Compliance With the World Health Organization Surgical Safety Checklist at a Tertiary Care Hospital: A Closed Loop Audit Study.

BACKGROUND AND OBJECTIVE: The WHO launched the "Safe Surgery Saves Lives" campaign in 2008 to improve patient safety during surgery. The campaign includes the use of the WHO Surgical Safety Checklist, which has been proven effective in reducing complications and mortality rates in several studies. This article discusses a clinical audit at a tertiary healthcare facility that assesses compliance with all three components of the checklist to minimize errors and improve safety standards. MATERIALS AND METHODS: This prospective, observational, closed-loop clinical audit study was conducted at Hayatabad Medical Complex, a tertiary care public sector hospital located in Peshawar, Pakistan. The audit aimed to assess compliance with the WHO Surgical Safety Checklist. The first phase of the audit cycle commenced on October 5, 2022, and involved collecting data from 91 surgical cases in randomly selected operating rooms. Following the completion of the first phase on December 13, 2022, an educational intervention was then conducted on December 15 to underscore the significance of adhering to the checklist, and the second phase of data collection began the following day, ending on February 22, 2023. The results were analyzed using SPSS Statistics version 27.0. RESULTS: The first phase of the audit showed that there was poor compliance with the latter two parts of the checklist. Certain components of the WHO Surgical Safety Checklist were well-complied with, including patient identity confirmation (95.6%), obtaining informed consent (94.5%), and counting of sponges and instruments (95.6%), while the lowest compliance rates were in recording allergies (26.3%), assessing blood loss risk (15.3%), introducing team members (62.6%), and inquiring about patient recovery concerns (64.8%, 34%, and 20.8% for surgeons, anesthetists, and nurses, respectively). In the second phase, after an educational intervention, compliance with the checklist improved significantly, particularly for those components with low compliance rates in the first phase, marking recording allergies (89.0%), introducing team members 91.2%), and inquiring about patient recovery concerns (79.1%, 73.6%, and 70.3% for surgeons, anesthetists, and nurses, respectively). CONCLUSION: The study showed that education is a critical factor in improving compliance with the WHO Surgical Safety Checklist. The study suggests that overcoming the obstacles to implementing the checklist requires a collaborative environment and effective instruction. It emphasizes the importance of adhering to the checklist in all surgical settings.

Primary Closure vs T-Tube Drainage Following Open Choledochotomy for CBD (Common Bile Duct) Stones.

BACKGROUND: Choledocholithiasis affects 10%-15% of individuals with gallbladder stones. Approximately 7%-15% of cholecystectomy patients develop common bile duct (CBD) stones. It occurs more frequently in older age groups. It may result in a complete or partial blockage of the bile duct and present as pancreatitis or cholangitis due to gallstones. OBJECTIVE: The aim of this study was to compare the outcomes of primary closure of duct and T-tube drainage after open choledochotomy and to evaluate the effectiveness and safety of primary closure. MATERIAL AND METHODS: From January 2018 to December 2021, this descriptive study was carried out in the surgical department of the Hayatabad Medical Complex in Peshawar. In total, 60 patients who had open choledocholithotomy after a failed endoscopic extraction were included in this study. Of these, 30 (50%) patients got primary duct closure after choledochotomy, while 30 (50%) patients had T-tube insertion. RESULTS:  Among the total of 60 patients (primary closure: 30 and T-tube drainage: 30 patients), 10 (16%) were males, while 50 (84%) were female patients. The mean age was recorded as 45.9±13.9, and the mean hospital stay in days in both groups was 4.87±1.4 (T-tube: 5.24±1.50 and primary closure: 4.50±1.3). Complications developed in group A were a biliary leak in three (10%) patients, postoperative jaundice in two (6.5%) patients, wound infection in three (10%), intra-abdominal collection in three (10%) patients, and dislodgement of a tube in two (6.5%), while 17 (57%) patients had no complications developed. CONCLUSION:  If the duct is free of stones, as determined by preoperative choledochoscopy, primary closure of the common bile duct (CBD) is a safe, cost-effective procedure with less morbidity than regular T-tube drainage after open choledochotomy.

Complicated jejunal diverticula as surgical emergency: experience at a tertiary care hospital in Peshawar, Pakistan.

