A reliable auditing of postop complication in gastric cancer surgery

Background Auditing of surgical outcome is controversial due to lack of standard auditing system. POSSUM （ Physiological and Operative Severity Score for the enUmeration of Morbidity and mortality） system provides a risk adjusted auditing in surgical practice, which is a reliable scoring system. However it has not been generalized in China, especially in gastric surgery. Present study evaluates the application of POSSUM system to compare surgical outcome of malignant gastric disease between specialized unit and general unit. Methods Retrospective study was performed on 394 patients who underwent surgical intervention for gastric cancer and malignant gastric lymphoma. POSSUM data were collected according to standard criteria described by its original authors. Exponential analysis method was used for data analysis. Observed to Expected morbidity （O：E） ratio was calculated for each unit to give risk adjusted comparison. All the complications were categorized into minor to severe to give an objective view of complications. Results There was significant difference in surgical outcome between specialized unit and general unit. POSSUM predicted morbidity well and O： E ratio of specialized unit was better than general unit. Further more postop stay was significantly shorter（P 〈0. 001 ） in specialized unit and number of moderate and severe morbidity was significantly lower （ P 〈 0.001 ） than general unit. Conclusions Surgical outcome of specialized unit was better than general unit. POSSUM can be used for risk adjusted auditing of postop complications in malignant gastric disease, which provides a reliable audit. However morbidity definition in POSSUM should be amended and modification in POSSUM formula may be necessary to fit major surgical interventions like gastric cancer surgery.     

Teaching and evaluation of basic surgical techniques: the University of British Columbia experience.

Surgical technical education has traditionally followed an apprenticeship format. The need for innovative undergraduate programs using dry and wet labs prior to clinical exposure continues to be an area of debate. Specific programs have been described to improve surgical skills; however, an accepted platform for training and evaluation of surgical skills programs has not been recognized. Therefore, introduction of specific programs to teach undergraduate medical students surgical skills is essential. This article describes the Basic Surgical Technique (BST) program taught at the University of British Columbia and reports the effectiveness of this program in improving the practical skills of undergraduate medical students. The program includes BST I for third-year students performed in a dry lab setting, and BST II for medical student interns (MSI) performed at the animal laboratories using female domestic swine as subjects. A total of 87 students participated in the study. The program is designed using Piaget's and Vygotsky's pedagogical philosophy of "learning by doing." A semiquantitative method is used to measure and analyze the outcome of this project. Data were validated using student self-evaluation tests and by quantitative evaluation by surgical staff from the surgical wards. Results of this prospective project indicated that the BST program significantly (p < .05) improved the surgical performance of undergraduate students, and that the time lapse between BST I and II has had a negative impact in retention of acquired surgical skills. This study concludes that the BST program taught at the University of British Columbia significantly improves the surgical skills of medical students and improves their self-confidence during their internship.     

The surgical trainee log we need: minimum of work, maximum of output

Background: The objective of this study was to design a trainee logbook suitable for both surgical training and surgical audit. The fields of the logbook should conform to both the current requirements for surgical trainee logbooks and the minimum and recommended datasets for surgical audit. The database should be able to share information with other databases including hospital information systems. The current logbook requirements do not include much outcome data. Therefore, keeping the logbook does not train the young surgeon to collect all the information necessary for surgical audit, particularly the recently promoted minimum (12 fields) and recommended (22 fields) datasets. Methods: An electronic logbook was developed as part of the hospital's clinical information system (CORDis). Patient identifier information was available in the system and did not need to be re‐entered (e.g. name, number, date of birth and sex). The trainee only input the necessary fields for his/her logbook and was able to derive information already available from CORDis on complications, outcome and final diagnosis of the patient. Results: Thirteen of 16 trainees used the program over a period of 2.5 years, and more than 4600 operative procedures were recorded. Information on outcome and complications was included in the logbook, regardless of who in the team entered the data. This also facilitated surgical audit presentations. Logbook reports for the Advanced Training Board were produced with the click of a mouse rather than by spending a whole weekend counting items in the operation register at the end of a 6‐month rotation. This system could be used at different hospitals or the data can be exported to another database including databases on a hand‐held device. Conclusion: The logbook contains all the data for reporting to the Specialty Training Board and Surgical Audit. Duplication of data entry was reduced, and presentation of unit/trainee surgical audits was facilitated. The data can be exchanged with other common databases when the trainee rotates out of Geelong.     

