Quality of inguinal hernia operative reports: room for improvement

Discussion

Narrative reports have traditionally been the standard of care for documenting procedures and examinations performed on patients.6 In the past decade, studies have shown that these dictations are inadequate and that synoptic reports have been adopted in pathology, radiology, internal medicine, pediatrics and surgery.1–5,7–14

In Ontario, Cancer Care Ontario implemented the College of American Pathologists (CAP) standardized checklists for cancer pathology across 14 regional health integration networks in an electronic form with discrete data fields. Srigley and colleagues15 reported that this implementation was associated with increased completeness rates (39.3% in narrative reports vs. 93.0% in synoptic reports for colorectal tumour pathology). Other studies in pathology have reported similar results with the use of synoptic reports.8,14 Synoptic reports have also been shown to increase the quality of disability exams,9 improve quality assurance participation in interventional radiology procedures10 and improve timeliness and completeness of neonatal discharge summaries.13 Computerized discharge summaries on medical and surgical services were shorter, contained more information, were faster to generate (at discharge v. up to 26-week delay) and were more likely to be created (98% v. 71%).7,16 Synoptic reports were found in general to be of similar quality to narrative reports,16 and they were preferred by general practitioners.7

It is not surprising that the synoptic report has been adopted in surgical reporting. Operative reports have been found to be lacking in consistency, quality and completeness and are frequently dictated after a significant delay.6,17–19 In a study of 250 laparoscopic cholecystectomy ORs, Stewart and colleagues6 showed that there was a large variation in the content of reports and that key elements, such as adequate dissection of the Calot triangle, were often omitted (present in 24.8% of ORs). Several studies have reported significant delays in the dictation of ORs: 55% were dictated more than 24 hours after surgery in one study17 and 33% after more than 48 hours in another study.18 Sixty-seven percent of delayed dictations (> 24h) in a study of resident dictations were noted to be incomplete.19 Flynn and Allen17 reported that incomplete description of surgical procedures led to delayed reimbursement in 76% of 550 ORs, which was the equivalent of $1 300 000. In a study of resident dictations by Novitsky and colleagues,19 9.7% of 97 ORs had deficiencies accounting for loss of $18 200 of reimbursement if audited. Factors that were identified as affecting the quality of dictations were the delay between the procedure and dictation, the level of training of the person dictating and lack of awareness of data that are important from medical, medicolegal or scientific standpoints.19

Some studies assessing ORs in Mohs micrographic surgery2 and obstetric/gynecological procedures (including cesarean section, postpartum tubal ligation, total abdominal hysterectomy, vaginal hysterectomy and laparoscopic tubal ligation)12 have shown improvement in completeness and quality. In general surgery, most studies on OR quality have been conducted in the subspecialty of surgical oncology. One of the early studies, conducted by Edhemovic and colleagues,3 assessed ORs for rectal cancer surgery. They examined the completeness of intraoperative data reporting, including resection method, clinical margins and node status in standard versus computerized synoptic ORs. They showed that the narrative OR contained 45.9% of the specified data elements with the most important data present in only 33.5%–47.5% of dictations; after development of a web-based synoptic reporting tool, 99% of the data elements were captured.3 The authors recommended that the synoptic format be adopted as a standard for rectal cancer surgery reporting and serve as an educational tool to remind the surgeon of essential steps of the operation.

In the area of surgical oncology, there have also been publications on synoptic ORs for thyroidectomy, breast cancer procedures and pancreatic resection. The completeness of narrative vs. synoptic thyroidectomy ORs were compared in the study by Chambers and colleagues,1 where no narrative reports (v. 100% of synoptic reports) contained adequate information to calculate the MACIS (distant metastasis, patient age, completeness of resection, local invasion, and tumour size) score, which is used for prognostication and risk stratification. Essential elements, such as presence of invasion, completeness of resection, and preoperative vocal cord assessment were poorly reported in narrative reports, whereas they were mandatory fields in the web-based template. In a large-scale study on pancreatic resections, synoptic ORs were associated with significantly higher completeness scores, quicker availability in patient charts and good interobserver agreement.5 The study suggested that electronic synoptic ORs could decrease errors in transcription, reduce costs and provide faster turnaround time. Another study examined the use of a synoptic reporting tool for breast cancer procedures and concluded that the tool was associated with quality improvement, increased efficiency and decreased costs.4 The study quoted benefits with the new tool, including easy outcomes analysis and assessment of success of breast cancer screening programs, and it also served an ongoing educational purpose. A separate study was conducted on residents’ use of computerized synoptic ORs for breast cancers and showed higher completeness scores and better understanding of the operative procedure and perioperative preparations.20

