general surgery, urology, orthopedics and neurosurgery were included in this study and were assessed according to published guidelines of the Royal College of Surgeons of England

Results: A total of 60 operative notes were reviewed. All of them were handwritten, out of which 40 [66.7%] were written by the operating surgeon. None of the notes mentioned the time of the surgery and the type of surgery and had no diagrams to illustrate the operative findings. Almost all [96.7%] included the patients name and the procedure performed [95%] and only 66.7% mentioned the operative findings. Incomplete post-operative instructions were present in all the notes that were studied

Conclusion: Several areas were highlighted, that lacked essential information in the operative notes, including the time of the procedure, type of surgery, instructions for postoperative care, operative diagnosis, findings, and complications during the procedure indicating that the operative notes were incomplete and inadequate in many respects

Students' perception of surgical objective structured clinical examination [OSCE] at Dow University of Health Sciences

To determine the student's perception of reliability and validity of Surgical Objective Structured Clinical Examination [OSCE] in Dow University of Health Sciences. Total 109 third year students of Dow International Medical College voluntarily and anonymously completed a self-administered questionnaire at the end of the OSCE examination from January 2012 to March 2013. Main outcome measures were student perception of examination attributes [which included the quality of instructions and organization, the quality of performance, authenticity and transparency of the process]. OSCE was considered as a fair examination method by 76% students. More than half of the students rated this examination as one covering wide range of knowledge [86%], clinical competence [72.5%], and well administered and structured [85-87%]. Sixty six percent students highlighted OSCE as tool that is reliable and valid in measuring their clinical competencies. OSCE as a tool to evaluate clinical competence among surgical students was highly appreciated by the students. Student believes that this assessment method cover broad knowledge component and clinical competence

Effectiveness of the primary trauma care course: is the outcome satisfactory?

Objective: To assess the improvement of knowledge and skills of trauma management among participant of Primary Trauma Care [PTC] workshop

Methods: A two days Primary Trauma Care [PTC] provider workshop was organized at Dow International Medical College, Karachi - Pakistan on March 5th and 6th 2011. Participant's knowledge was assessed by 30 Best Choice Questions [BCQs] and their trauma management skills were assessed by management of trauma case scenario both at pre and post workshop. All scenarios performed by participants were video recorded and marked on a 20 points check list and evaluated by two PTC trainers and graded after consensus. Percentage of participants who scored more than 70% marks on knowledge and skills component were also analyzed. Data was analyzed by SPSS version 17. Wilcoxon Sign Rank test was used to find out significant difference between pre and post workshop score

Results: A total of 20 participants attended the full workshop. Median One best question score before the workshop was 19.5 and post workshop was 25 [p < 0.0001]. Trauma skills scenario score also showed marked improvement with median score of 3.5 pre workshop and 9.5 post workshop [p < 0.0001]. Total 19 participants had >/= 70% post workshop knowledge score. However, only 4 participants had trauma skill score with >/= 70 marks

Conclusion: Primary Trauma Care workshop could be an effective course for gaining of knowledge and skills of initial management of trauma patients. However, some modifications need to be done for training of skills components to maximize the output of this interactive workshop

Quality of surgical case notes at Dow university hospital according to modified ANKLe score

To find out quality of surgical case notes according to modified Adjusted Note keeping and Legibility [ANKLe] score in Dow University Hospital. For this audit, medical records of all the patients admitted in Dow University Hospital surgery department were reviewed from February 2012 to April 2012. The modified ANKLe score [total 24] is formed by the combination of, the content [out of 20] and legibility [out of 4] to give an overall score out of 24. A score of at least 20 [content score 17/20; legibility score 3/4] is considered as acceptable. It means that a surgical record is legible and the majority of the essential content is recorded. A total of 236 records were evaluated. Overall mean +/- standard deviation [SD] of ANKLe score was 18.4 +/- 2.1 out of maximum score of 24. Content and legibility has overall mean scores of 14.4 out of 20 and 3.9 out of 4 respectively. Only two variables, patient's name and consultant on call were documented in 100% of records while the least documented variable were social history 2 [0.2%]. Legibility scoring system provides that 218 notes out of total set of 236 notes [that is 92.4% of overall notes] have achieved a score of 4. The benchmark of 80% was achieved in 26.1% for total ANKLe score, 6.8% for contents and 99.1% for legibility. Overall, quality of records is not good but legibility part scores exceptionally high