Complexity- and risk-adjusted model for measuring surgical outcome

BACKGROUND: Although currently available surgical scoring systems have good outcome predictive power, their use is often limited by complexity and their non-dynamic nature. The aim of this study was to develop and test a risk adjustment for general surgical audit which is both simple and dynamic, while preserving a high predictive power for surgical morbidity. METHODS: Twelve easily measured, well defined prognostic variables for morbidity were identified from the Otago Surgical Audit data collection form and stratified into suitable categories. Logistic regression was used to adjust for confounding between factors, identifying risk factors with the strongest prognostic value for the outcome of severe and intermediate complications. The resulting model was tested by back-validation and validation. RESULTS: The derived risk adjustment included all 12 variables. Adjusted odds ratios for all variables were markedly lower than unadjusted values. After logistic regression, the strongest predictors of postoperative morbidity were duration of operation, operation category, inpatient status and organ system in which the procedure was carried out. The area under the receiver operating characteristic curve was 0.86. CONCLUSION: A simple dynamic model for surgical morbidity has been developed which is comparable to previously published surgical scoring systems in terms of predictive power. This risk adjustment tool can be incorporated into the existing audit system, enabling comparison of surgical unit performance.     

Developing a system for surgical audit

A system for surgical audit, which has been developed during a 6 year period in an active surgical unit of a teaching hospital, is described. Following a review of the first 3 years of our computerized audit, major modifications to the audit processes and computer program were made. The key lessons for systematic practical surgical audit include the collection of essential data only, establishing audit processes within current department practices, verification of data by consultants, and the provision of incentives for all users. The current system is proving a valuable resource for quality assurance, surgical training and departmental management.     

Complete clinical outcomes audit

Background: Clinically relevant surgical outcomes are usually monitored by surgeons only for new and/or high-volume procedures. Prospective outcomes audit studies are rarely done on 100% of procedures performed by a single surgeon, a surgical practice, or an institution. Therefore, we set out to determine the resource utilization and accuracy of a well-validated system at its introduction into a North American university surgical practice. Methods: The Otago Surgical Audit, which has been validated in a wide spectrum of surgical practices in Australasia, was applied to a university practice in general and laparoscopic surgery. Data were recorded by the surgeon on the day of operation, at discharge, and during any subsequent readmission. Resource utilization was determined by timing the important steps in data acquisition and computer entry. Data accuracy was assessed by an independent chart review of 22% of all records. Case capture was audited by reviewing operating room case logs. Results: Over 1 year, from October 1, 1996 to September 30, 1997, 338 procedures were performed. Data recording and coding by the surgeon required 2 min per form, or a total of 676 min (11.3 h) annually. Data entry required 2.11 min per form, or a total of 713 min (11.9 h) for the year. Eight percent of cases were returned to the surgeon for additional information. In the medical record audit, no additional mortality or readmissions were discovered, and one minor complication was recorded in the hospital record but not the outcomes audit. One complication and three operations recorded in the audit database were omitted from operating room records. Two minor procedures on the operating room log were omitted from the audit database. Operating time reported by the surgeon averaged 19 min less than recorded in the operative log. Data accuracy and coding accuracy improved significantly between the 1st month (month 4) and the 2nd month audited (month 12), (p < .01). Conclusions: It is possible to perform a 100% clinical outcome audit with the use of minimal resources. When the surgeon is involved with data acquisition and coding, the accuracy and completeness of the log may outstrip the medical record, but a learning curve of 4–6 months may be required to achieve this goal. Received: 15 May 1998/Accepted: 12 February 1999     

Surgical procedure logging with use of a hand-held computer.

