HPB P45 Assessment of quality of documentation for Laparoscopic cholecystectomy: a quality improvement project

Abstract

Abstract Background Laparoscopic cholecystectomy is one of the most common procedures carried out in a General Surgery unit both in emergency and elective theatres. Getting It Right First Time (GIRFT) and the Royal College of Surgeons England (RCS) have made best practice recommendations to ensure adequate documentation of laparoscopic cholecystectomy operation details for good clinical communication with colleagues and to aid in the review of operations after a patient complaint. This is a Quality Improvement Project (QIP) in a NHS Trust in West Midlands to assess the quality of documentation in view of the recommendations made by GRIFT and RCS. Methods Documentation including operative note, clinical noting, ward round entries, laboratory results, imaging records and clinical letters were reviewed for 100 consecutive laparoscopic cholecystectomies carried out during the month of May 2023 and assessed against a checklist based on recommendations made by GIRFT and RCS. Following the audit, a multifaceted intervention is planned, including teaching presentations and an electronic documentation template. A re-audit following interventions will be carried out in July, 2023. Results There was mixed compliance with GIRFT recommendations. Some recommendations, including indication for surgery, consent, WHO checklist, and surgeon details were followed in all cases. Documentation shortcomings included missing details on technique for pneumoperitoneum with 19% of operation notes failing to mention this detail ,intraoperative drug administration (54%), intraabdominal pressure levels (95%), Number of clips applied (66%), gall bladder retrieval method and port used for the purpose (38%), confirmation of port removal under vision (32%), hemostasis achievement (12%), fascia closure (26%), critical view of safety/safe view assessment (49%), anesthetist names (62%), and first surgeon's signature (41%). Conclusions We found significant shortcomings in documentation of patients undergoing laparoscopic cholecystectomy. This documentation needs improvement and standardization so that it meets the GIRFT and RCS Guidelines.