Daily progress notes by surgical interns: an assessment of quality

To evaluate the quality of daily progress notes documented by surgical interns in a tertiary care teaching hospital. Daily progress notes documented by interns during two months period from February to March 2008 were assessed according to the guidelines developed by the Unit. During each working day progress notes were evaluated in a specially designed proforma about documentation, which included subjective, objective, assessement and plan. Data was analysed by SPSS version 10 and Chi square test was applied between categorial data. Two hundred fifty patient's record were assessed for daily progress notes. Out of them 44 [17.6%] daily notes were not found, so a total of 206 morning follow up notes were analyzed. These included 63 [30.6%] preoparative and 143 [69.4%] postoperative patient notes. Most common documented variable was Blood Pressure reading in 194 [94.2%] notes followed by pulse rate in 193 [93.7%]. The leaset documented variable was assessement of patient's current condition in 111 [53.9%] patients' notes. There was statistical significant difference between quality of notes in preoperative patients as compared to postoperative patients. Overall no significant difference was noted while comparing elective vs emergency surgery patient's notes and hepatits positive vs negative notes. Our results showed that our documentation as regards daily progress notes was overall fair. Systematic audit of this type can lead to the development of improved documentation supporting the clinical process within a busy general surgical department with benefits for patient care, clinical governance and inter-specialty communication

Disclosure of cancer diagnosis: Pakistani patients perspective

To ascertain cancer patients' views regarding disclosure of diagnosis in the Pakistani population, anxiety levels after disclosure of the diagnosis, interest in knowing all the treatment options and desire to inform their families. In this cross-sectional study, 147 cancer patients from different hospitals in Pakistan were asked questions to determine their opinions regarding whether the diagnosis of cancer should be disclosed to patients and their relatives or not. Anxiety after diagnosis disclosure and who should disclose this information were also asked. Patients were also asked about their views regarding whether their families should be informed about the cancer diagnosis without patient's prior consent. A total of 147 cancer patients completed the questionnaire. Of these, 112 [76.2%] wanted to know about their cancer diagnosis while only 28 [19.0%] patients refused. Anxiety levels were increased in 59 [40.1%] patients, remained the same in 61 [41.5%] and decreased in 27 [18.4%]. One hundred and twenty three patients [83.7%], wanted to know the diagnosis from their physicians. Eighty-four [57.1%] patients were interested in all treatment options, while 102 [69.4%] patients wanted to be actively involved in decision making about their treatment. Only 37 [25.2%] patients answered affirmatively to the question which asked if their families were informed about the patient's disease without patient's prior knowledge, while 82 [55.8%] disagreed. The majority of cancer patients wanted disclosure of their disease by their doctor. The results of this study provide important implications for Pakistani doctors concerning the practice of diagnostic cancer disclosure to the patients

Topical diltiazem hydrochloride and glyceryl trinitrate in the treatment of chronic anal fissure

To compare the symptomatic relief, healing and side-effects of topical diltiazem [DTZ] and glyceryl trinitrate in the treatment of chronic anal fissure. Randomized controlled trial. The Surgical Outpatient Department of Civil Hospital, Karachi, from March 2006 to February 2007. Patients with chronic anal fissure were included in the study and randomized to two groups. One group was administered topical 2% diltiazem hydrochloride and other was given 0.2% glyceryl trinitrate [GTN], perianally twice daily for 8 weeks. Patients with anal fissure due to other diseases like inflammatory bowel disease, malignancy, sexually transmitted diseases, previous treatment with local ointment or surgery; patients who required anal surgery for any concurrent disease like hemorrhoids, pregnant women and patients with significant cardiovascular conditions were excluded. There were four follow-up sessions during the course of treatment. Healing and side-effects were recorded. Analysis was done by SPSS version 10 on intention-to-treat basis. Chi-square was used where appropriate. Eighty patients with symptomatic chronic anal fissure were included in the study and equally divided into two groups. After 8 weeks of treatment healing occurred in 31 of 40 patients treated with diltiazem and 33 of 40 patients treated with GTN [p = 0.576]. There were less side-effects with DTZ [n=13] than with GTN [n=29, p < 0.001]. In particular, headache occurred more commonly with GTN [n=27] than with DTZ [n=9, p < 0.0001]. Diltiazem hydrochloride and glyceryl trinitrate were equally effective in healing chronic anal fissure. Diltiazem caused fewer side-effects particularly headache than glyceryl trinitrate ointment. Diltiazem may be the first-line treatment for chemical sphincterotomy for the chronic anal fissure