OBJECTIVE: To evaluate the feasibility of incorporating hand-held computing technology in a surgical residency program, by means of hand-held devices for surgical procedure logging linked through the Internet to a central database. SETTING: Division of General Surgery, University of Toronto. DESIGN: A survey of general surgery residents. METHODS: The 69 residents in the general surgery training program received hand-held computers with preinstalled medical programs and a program designed for surgical procedure logging. Procedural data were uploaded via the Internet to a central database. Survey data were collected regarding previous computer use as well as previous procedure logging methods. MAIN OUTCOME MEASURE: Utilization of the procedure logging system. RESULTS: After a 5-month pilot period, 38% of surgical residents were using the procedure-logging program successfully and on a regular basis. Program use was higher among more junior trainees. Analysis of the database provided valuable information on individual trainees, hospital programs and supervising surgeons, data that would assist in program development. CONCLUSIONS: Hand-held devices can be implemented in a large division of general surgery to provide a reference database and a procedure-logging platform. However, user acceptance is not uniform and continued training and support are necessary to increase acceptance. The procedure database provides important information for optimizing trainees' educational experience.     

Guidelines for surgical audit in Australia and New Zealand

Surgical audit is an important part of the process to measure performance, reduce clinical risk and improve quality of care. Recognizing this, the Royal Australasian College of Surgeons established a Surgical Audit Taskforce as a subcommittee of the Board of Continuing Professional Standards. This study aims to review the recommendations of the Taskforce for data collection and peer review. The minimum data for whole-practice, continuing audit have been defined. The method of data collection, devices and databases are personal choices for the individual surgeon. However, there are many benefits of developing an electronic surgical audit, and these include facilitating comparison and sharing of audit data between units. Surgical audits should not only report on work carried out but also ensure that outcomes include key performance indicators such as major complications, readmissions, reoperations, transfers, incident reports, complaints and mortalities. Effective clinical governance demands that issues raised by audit need to be documented and reported together with recommendations for improvement. Surgeons should be proactive in helping to find and implement solutions to the issues arising from surgical audit.     

Surgical capability and surgical pathology in Papua New Guinea in the year 2000

Background : Papua New Guinea (PNG) is a country of 4.5 million people with an annual health budget of only 96 million Kina (1K = US$0.35). There are 19 hospitals in the country and national surgeons are now staffing most of these hospitals. This review aims to describe the surgical pathology in the year 2000 and the capability of PNG surgeons to manage it. Methods : A review of publications, reports and surgical audit data on surgery in PNG was conducted. Surgical audit has been computerized for over 5 years. The review also draws on personal experience and data from MMed theses submitted to the University of Papua New Guinea. Results : Surgical pathology Surgical practice in PNG remains very general. Late presentation and advanced disease are common. Trauma, infection, malignancy and congenital anomalies dominate the surgical scene. The pattern of disease is different from what is found in the West. Western diseases are emerging with the incidence of appendicectomy rising from 5/100 000 to 75/100 000 in the past 30 years. The incidence of diabetes and gallstones has also risen. Osteoporosis, Colles’ and neck of femur fractures are rare. Surgical capability The standard of surgical care is acceptable with a low wound infection rate for clean and clean‐contaminated abdominal surgery of 0.9% and an anastomotic leak rate of 1.6%. Transurethral prostatectomy is also being performed to a satisfactory standard for head injuries admitted with a Glasgow Coma Score of 6–8 and a good outcome is achieved in over 70% of cases. Hospital mortality for surgical admissions is 3.7%. Subspecialties in orthopaedics, urology and head and neck surgery have been established. Neurosurgery, paediatric and cardiac surgery are being developed. Priorities for the next decade Papua New Guinea needs to continue to develop surgical subspecialties, particularly paediatric and neurosurgery, while maintaining a broad competence in general surgery. Services for burns, spinal injuries, rehabilitation and oncology need to be improved. Surgeons need to be more involved in rural health and teaching basic skills to primary health‐care workers. Acquisition, maintenance and repair of surgical equipment needs to be improved so that PNG’s well‐trained surgeons can have the right tools for their trade. Conclusions : Papua New Guinea offers a wide range of surgical pathology. The standard of surgery in PNG is reasonable but there are many areas that need development during the period of the next national health plan, 2001–2010. Australasian surgery has many opportunities to assist surgeons in PNG to achieve their objectives.     

