ABSTRACT
Introduction Tourniquets are used widely in trauma and orthopaedic surgery to reduce blood loss and facilitate better visualisation of the operative field; however, some complications can result from improper use such as pressure sores, chemical burns, compartment syndrome, and deep vein thrombosis. We audited the use of intraoperative tourniquets in our trauma theatre against the guidance published by the British Orthopaedic Association (BOA) in 2021. Methods This was a closed-loop audit evaluating 80 trauma operations that utilised tourniquets. In the first cycle, we audited 40 operations (23 upper limbs vs 17 lower limbs) over a period of two months through a review of operation notes and theatre documentation. We presented our findings and implemented changes including the addition of tourniquet use to the operation note template and labels on the tourniquet machines aiding the calculation of tourniquet pressures. A re-audit was then performed involving a further 40 operations (20 upper limbs and 20 lower limbs). Statistical analyses were performed to compare the two cycles. Results Tourniquet time was on average similar across both audit cycles (60.7 vs 70.0, p = 0.192) with compliance up to standard in 97% of cases. Post-intervention, there was an improvement in the documentation of skin status (37 vs 69%, p = 0.004), tourniquet isolation method (43% vs 74%, p = 0.003), and tourniquet pressure (71% vs 94%, p = 0.003). The difference between tourniquet pressure and systolic blood pressure was on average lower post-intervention for the upper limb (125.9 vs 99.9, p < 0.01) and lower limb operations (154.2 vs 121.7, p < 0.01). Adherence to the British Orthopaedic Association Standards for Trauma (BOAST) guidance with tourniquet pressure improved with intervention (25% vs 75%). Conclusion The introduction of tourniquet parameters in the operation note template and patient-specific calculation of tourniquet pressures improved the safe use of tourniquets within the trauma theatre.
ABSTRACT
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.
