Royal College Of Surgeons Of England Research Articles

Assessing the standard of emergency general surgical (EGS) operation notes in accordance with the Royal College of Surgeons guidelines

Objective: Operation notes are important for care in surgical patients. The objectives of this study were to analyze the emergency general surgery (EGS) operation note documentation in accordance with the Royal College of Surgeons of England (RCSEng) guidelines and to assess the impact of creating awareness of the guidelines and effect of a new proforma. Material and Methods: A retrospective review of 50 EGS operation notes was conducted between December 2019 and March 2020 and compared to RCSEng guidelines. Education was delivered on the importance of documentation in accordance with RCSEng guidelines. A new electronic proforma was introduced. A further 50 EGS operation notes were analysed between August 2020 and December 2020. Results: One hundred operation notes were reviewed, and each given a score out of 19. Our interventions showed significant improvement to the average score (15.64 vs 17.96; p< 0.001). Within the second cycle, there was a statistically significance difference when comparing electronic to handwritten notes (18.55 vs 17.50; p= 0.001). Conclusion: Implementation of the new proforma showed improvement in operation note documentation when compared to the RCSEng standard. Therefore, this study emphasizes the need for surgeons to familiarize themselves with the current guidelines.

A quality improvement project on operative records

Introduction: In 2013 the Royal College of Surgeons of England (RCSEng) published a Standard of Good Practice for surgeons to adhere to in the UK. The guideline included the importance of legible documentation and what should be included in the operative notes. We conducted an audit and quality improvement project in our regional vascular unit in Northern Ireland which showed multiple elements of our operative records that could be improved, such as the documentation of deep vein thrombosis prophylaxis, antibiotic prophylaxis and the use of electronic operative records. Methods: We organised an audit between 3rd and 16th October 2022 where operative notes were collected consecutively and analysed. Multifaceted interventions such as discussion with colleagues, reminder emails and the placement of guidelines around the vascular theatres were done. The second loop of audit was completed between 7th and 20th November 2022. After the audit, we underwent four cycles of Plan-Do-Study-Act (PDSA) where we designed and developed an electronic operative note template and linked it to our electronic records system within the Trust.Results: A total of 24 and 28 operative records were collected, respectively, in the first and second loop of the audit. The majority of the domain showed improvement after the multifaceted interventions: for instance, the documentation of incision (from 46% to 89%), operative diagnosis (from 58% to 93%) and details of closure technique (from 92% to 100%). Through our PDSA cycles, an electronic operative note template was created and improved via feedback from the vascular surgeons. Logistic and IT issues were addressed and we are currently in the process of increasing the number of computers and printers around the vascular theatres. The Vascular Surgical Unit is currently slowly adapting to the use of electronic operative records. Conclusion: Our work has improved the compliance of operative records with the RCSEng guideline and increased the use of electronic operative notes, which are more accessible and legible for our multidisciplinary team.

901 Assessing Adherence to RCSEng Standards for Operation Notes in Patients With Neck of Femur Fractures: A Closed Loop Audit

Abstract Aim To determine the accuracy with which Royal College of Surgeons of England (RCSEng) standards for documenting surgical procedures were met within a defined patient group, with the goal of improving patient safety, and improving documentation for medicolegal purposes. Method We conducted a closed loop audit on adherence to RCSEng standards for operation notes. We calculated the percentage adherence for each measurable standard and overall note, and presented the data at a local clinical governance meeting. We implemented autotext templates for operations to improve quality of operation notes in following RCSEng standards. We collected data retrospectively after 3 months to complete the audit cycle. Results We included 24 patients in the first cycle and 16 patients in the second cycle. Prior to intervention, the overall percentage of measurable standards met was 69.4%, which increased to 76.4% after intervention. The five least adherent standards all improved in percentage, with the largest increase from 33.3% to 93.8%. Conclusions In the first cycle, 3 of the measurable standards were met 100% of the time, which increased to 4 in the second cycle. Along with the general improvement of standards met, the interventions improved patient safety and surgeon documentation. Operation notes using templates generally recorded higher percentages of standards met than those without templates, but further work is needed to ensure more standards meet the 100% ideal.