Blood pressure control in haemodialysis patients: an audit

OBJECTIVE: This audit was conducted to study the level of achievement of some criteria relevant to blood pressure control in haemodialysis patients and to evaluate if auditing process improves the quality of medical care given to these patients. METHODS: The records of all 105 patients on maintenance haemodialysis were included in the study. Five criteria relevant to blood pressure control were selected for auditing. The criteria were: predialysis blood pressure control <140/80, dry weight, dialysis adequacy, salt and water intake restriction, and patient education. The auditing process was conducted at two different times 6 months apart. RESULTS: The first data collected in the auditing process showed that there were only 40 patients (38%) with controlled predialysis blood pressure. In the second data collection the number of patients with controlled predialysis blood pressure had risen significantly to 78 (74.3%), P < 0.0001. The same improvement was achieved for dry weight 39 (37%) to 73 (69.5%) P < 0.0001, dialysis adequacy 38 (36.2%) to 75 (71.4%) P = 0.043, salt and water intake restriction 39 (37%) to 71 (67.6%) P = 0.045, and patient education 30 (28.6%) to 55 (52.4%) P < 0.0001. CONCLUSION: Setting up audit cycles to evaluate achievement of required standard in relevant criteria contribute to better blood pressure control and leads to improvement in the care of patients on dialysis. Auditing can be an essential tool in identification of poorly controlled blood pressure, its cause and is useful in control of hypertension in the haemodialysis population.     

Operation documentation. A program for the detection and statistical documentary evaluation of surgery reports

A computer program specifically designed for surgical data retrieval was tested for longer than one year. By using the information contained in operation reports, with this program statistical analysis may be achieved. The reports are generated and printed using a personal computer running MS-DOS. Entering data does not cause any additional effort for the secretary. The selection of requested data is possible with any combination of criteria, and the resultant information is displayed on the computer terminal screen or printed on the computer printer. A combination of terms is used instead of a numeric code for data entry allowing far greater selectivity, with a reduced risk of data loss due to wrong numeric code entry.     

Current status of cardiovascular surgery in Japan, 2013 and 2014: A report based on the Japan Cardiovascular Surgery Database (JCVSD). 1: Mission and history of JCVSD

The Japan Cardiovascular Surgery Database (JCVSD) was created in 2000 with the support of the Society of Thoracic Surgeons (STS). The STS database content was translated to Japanese using the same disease criteria and in 2001, data entry for adult cardiac surgeries was initiated online using the University Hospital Medical Information Network (UMIN). In 2008, data entry for congenital heart surgeries was initiated in the congenital section of JCVSD and preoperative expected mortality (JapanSCORE) in adult cardiovascular surgeries was first calculated using the risk model of JCVSD. The Japan Surgical Board system merged with JCVSD in 2011, and all cardiovascular surgical data were registered in the JCVSD from 2012 onward. The reports resulting from the data analyses of the JCVSD will encourage further improvements in the quality of cardiovascular surgeries, patient safety, and medical care in Japan.     

How accurate is a computerized surgical audit when resident medical staff collect the data?

Since July 1988 all eight general surgeons at Fremantle Hospital have used a computer-based surgical audit and discharge system. At the time of writing (September 1991) 10,919 computer-generated discharge letters have been produced by the system. This paper describes the system and reports a series of quality control assessments carried out between 1 July 1988 and 30 June 1990 during which 30 pre-registration surgical residents completed 5,716 data collection forms. It was found that: (1) data collection for 23 of 24 monthly surgical audits was at least 95% complete; (2) outstanding surgical discharge summaries were reduced by 89%; (3) the residents recorded 17/19 wound infections and identified 15 (79%) of these as a surgical complication; and (4) the residents tended to under-record complications in patients who had more than one complication during their hospital stay. It was concluded that the system was robust, and that resident staff collected data in such a way that good quality computer-generated discharge letters were produced in a timely manner. Closer attention to aspects of data collection will be required before the optimum surgical audits of the QX system can be generated.     