Pre-operative analgesia in the accident and emergency department

To evaluate the adequacy of pre-operative analgesia and patient's satisfaction at the accident and emergency department, in terms of pain relief. Observational study. The Accident and Emergency Department [A and E] of Civil Hospital, Karachi, during April and May, 2007. Patients presenting with acute abdomen or tauma were included. Visual Analogue Scale [VAS] was used to grade severity of pain. Pain at presentation, analgesic prescribed, post-analgesic residual pain and patient satisfaction were assessed. A total of 166 patients [109 males and 57 females] were enrolled in the study. It included 98 [59%] cases of trauma and 68 [41%] patients with acute abdomen. Mean pain score was 6.95 +/- 2.03 on VAS. Female patients [p=0.008] and patients with acute abdomen [p<0.001] experienced significantly more pain as compared to male and trauma patients respectively. Analgesics were prescribed to 104 [62.7%] patients. Post-analgesic mean residual pain score was 5.0 +/- 1.8. Out of them, 47.1% patients waited to be given more analgesia. There was significant less prescription of analgesic to patients with acute abdomen [52.9%] as compared to trauma patients [26.5%] [p=0.001]. Overall, more than half of the patients [59.6%] were not satisfied with the pre-operative analgesic treatment in the A and E department. Pre-operative analgesia was underprescribed and pain was undertreated in accident and emergency department resulting in more than half patients being not satisfied

Spinal injuries: experience of a local neurosurgical centre

To find out the pattern of traumatic spinal injuries and their management in patients admitted to a neurosurgical unit of a tertiary care hospital in a developing country. All patients admitted with spinal injuries between July, 2003 and June, 2007, in the Department of Neurosurgery, Civil Hospital, Karachi, were included. Information was recorded and analysed with respect to demographic data, mechanism of injury, level of bony injury, neurological degree [complete, incomplete and intact], duration between injury and admission, associated injuries, management, hospital stay and outcome. A total of 214 patients were admitted. These included 189 males [88.3%] and 25 females [11.7%]. Most affected patients [72/214 - 33.6%] were in their third decade of life, followed by second and fourth decades, 38 /214 [17.7%] in each decade. The commonest cause of injury was fall from height in 122 patients, [57.0%], followed by fall while carrying weight in 23 [10.7%], road accidents in 50 [23.4%] and gunshot injuries in 10 [4.7%] cases. Cervical spine was affected in the majority 101 [47.2%] cases followed by thoracic spinal injury, 64 cases and lumbar spine with 59 cases [27.6%]. Seventy seven patients [36%] had complete neurological loss, 119 [55.6%] had partial deficit while 18 patients [8.4%] were neurologically intact. Surgery [decompression and fixation] was performed in 50 cases. Long bone fracture was the commonest associated injury. The average time between injury and admission was 6.2 days [range 0-60]. Mean hospital stay was 8.4 +/- 7.6 days. Twenty three [10.7%] patients died during hospitalization. This study shows that young adults, predominantly males in their most productive years of life, are especially prone to spinal cord injury. Fall from height is the most common preventable cause of spinal injury. Recognizing the pattern of spinal injury helps to identify high-risk groups which will then help us to design more appropriate preventive measures

Post-operative complications in a general surgical ward of a teaching hospital

To find out post-operative complications during hospital stay of patients in a general surgical ward at a tertiary care teaching hospital of Karachi. Descriptive retrospective analysis. Surgical Unit IV, Civil Hospital Karachi. Six months, from January 1, 2004 to June 30, 2004. The records of all patients who underwent surgery between January 2004 to June 2004 were reviewed regarding postoperative complications developed during hospital stay. The following data were collected: age, sex, presentation at time of surgery [emergency or elective], surgery performed, complications during postoperative period and outcome. All data was analyzed with the help of SPSS-10. Surgery performed, post operative complications. A total of 501 patients were admitted during the study period. Total 411 surgeries were performed. 258 [62.8%] were elective and 153 [37.2%] were emergency procedures. Hernia repair was the most common surgery performed in 92 [22.4%] patients, followed by appendicectomy in 64 [15.6%] and cholecystectomy in 54 [13.2%] patients. Complications were documented in 122 [29.6%] patients. Most common complication observed was postoperative pyrexia in 75 [18.2%] patients, followed by postoperative nausea and vomiting [PONV] in 48 [11.6%], wound infection in 47 [11.4%], respiratory tract infection in 29 [7.0%] patients. During the study period 4 patients [0.9%] died in the postoperative period. This study revealed that the commonest postoperative complication was fever followed by PONV, wound infection and respiratory tract infection. It is important that the resident staff should be aware of these complications and how to manage them because these are better yardstick to measure the quality of care