Operation Note Transformation: The Application of Lean Six Sigma to Improve the Process of Documenting the Operation Note in a Private Hospital Setting

Clinical documentation is a key safety and quality risk, particularly at transitions of care where there is a higher risk of information being miscommunicated or lost. A surgical operation note (ON) is an essential medicolegal document to ensure continuity of patient care between the surgical operating team and other colleagues, which should be completed immediately following surgery. Incomplete operating surgeon documentation of the ON, in a legible and timely manner, impacts the quality of information available to nurses to deliver post-operative care. In the project site, a private hospital in Dublin, Ireland, the accuracy of completion of the ON across all surgical specialties was 20%. This project sought to improve the accuracy, legibility, and completeness of the ON in the Operating Room. A multidisciplinary team of staff utilised the Lean Six Sigma (LSS) methodology, specifically the Define/Measure/Analyse/Design/Verify (DMADV) framework, to design a new digital process application for documenting the ON. Post-introduction of the new design, 100% of the ONs were completed digitally with a corresponding cost saving of EUR 10,000 annually. The time to complete the ON was reduced by 30% due to the designed digital platform and mandatory fields, ensuring 100% of the document is legible. As a result, this project significantly improved the quality and timely production of the ON within a digital solution. The success of the newly designed ON process demonstrates the effectiveness of the DMADV in establishing a co-designed, value-adding process for post-operative surgical notes.

EP.TU.2Standards in Operation notes

Guidelines exist for operation notes from the Royal College of Surgeons of England but compliance has been shown to be variable. Aim The authors performed an audit of compliance with RCS standards in a colorectal department. Methods Thirty random operation notes were selected from a conserved pool. Their compliance was recorded against RCS good surgical practise record keeping and also looked particularly at fistula surgery and there documentation. Result Compliance was found to be poor and recommendations were put in place and the following was re audited. Conclusion As some specialities are developing operation note standards specific to individual procedures, the findings are compared with previous similar published work.

SP7.2.6 Where is the nerve? Review of operation note documentation practice for inguinal hernia repair

Introduction Careful identification and management of inguinal nerves during inguinal hernia repair is important to avoid iatrogenic injury. Documentation of this practice informs postoperative clinical management. We set out to investigate how often surgeons identify inguinal nerves and document findings and management in operation notes. Methods Retrospective review of operation notes at single District General Hospital (DGH). Operation notes analysed for documentation of identification and intraoperative management (preservation vs sacrifice) of the inguinal nerves: iliohypogastric, ilioinguinal and genital branch of genitofemoral nerve. Data including baseline characteristics of each patient, hernia characteristics, and primary operating surgeon ascertained for subgroup analysis. Results A total of 100 patients were included in the analysis. Identification of any of the inguinal nerves (generic - “nerve”) was documented in 17% of operation notes. Documentation of named individual nerves in operation notes was limited. No documentation of intraoperative management of inguinal nerves found in 83% of operation notes. Preservation of the inguinal nerves (generic - “nerve”) was recorded in 8% and sacrifice recorded in 9% of cases. Subgroup analysis revealed similar incidence of documentation of identification and management of inguinal nerves across grades of primary surgeon, with overall incidence low for all grades. Conclusion This study has revealed a lack of appreciation of the importance of documentation of identification and intraoperative management of inguinal nerves in operation notes. Further consideration of the potential implications of poor documentation would be beneficial to improve standards.

EP.FRI.489 Audit of emergency Operation notes (audit cycle)

The Royal College of surgeons has recommended guidelines for documenting operative surgical notes. An operation note must include ample information about the operation. In our initial audit, we found some areas for improvement. This re-audit of operative notes was aimed to review compliance with the guidelines by the Royal College of Surgeons and to identify areas of further improvement. Methods The notes of all patients who underwent emergency surgery from 1st of January to 15th of March 2020 under the General Surgical department were reviewed. Endoscopic procedures were not included in the study. Electronic records were used to review the operation notes. Results Notes of a total of 176 patients were included in the study. Significant improvement was seen in most of the domains. Compliance of 100% was seen in documenting operative findings, type of incision, wound closure technique, procedural details, documenting extra procedures, and post operative instructions. 17.6% notes did not clearly document the indication/diagnosis for surgery. 15.3% notes missed information about DVT prophylaxis. 25.57%notes did not include information about peri-operative antibiotics in the context of prophylaxis or post-op need. A significant number (71.6% ) of the notes were missing information about operative blood loss if there was any or none. Conclusion Overall operation notes detail most of the information expected by the Royal College of Surgeons. The key areas for improvement are to include specific details about the following:

EP.TH.625Consenting for a Bedside Procedure: A Prospective Observational Analysis of Consenting Practice in the Surgical Emergency Admissions Unit of a District General Hospital

Aims Consent is necessary to enable patient autonomy and essential to providing good clinical care. Recent case law has grown around consent and practice guidance has evolved. This was a prospective, observational study consisting of two cycles. It investigated the quality of consent for bedside incision and drainage (I&D) procedures performed in the surgical emergency admissions unit (SEAU) at a district general hospital compared with GMC guidance. Methods A prospective analysis of consent documentation was performed from August to September 2020. Data was gathered for quality of consent including risk and benefit discussions, local anaesthetic used, operation note documentation and procedure discussion. We communicated these results at a departmental level, increased awareness of available consent forms and placed them in more accessible locations. Data to see the benefit of these interventions were gathered from November 2020 to January 2021. Results In cycle one, of 20 cases (n = 20), 5.0% had written consent documentation, and 75.0% had verbal consent documentation. 20.0% of cases had no consent documented. Following interventions, of 14 cases (n = 14), 57.1% of cases had written consent documentation, and 7.14% had verbal consent documentation. 35.0% of cases had no consent documented. Conclusion This study highlighted a deviation from GMC guidance. Interventions have shown to increase the proportion of cases with written consent. Overall cases with no written evidence of consent remain high and further work is required to increase compliance. We aim to refine the interventions we have implemented in order to promote the highest quality of consent documentation.

EP.WE.406Adherence to operative standards for ulnar polydactyly excision in times of COVID-19 pandemic

Aims Simple ulnar polydactyly excision is a very common surgical procedure ideally performed within the first 6 months of infants life and under local anaesthetic. In conditions preceding COVID-19 pandemic this procedure was performed in controlled environment of operating theatres on a weekly basis. Increase in pressure on the NHS and operating theatre reorganisation meant elective procedures had to be cancelled with no alternatives in sight. We have suggested therefore, it be performed in a clinic environment instead under strict supervision and guidelines. No recommendations however, have been implemented when considering completion of WHO checklist and standard operation documentation. We investigated therefore adherence to typical Evelina Hospital theatre guidelines when considering documentation. Methods Completed documentation for each patient undergoing ulnar polydactyly excision in clinic room was reviewed between May 2020 and December 2020. Categories of WHO checklist completion, operation note present and legible, appropriate local anaesthetic information and instrument count correct were reviewed. Results 92% of procedures did not have WHO checklist completed. Furthermore, as many as two thirds of the documents were completed illegibly and did not contain required information. Conclusions Following the transfer of ulnar polydactyly excision procedure to clinic rooms we found the quality of documentation to be substandard. This provides opportunity for error and cause for concern. We introduced therefore standardised operative documentation pack to be completed at each polydactyly excision procedure in clinic room. Re-audited results showed improved compliance with standard operative rules and regulations and therefore improved quality of care.

607 A Close Loop Audit on Proper Documentation of Ventriculo-Peritoneal (VP) Shunt Valve Settings in Operation Note

Aim Re-audit the practice of proper documentation of shunt type and settings in VP shunt surgery in Queen's Medical Centre, Nottingham for the period of 1st November 2019 – 31st October 2020. It is very important as programmable shunt setting could get changed during MRI, causing shunt failure. Method It was a retrospective collection of data of patients admitted to Queens medical Centre, Nottingham who had undergone VP shunt procedure. Exceptions: 4 files were excluded from study as they did not undergo VP shunt procedure. Results Total number of patients: 98. 4 patients were excluded. Actual sample size 94. Total VP shunt procedure done: 107. In 96 out of 107 procedures the shunt valve type and settings were properly documented. In 11 out of 107 procedures the shunt valve type and settings were not documented. In 33 out of 107 procedures programmable shunt valves were used. All 33 procedures had proper documentations. Previous audit result Duration of data collection: 2 years (from March 2016 to February 2018). Sample size 200. Total VP shunts done 247. Proper documentation of shunt valve type and settings were done in 209 out of 247 procedures. In 38 out of 247 procedures shunt valve type and settings were not documented. In 55 out of 247 procedures programmable shunt valves were used. 3 out of these 55 procedures (programmable shunt valves) lacked proper documentation. Conclusions There is an overall improvement in the practice of documentation of VP shunt valve type and settings in operative notes after implementing the plan of actions decided on first audit.