Anesthesiology Resident Wellness Program at the University of Saskatchewan: curriculum content and delivery

Resident and physician health are increasingly recognized by the Royal College of Physicians and Surgeons of Canada and its CanMEDS framework as integral to residency training in Canada. Resident stress, burnout, and depression also have implications for patient care. Although curricula have been advocated to promote resident wellness and resilience, no such published curricula exist to guide programs in addressing these needs. The purpose of this article is to describe the curriculum content and delivery of the Anesthesiology Residency Wellness Program (ARWP) at the University of Saskatchewan. The ARWP curriculum is comprised of four components: modular curriculum, peer support curriculum, self-directed learning activities, department wellness program. The program matrix illustrates the mission, target population, inputs, outputs, and outcomes of the ARWP. Content and suggestions for delivery of the eight curricular modules are detailed. The described ARWP is a novel innovation in Canadian postgraduate medical education. We believe this ARWP is the first comprehensive, formalized, actualized program in Canada. It also provides a guide and a helpful resource for further development of resident wellness programs by other disciplines in Canada and internationally.     

Improved continuity of care in a community teaching hospital model.

HYPOTHESIS: We created an ambulatory resident clinic in a community teaching hospital to improve the continuity of care in a surgery residency program. DESIGN: A retrospective chart review analysis. SETTING: A community hospital, general surgery residency training program, and its ambulatory practice. INTERVENTIONS: Providence Hospital, Southfield, Mich, has established a new model, the Surgical Associates of Michigan, which is an association comprising private practice physicians serving as full-time faculty in the Department of Surgery. In addition to clarification of teaching requirements and reimbursement for educational activities, the most dramatic feature is the relocation of private practice offices and the staff surgical office to one central location within the hospital. The proximity of the staff and private surgical offices facilitates closer interaction of attending physicians, residents, and patients. MAIN OUTCOME MEASURES: Compliance rates of continuity of patient care provided by the same resident, as presented by the Surgery Residency Review Committee, including confirmation of diagnosis, provision of preoperative care, discussion with attending physician, selection and provision of intervention, direction of postoperative care, and postdischarge follow-up. RESULTS: Since the inception of this arrangement at our institution, surgical residents have seen 229 staff patients and 465 private patients in the offices under supervision. Compliance rate of continuity of care was defined as patient follow-up with the same senior surgical resident who performed an operation or evaluated the patient on initial presentation to the emergency department or offices. We achieved a compliance rate of 92.8% (169/182) in the staff surgical clinics. A compliance rate of 63.5% (205/323) for private general surgical patients and 70.4% (100/142) for vascular surgical patients was obtained. With the establishment of the teaching faculty group and the relocation of offices, we were able to achieve a dramatic improvement in continuity of care. CONCLUSIONS: In addition to fulfilling the Surgery Residency Review Committee requirements, we believe our model facilitates broader education of surgical residents and improves risk management. We recommend further similar studies, greater involvement of primary care specialties in recruiting staff surgical referrals, and implementation of a specialized computer program to continue to improve continuity of care in surgery residency programs.     