BACKGROUND: Diverticula of small intestine are rare. Jejunal diverticula can be single or multiple. Diverticula in the jejunum tend to be large and multiple. Clinically they may be asymptomatic or may give rise to symptoms like pain, flatulence and borborygmi, may produce malabsorption syndrome or may present in emergency with different acute pathologies like perforation, haemorrhage, obstruction, enterolith formation and inflammation. The Objective was to see the pattern of complications in jejunal diverticula presenting as a surgical emergency. METHODS: This descriptive study was conducted at Surgical Units of the 3 tertiary care Hospitals of Peshawar, for 7 years from January 1, 2002 to December 31, 2008. Study included all patients presenting to and admitted in Surgical Unit, Hayatabad Medical Complex, Peshawar with complicated jejunal diverticula during the above mentioned period. Name, age, sex, other relevant data, history and examination findings and results of investigation were recorded. Uncomplicated jejuna diverticula were excluded from study. The operative findings and the type of complication were recorded. RESULTS: Ten patients were admitted during 7 years of study. Out of all patients 9 were male and 1 was female. Eight out of 10 patients presented with perforation of diverticula while 1 patient had severe inflammation of diverticulum causing pain, ileus and acute abdomen. One patient had acute pain due to adhesion formation. CONCLUSION: It is seen that complicated jejunal diverticulae are quite rare and the most common complication is perforation. Inflammation and adhesion are other complications with which jejunal diverticula presented during this study.

Pattern of breast cancer: experience at Lady Reading Hospital, Peshawar.

BACKGROUND: Breast Cancer is the commonest malignancy of females all over the world and second leading cause of death due to cancer among females. The aim of this Descriptive study was to see the various features of breast cancer in order to know the pattern of disease in the recent time. The study was conducted from Jan. 2007 to Dec. 2007 in Surgical C Unit, Postgraduate Medical Institute, Lady Reading Hospital, Peshawar, Pakistan. METHODS: Study included all patients presenting to and admitted in Surgical C Unit LRH, with carcinoma of breast during the above mentioned period. Name, age, sex, other relevant data, history and examination findings and results of histopathology and other investigations were recorded. RESULTS: Total of 46 patients was included in the study, out of which there were 46 female and 1 male patients. Most common age group was 40-49 years with 14 patients, followed by 50-59 years with 12 patients. Most common type of carcinoma was infiltrating ductal carcinoma with no specific features with 38 patients. Other types included 2 infiltrating ductal carcinomas of papillary type, 1 mucinous type and 1 medullary type; 3 invasive lobular carcinomas, and 1 mixed lobular and ductal carcinoma. The disease was left sided in 24 cases, right sided in 20 cases while it was bilateral in 2 cases. Upper outer quadrant of the breast was most commonly involved (n = 26). There were 2 cases of stage I, 16 stage II, 20 stage III and 08 cases of stage IV disease. There were 2 cases of grade I, 16 grade II, and 28 cases of grade III. CONCLUSION: Carcinoma breast is still a common problem presenting at a young to middle age group with invasive ductal carcinoma being the commonest variant with a high grade and a late stage of presentation due to lack of screening and awareness programs.

Pattern of change in the frequency of Helicobacter pylori with perforated duodenal ulcer.

BACKGROUND: Peptic ulcers were believed to be caused by stress, dietary factors, and gastric acid, but the link between H. pylori and peptic ulcers was identified in 1983. To see the frequency of Helicobacter pylori infection in patients with perforated duodenal ulcer and advise eradication therapy in these patients. This cross sectional study was conducted in Surgical Unit Hayatabad Medical Complex, Peshawar, during January 2007-June 2008. METHODS: A total of 50 cases were included in the study. All cases presenting to our unit with acute perforated duodenal ulcer were recruited. After resuscitation and baseline investigations, all underwent emergency laparotomy via upper midline incision, after thorough peritoneal lavage, the perforation margins were freshened and closed over an omental patch. Serum from every patient was tested for H. pylori and accordingly managed. RESULTS: Out of the 50 cases, 45 were males, and 5 were females. Age ranged from 20- 80 years old. All patients underwent emergency laparotomy. Postoperatively, all were started on PPI treatment and serum testing for H. pylori was done. Thirty-four (68%) turned out positive and 16 (32%) were found to be negative for H. pylori. CONCLUSION: There is still a high frequency of H. pylori infection in patients with perforated duodenal ulcer. But comparing these results with the various data available, there is a significant decline in H. pylori positive perforated duodenal ulcer patients.

