Hospitalization of British troops during Operation Joint Endeavor (Bosnia).

Of 414 recorded hospitalizations among British troops during Operation Joint Endeavor (Bosnia) in 1996, 2% were attributable to battle injuries, 46% to routine injuries, and 52% to disease; most injuries were to the lower limbs, and most diseases were of the skin and musculoskeletal system. The median length of inpatient stay was 4 days for injury (range, 1-146 days) and 3 days for disease (range, 1-60 days). Correcting for uncaptured data, the number of hospitalizations attributable to both injury and disease was significantly lower than the number predicted from the NATO planning figures (p < 0.0001). The NATO planning estimates for expected hospitalizations need to be revised. The electronic recording at source of all patient information should be introduced during military deployments to optimize data capture, facilitate the audit of clinical activity, and inform future medical planning. All hospitalizations occurring during military missions should be recorded, and surgical interventions during deployments should be coded at source. Ineffective paper-based morbidity surveillance procedures such as Jefferson 97 (or J97) must be discontinued and replaced by an electronic, fully integrated, NATO-wide clinical information system. This clinical information system should encompass primary care, secondary care, medical training, and medical supply. It should be built on a Microsoft Office platform and should be capable of interfacing electronically with existing civilian databases. Important clinical outcomes should be structured hierarchically within the data set. The database should be configured so that it can be accessed locally by clinicians and remotely by epidemiologists and planners.

Clinical audit activities in surgery.

Large scale audits can attract the participation of the majority of surgeons. They require careful planning and must be supported by an infrastructure to co-ordinate the running of the audit and to ensure accuracy of data. Audits can be important sources of information for the development of evidence-based guidelines, and this approach is a good strategy for bringing the lessons obtained from the audit to the profession. Audits that work closely with professional bodies produce the best results and are enhanced by patient representation. Risk stratification is an essential component of comparative studies and should be incorporated to ensure that multi-centre audits are systematic.

Use of database management system by surgeons to produce operation notes.

A computer system for the generation of printed operation records based in the operating suite and used by the surgeon is described. The time necessary for producing such a record is in the order of 4-6 minutes for the majority of cases and does not interfere with the conduct of an operating list. The advantages include a printed legible operative record, automatic OPCS coding and automatic grading, the storage of data in a form that allows later analysis for audit and research and the production of an operating log for trainees. The use of mandatory fields forced individuals to follow a structured format complying with the guidelines on medical records and notes from The Royal College of Surgeons of England reissued in 1994. The potential value of using the same data for the production of discharge documentation suggests an opportunity for improving the efficiency in the production of such documentation.

Is perianal sepsis adequately managed? The results of a five year audit at Royal Naval Hospital Haslar.

A retrospective audit and postal questionnaire of 148 patients presenting with perianal sepsis confirms that the isolation of gut-related organisms remains a sensitive indicator of a perianal fistula. It did not confirm that the use of microbiological results affects the long term outcome for these patients. It suggests that early examination under anaesthetic and laying open of a fistula may not be necessary in all patients in which gut-related organisms are identified. There was no statistical difference in recurrence rates of perianal sepsis between those operated on by senior or junior surgeons, though there may have been selection bias in these patients.

The effect of manpower and medical facility reduction on surgical practice during the Gulf Conflict 1991.

The General Surgical admissions to Royal Naval Hospital, Stonehouse from 1 April 1990-31 March 1991 were audited. This period included the Gulf War. There remained throughout the build-up to Operation Desert Storm, and during the actual conflict, a requirement to treat Service personnel as well as maintaining surgical training. This paper shows that both criteria were met despite reduced medical manpower and facilities.

Combined surgical audit by microcomputer involving units in four health regions.

General surgeons from hospitals in four well-separated health districts collected audit data about their patients using common software. They pooled their results in order to make comparisons between their practices. Data on 22,497 admissions including 17,473 operations were available. The data were found to be easy to collect and analyse using this program. There were significant differences in overall complication rates between the four centres, but these seem to be explained by differences in the emergency workload, case mix, and age range of the population treated. A study of inguinal hernia repairs and appendectomies showed low complication rates with no significant differences between centres, with the single exception of a higher incidence of wound problems in one centre. Because of the multiplicity of factors affecting them, complication rates could only be properly understood in a professional surgical context. Isolated figures would be open to damaging misrepresentation. Meetings between surgeons well armed with their own results seem to be the best way to forward the audit process.

The Cambridge Audit System in a service hospital.

The introduction of clinical audit into the environment of service hospitals poses particular problems. Experience at RNH Plymouth has shown that one approach, the adaptation of the 'Cambridge Audit System', has succeeded in overcoming certain administrative hurdles and has confirmed the advantages that can accrue from introducing a clinical audit based around a computer system.

Primary lymphoedema when found with distichiasis is of the type defined as bilateral hyperplasia by lymphography.

The occurrence of primary lymphoedema with distichiasis is well recognised, but that the form of lymphoedema appears restricted to bilateral hyperplasia, as defined by lymphography, has not been reported.

Autotransfusion, an experience of seventy six cases.

The use of autotransfusion with a centrifugal cell washer in a series of 76 cases is reviewed. The requirement for bank blood is reduced in patients with major operative haemorrhage, although it does not appear to be able to provide the main source of blood replacement in such cases. The major impact of autotransfusion may lie in reducing the amount of blood that needs to be crossmatched for elective operations. Nevertheless in certain cases its use can be life saving.

Combined computer generated discharge documents and surgical audit.

A computerised audit system using a commercially available database program and a word processing program was devised to produce discharge documents close to the time of discharge. The data were available for audit of the surgical unit's work. It was found that secretarial time was more efficiently used and general practitioners received more information about their patients earlier than before.

The inheritance of primary lymphoedema.

A family study is reported on 312 index patients who had primary lymphoedema with onset before 36 years. All had been investigated at St Thomas's Hospital, London, between 1965 and 1980. Most of the information was obtained by questionnaire, but 70 patients were also interviewed to check the reliability of the answers to the questionnaire. The frequency at birth of those who will develop primary lymphoedema is estimated to be about 1 in 6000, with a sex ratio of about one male to three females. Approximately 10% of children of index patients and 10% of sibs were affected when these relatives were at least five years older than the age of onset in the index patient. The proportion of female relatives affected was between two and four times that of males affected. The proportion of parents affected was about 10%. The proportion of grandparents, aunts, and uncles was about 2.5%. Where the index patient had an affected parent, the proportion affected of sibs and children was about 20%. The risk to relatives of male index patients was about 50% higher than for female index patients.