Development of a functional, internet-accessible department of surgery outcomes database

The need for surgical outcomes data is increasing due to pressure from insurance companies, patients, and the need for surgeons to keep their own "report card". Current data management systems are limited by inability to stratify outcomes based on patients, surgeons, and differences in surgical technique. Surgeons along with research and informatics personnel from an academic, hospital-based Department of Surgery and a state university's Department of Information Technology formed a partnership to develop a dynamic, internet-based, clinical data warehouse. A five-component model was used: data dictionary development, web application creation, participating center education and management, statistics applications, and data interpretation. A data dictionary was developed from a list of data elements to address needs of research, quality assurance, industry, and centers of excellence. A user-friendly web interface was developed with menu-driven check boxes, multiple electronic data entry points, direct downloads from hospital billing information, and web-based patient portals. Data were collected on a Health Insurance Portability and Accountability Act-compliant server with a secure firewall. Protected health information was de-identified. Data management strategies included automated auditing, on-site training, a trouble-shooting hotline, and Institutional Review Board oversight. Real-time, daily, monthly, and quarterly data reports were generated. Fifty-eight publications and 109 abstracts have been generated from the database during its development and implementation. Seven national academic departments now use the database to track patient outcomes. The development of a robust surgical outcomes database requires a combination of clinical, informatics, and research expertise. Benefits of surgeon involvement in outcomes research include: tracking individual performance, patient safety, surgical research, legal defense, and the ability to provide accurate information to patient and payers.     

Medical audit: assessment of surgical performance in a low volume specialty

We describe a simple technique for auditing one aspect of the activity of a neurosurgical unit--the surgical operations performed. A proforma completed by the surgeon at the time of operation was brought up-to-date on subsequent daily ward rounds. Each week, the medical staff of the unit met to review the data sheets of those patients discharged during the previous seven days. This meeting served to ensure the completeness of the data and to discuss any problems in management before the records were computerized. At the end of the first year, problems which had become apparent in the system were identified and corrected. The revised system involves a comprehensive and prospective audit of relevant clinical information. It has led to the accumulation of a considerable quantity of reliable data and it involves frequent positive feedback which appears to be leading to an improvement in treatment outcome. The system is simple to administer and is economical of time. It should be suitable for any surgical specialty which resembles neurosurgery in dealing with a relatively small volume of major procedures, and it could easily be adapted to audit other aspects of the activity of a unit.     

The STAR score: a method for auditing clinical records

INTRODUCTION

Adequate medical note keeping is critical in delivering high quality healthcare. However, there are few robust tools available for the auditing of notes. The aim of this paper was to describe the design, validation and implementation of a novel scoring tool to objectively assess surgical notes.

METHODS

An initial ‘path finding’ study was performed to evaluate the quality of note keeping using the CRABEL scoring tool. The findings prompted the development of the Surgical Tool for Auditing Records (STAR) as an alternative. STAR was validated using inter-rater reliability analysis. An audit cycle of surgical notes using STAR was performed. The results were analysed and a structured form for the completion of surgical notes was introduced to see if the quality improved in the next audit cycle using STAR. An education exercise was conducted and all participants said the exercise would change their practice, with 25% implementing major changes.

RESULTS

Statistical analysis of STAR showed that it is reliable (Cronbach’s a = 0.959). On completing the audit cycle, there was an overall increase in the STAR score from 83.344% to 97.675% (p<0.001) with significant improvements in the documentation of the initial clerking from 59.0% to 96.5% (p<0.001) and subsequent entries from 78.4% to 96.1% (p<0.001).

CONCLUSIONS

The authors believe in the value of STAR as an effective, reliable and reproducible tool. Coupled with the application of structured forms to note keeping, it can significantly improve the quality of surgical documentation and can be implemented universally.     

A comprehensive computer system for anesthetic record retrieval

We have developed computer software to store data on all surgical and obstetrical anesthetics administered by our department. The computer system provides information for monitoring the residency training program, department and operating room management, professional fee billing, and research. It imposes little additional workload on our clinical personnel, who use simple codes to record the necessary data directly on the anesthetic record. Department secretarial staff transcribe data from the anesthesia and operating room records into the computer file, which is then available for producing scheduled reports and for answering inquiries from a video terminal. The system employs extensive manual and computer verification to minimize errors and omissions in the data. We report design details and more than 3.5 years experience with this system, which is now used at four affiliated teaching hospitals, has over 50,000 cases on file, and adds more than 1800 cases monthly.