Frequency of HER-2/neu receptor positivity and its association with other features of breast cancer.

BACKGROUND: Carcinoma breast is the commonest malignancy of females all over the world and second leading cause of death due to cancer among females. In Pakistan it is more common at a young age contrary to the West where it is more common in old age (after 60 years). The objectives of this cross sectional study were to determine the frequency of HER-2/neu receptor over-expression and its association with some of the features of breast cancer like patient age, ER/PR status, tumour size, histological grade and axillary lymph node involvement. METHODS: This study was conducted at Surgical C Unit, Postgraduate Medical Institute of Lady Reading Hospital, Peshawar, from January 2007 to December 2007. Study included all patients with breast cancer admitted in Surgical 'C' unit LRH, Peshawar for Modified Radical Mastectomy (MRM). The resected specimens were sent to histopathologist for immunohistochemical (IHC) studies (HER-2/neu receptor and ER/PR) and detailed histopathological analysis including tumour subtype, size, histological grade and involvement of axillary lymph nodes. Patients refusing HER-2/neu receptor immunohistochemistry were excluded from the study. Name, age, sex, other relevant data, detailed history and clinical examination findings and results of investigation were recorded. Data was analyzed with SPSS version 10. RESULTS: This study included 24 female patients of breast cancer having modified radical mastectomy (MRM). Age distribution ranged from 32-75 years with a Mean +/- SD of age 48.3 +/- 18.2 years. Fifteen out of 24 patients (62.5%) were >40 years, while nine patients out of 24 (37.5%) were <40 years of age. The HER-2/neu receptor status was found positive in 11 patients (45.9%) and negative in 13 patients (54%) of the total cases. HER-2/neu receptor positivity was not significantly associated with histopathological sub-type (p > 0.05), number of axillary lymph nodes involved (p > 0.05) and histological grade (p > 0.05). While, it was significantly associated with tumour size (p < 0.05) and negative ER/PR status (p < 0.05). CONCLUSION: Due to high prognostic significance and frequency in Pakistani females with breast cancer, HER-2/neu receptor should be checked in all patients with breast cancer so that the positive cases should have herceptin therapy and benefit from anthracycline based chemotherapeutic agents which can improve survival in these patients.

Phloroglucinol for acceleration of labour: double blind, randomized controlled trial.

OBJECTIVES: To determine the effects of Phloroglucinol in acceleration of labour and its adverse effects on mother and foetus. METHODS: A double blind randomized, placebo controlled trial was conducted on 100 patients in active phase of uncomplicated labour selected by convenient sampling. Patients were given Phloroglucinol or Placebo (distilled water) intravenously. Progress of labour was plotted on Partogram. Any adverse effects of the drug on mother and fetus were noted. Student's t-test was applied for statistical analysis. RESULTS: In patients receiving Phloroglucinol there was a mean 34% reduction in duration of 1st stage of labour and a mean 23% reduction in 2nd stage as compared to Placebo group respectively. Blood loss >500ml was observed in 2% patients. Otherwise there were no adverse effects on mother or foetus. CONCLUSION: Phloroglucinol shortens the duration of labour, is non toxic to both mother and fetus and does not cause primary post partum haemorrhage.

Premenstrual syndrome: frequency and severity in young college girls.

OBJECTIVES: To find out the frequency of premenstrual syndrome (PMS) in young college girls and to describe the severity of emotional, physical and behavioural symptoms. METHODS: An observational study was conducted at the Khyber Medical College, Peshawar by convenient sampling on 384 young girls. Data was collected over two cycles by filling a 29 items shortened premenstrual assessment form based on Moos Menstrual Distress Questionnaire after taking consent from medical students. Results were given according to both criteria i.e. ICD-10 and DSM-IV. RESULTS: The frequency of premenstrual syndrome was 53% according to ICD-10 criteria, among which 42% was mild, 18.2% moderate and 31.7% severe. A total of 64 girls (18.2%) met the DSM-IV criteria for severe PMS or Premenstrual Dysphoric disorder (PMDD). The order of frequency of symptoms occurring in PMS was general body discomfort, anxiety, backache, fatigue and depression. Most frequently reported symptoms in PMDD group were anger, anxiety, stress, depression, fatigue and general body discomfort. CONCLUSION: Premenstrual syndrome is a common problem in young girls. Doctors should adopt comprehensive measures to reduce its incidence and improve the quality of life in the affected.