1184 Operation Note – Are We Documenting Accessibility to The Larynx

Introduction Diagnostic laryngeal procedures are often done under general anaesthesia to aid in assessment and management of laryngeal lesions. Obtaining tissue samples for histology is an extremely important tool used to aid in further surgical planning. Documentation of accessibility to the larynx is paramount to patient care and future surgical planning. We aimed to highlight operative notes for those undergoing diagnostic procedures and assess whether sufficient detail is documented. The Royal College of Surgeons recommends that all operative notes must be comprehensive and “all problems/complications” must be documented for good practice. Method We carried out a 3-month retrospective data collection on patients who have undergone diagnostic laryngeal procedures at the Royal Glamorgan Hospital. We included microlaryngoscopies, panendoscopies and laser-specific procedures. We accessed the theatre booking system and retrieved the operation notes. Results During the 3-month period, 33 procedures were undertaken. 52% of the operative notes did not document level of accessibility. 48% of the operative notes included the level of accessibility, highlighting keywords such as “good access”, “difficult access” and “difficult access but possible for laser therapy”. Conclusions Documentation of intra-operative findings can aid further surgical management and help prepare the surgeon and theatre staff. It is especially important in patients who have vocal cord lesions that might benefit from laser therapy. We recommend documenting the intubation grade (Malampati Score) and accessibility to the larynx.

684 The Standard of Emergency Operation Note Documentation at A District General Hospital Compared Against The Royal College of Surgeons of England (RCSEng) Standard

Introduction Meticulous operation note documentation is essential for seamless, safe continuity of care in postoperative surgical patients. This study evaluated the standard of emergency operation note documentation at a district general hospital, when compared to the Royal College of Surgeons of England (RCSEng) guidelines and assessed the impact of a new operation note proforma. Method A retrospective review of 50 emergency operation notes was conducted between December 2019 and March 2020 and compared to RCSEng guidelines. Initial findings were presented at a local clinical governance meeting and a new electronic operation note was introduced. A further 50 emergency operation notes using the new proforma were analysed between August 2020 and December 2020. Results RCSEng mentions 19 main points that all operation notes must include. A total of 100 operation notes were reviewed and each given a score out of 19. Intervention of the new proforma showed significant improvement to the average score (15.64 vs 17.94; p < 0.0001) when compared to RCSEng guidelines. In particular, there was significant improvement in the documentation of assistants involved in the procedure (58% vs 98%; p < 0.0001), estimated blood loss (2% vs 63%; p < 0.0001) and specific mention whether the operation was emergency or elective (20% vs 86%; p < 0.0001). Conclusions Implementation of the new proforma showed significant improvement in operation note documentation when compared to the RCSEng standard. Therefore, this study emphasises the need for surgeons to familiarise themselves with the current guidelines and highlights the importance of tailoring local operation note proformas to match this national standard closely.

408 The Swiss Cheese Effect: Following Lower Limb Emergency Admissions Through Hospital

Introduction The Swiss cheese model analyses failure in a system: when holes align this creates ‘a trajectory of accident opportunity’. In healthcare this could translate to morbidity and/or mortality of patients. We investigated potential points of failure in treating lower limb injury patients through their hospital journey. Three points were investigated: (1) prescription of venous thrombo-embolism (VTE) prophylaxis, (2) operation note information and legibility (3) time delay in post-operative blood tests. Method A total of 105 patients of emergency lower limb surgical patients were identified retrospectively from two centres across the North West Region between the 31/07/20 and 21/11/20. Data was collected on (1) prescription of thrombo-prophylaxis, (2) information recorded, and legibility of operation notes as per RCSEng and (3) time delay in post-operative full blood count when compared to operation note recommendation. Results We found that between 10-55% of patients were prescribed anti-embolism stockings versus 100% given chemical anti-coagulation on day 1 of admission. Of a total of 23 data points, the mean number of points missing on operative notes was 4.90 (range: 2-10). A total of 82.5% handwritten operation notes were deemed legible. Post-operative full blood counts were ordered in 83.3% of patients, with the first order ranging between 1-5 days post operatively. Conclusions The cumulative effect of having these errors at all three points greatly increases the chance of morbidity/mortality of patients. Our experience demonstrates a failure to meet trust and Royal College of Surgeon’s guidelines. We aim to re-audit this nationally with our planned intervention.