Title : Impact of compliance with UK national Royal college of surgeons operative notes guidelines on post-operative VTE and antibiotic administration in trauma and elective orthopaedic patients
Abstract:
Background: Comprehensive operation notes with detailed post operative instructions are key for optimising patient care and safety throughout a patient’s surgical journey. Royal college of surgeons (RCS) guidelines provide a gold standard pan-specialty framework for transcription of operative notes however research has shown variable compliance globally. There is no clear evidence if good compliance to these guidelines impacts affects the patient’s clinical pathway more than being a medico-legal element of their care. The objective of this research project is to assess if there is a correlation between operative note transcription compliance to RCS guidelines and the effect on post-operative timing and administration of correct VTE prophylaxis and antibiotics.
Methodology: Data was collected prospectively from 31/08/22 – 14/09/22 in a UK based trauma unit for all adult cases with capacity on trauma and elective theatre lists and each patient’s operative note was examined based on RCS guidelines. All notes should address each heading listed in the RCS operative note guidelines. Post operatively patient drug charts were assessed if the requested VTE and antibiotic prophylaxis was administered and how soon it was given. Presence of any post-op infection and DVT was also assessed up to 30 days following the procedure.
Results: The final study cohort was 126 patients (75 trauma, 51 elective cases). Operation notes were least compliant with documenting blood loss (trauma: 15%, elective: 23%) and any problems or complications experienced during surgery (trauma: 35%, elective: 11%). Operation notes were most compliant with documenting incision details (trauma: 88%, elective: 93%), operation findings (trauma: 92%, elective: 100%), signatures (100%), and post-operation instructions (100%). 81% of trauma and 82% of elective notes outlined specific antibiotic prophylaxis. Furthermore, 58% of trauma and 78% of elective operative notes outlined specific plans for VTE prophylaxis. Only 5% of elective notes had 100% compliance to RCS guidelines and none of the remaining elective or trauma notes. Mean time to delivery of VTE prophylaxis from time of writing operation note was 6.22 hours for trauma and 6.21 hours for elective respectively which is in keeping with the NICE guidelines post surgery VTE prophylaxis. In our trust rivaroxaban or enoxaparin can be used in the post-op period for VTE prophylaxis. In this regard where outlined in the op note there was 100% compliance to the correct VTE prophylaxis type. In our trust most cases use teicoplanin and gentamicin on induction and nil further needed post op. Cases that required post op antibiotic where flucloxacillin was used or surgeon specified was 26 cases. Amongst these only 50% specifically stated what type of antibiotic and timing of its use. The 13 cases that did specify had the correct antibiotic administered within 6.33 hours post op and the other 13 had it delivered in 8.12 hours (P = <0.001)
Conclusions: This audit demonstrated operative notes compliance to RCS guidelines can have an impact on clarity of what specific post-operative VTE and antibiotic option is requested by the operating surgeon and additionally impact timing of its administration. We recommend electronic operative note proformas be implemented where possible with headed titles for each RCS guideline element to prompt and alert surgeons if any areas are left blank as this may alter post-operative management especially with regards to: blood loss, specific antibiotics / anticoagulation and their duration or need to revise/remove a prostheses down the line.
Audience Take Away Notes:
• Surgical guidance for transcription of operative notes
• Does clarity of operative notes have an impact on correct VTE choice and prophylaxis timing
• Does clarity of operative notes have an impact on correct antibiotics choice and prophylaxis timing