Operative reports for common general surgery procedures have not been examined in great detail. To our knowledge, the quality of narrative ORs for IHRs has not been studied to date even though IHRs are among the most common procedures performed by general surgeons. In our own study we reviewed 206 open IHRs dictated by individuals with various levels of training. The completeness scores ranged from 1.9% (DVT prophylaxis) to 100% for individual elements on the checklist. Essential elements were dictated with an inclusion rate of 71.7%. When all elements were considered, however, completeness of ORs scored between 59.2% and 69.0% depending on the level of training of the person dictating the OR. This calculation was limited because of missing data on sex and sex-specific elements. For example, completeness of spermatic cord exploration may have been inaccurately calculated because we included it into the completeness calculation when sex was not specified despite the possibility that the patient could have been a woman. Repair-specific detail scores also varied among the types of repairs. Although our study examined factors such as turnover time for dictation, resident comfort with dictation and cost of dictated reports, our low completeness scores were consistent with those reported in other studies reviewing narrative ORs and showed substantial room for improvement.

The University of Toronto has implemented a synoptic template for laparoscopic cholecystectomy for residents but has yet to conduct a quality study of subsequent dictations. We have yet to develop a web-based synoptic reporting tool, but this is our ultimate goal. The studies we discussed demonstrate that this method would allow real-time entry of pertinent operative information and immediate generation of a synoptic OR for inclusion in the patient’s chart upon their transfer out of the operating room, improving communication and continuity of care between hospital teams. The addition of discrete data fields also allows for easy extraction of data for use in quality assessment and for research purposes. Several studies from Alberta have reported success with implementation of a web-based system for oncologic operative reporting (the WebSMR). In a recent publication studying implementation and ease of use of the system, 75% of staff surgeons were moderately or highly satisfied, and 80% said they would recommend the system to surgeons at other sites.21

There are important hurdles to changing the status quo regarding dictation of general surgical procedures. These include accessibility and ease of use, privacy issues and technical aspects of implementing a web-based application. There is always a learning curve associated with new tools in health care, and residents and surgeons alike require training on a new system that could be time-consuming in an already busy timetable. Eventually the goal would be for a net decrease in the amount of time required to record operative details in a new system. Privacy issues surrounding personal health information is always an area of concern when a patient’s medical record is available on a computer connected to the Internet or intranet. Specific security measures would have to be in place to prevent external or inappropriate access to the synoptic reports. Appropriate consultation with information technology professionals could be pursued, as most hospitals already have electronic medical records with similar security requirements. Technical difficulties include design of a user-friendly, efficient application requiring close interaction among surgeons, health records and computer programmers. However, there are important potential benefits of implementing a computerized synoptic OR, including decreased transcription costs, faster and greater completion of ORs and prevention of duplication of information on the electronic health record and the electronic OR.

One topic of discussion in studies comparing narrative reports with synoptic reports is the high correlation between the list of essential items and the elements included in a synoptic report. It is possible that the same surgeon provides input into creation of a synoptic report and subsequently participates in the creation of an audit checklist, skewing the results in favour of synoptic reports. To minimize this concern, our checklist for data extraction was based on a consensus committee among a group of academic surgeons at the University of Toronto. In addition, no other validated checklists in the literature nor publications on essential elements of an IHR were available. Neither the initial checklist nor the selection of essential elements were based on precedent evidence. However, one source of bias is that the checklist was created by some surgeons who were also audited in this study.