Surgical Operative Notes Compliance with the Standard Guidelines of the Royal College of Surgeons: A Retrospective Clinical Audit at a Tertiary Hospital in Bangalore, India

Introduction: Operative notes are essential documents that record the operative findings and procedures performed during surgeries. Therefore, it is crucial to document them with clarity and objectivity. They serve various purposes, including auditing, teaching, research, and providing valuable information in medicolegal cases. Aim: To assess the accuracy of operative note-keeping in accordance with the guidelines set by the Royal College of Surgeons (RCS) of England. Materials and Methods: A retrospective clinical audit was conducted to evaluate the quality of operative notes in the Department of General Surgery at St. John’s Medical College and Hospital in Bengaluru, Karnataka, India, from June 2022 to October 2022. A total of 75 surgical notes were analysed, including cases of both elective and emergency surgeries. The audit assessed all 19 parameters mentioned by the RCS. A master sheet was created to record the analysed variables, and each variable was categorised as present, absent, or not applicable. Statistical analysis was performed using the Statistical Package for Social Sciences (SPSS), version 21.0, and the results were expressed as percentages. Results: The documentation of the surgeon’s name, diagnosis, intraoperative findings, and procedure performed was accurate in both groups, comprising 45 (100%) cases of elective surgeries and 30 (100%) cases of emergency surgeries. However, there was a lower compliance with Deep Venous Thrombosis (DVT) prophylaxis in both groups, with 10 (22%) cases in elective surgeries and 4 (13%) cases in emergency surgeries. Conclusion: Based on the findings of the present study, it is recommended to adhere more strictly to the guidelines provided by the RCS of England, particularly in emergency cases. Regular audits should be conducted to ensure quality management, enhance surgical training, and address medicolegal implications effectively.

Development, implementation and feedback for an online speciality membership examination in orthodontics during the COVID-19 pandemic

Introduction The Royal College of Surgeons of England (RCSEng) and the Royal College of Physicians and Surgeons of Glasgow (RCPSG) offer the bi-collegiate Membership in Orthodontics (MOrth) examination, a summative assessment of specialist knowledge, skill and behaviour in orthodontics. The COVID-19 pandemic has had a profound global effect on almost every facet of normal life, including the conduct of face-to-face examinations. We highlight development, implementation and feedback for the bi-collegiate MOrth Part 2 examination delivered remotely to a cohort of candidates in September 2020 by RCSEng/RCPSG.Methods Two anonymised online surveys (Google Forms) were distributed via electronic mail following completion of the examination diet. Forty-two candidates were sent a survey covering four domains and comprising a total of 31 questions. The 20 examiners were sent a survey containing eight questions. In both surveys, free-text responses were also collected. A rating system was used to categorise responses. All survey responses were summarised in an online data collection sheet.Results The response rate was 78.5% (33/42) and 75% (15/20) for candidates and examiners, respectively. Overall, favourable responses in relation to all sections of the assessment were elicited from candidates with the majority (mean 79.8%; 75.8-81.9%) reporting that the online examination format worked well. Equally, favourable responses were reported by examiners. Notably, 80% of examiners felt that the online exam style did not affect the mark a candidate would receive, and 100% were confident that the marks the candidates received were a reflection of their ability and were not affected by the online delivery of the assessment.Conclusions The feedback from both candidates and examiners relating to an online remote assessment of the bi-collegiate MOrth Part 2 was generally positive. Based on the survey responses, this format of a high-stakes examination was acceptable to all stakeholders, and demonstrated a high level of perceived validity and reliability in terms of content.

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

Abstract 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.

1018 Implementing A Standardised Orthopaedic Admission Pro-Forma to Improve Adherence to The Royal College of Surgeons of England (RCSEng) Best Practice Clerking Guidelines

Abstract Introduction Within our Trust, Orthopaedic patients are clerked in on A&E notes via freehand text. Audit, clinical incidents, and root cause analysis revealed suboptimal documentation. Using RCSEng Best Practice Guidelines we designed, implemented, and evaluated the impact of an admission pro-forma on quality of clerking. Method An Orthopaedic clerking pro-forma was designed based on standards set by RCSEng and feedback from Orthopaedic colleagues. First- and second-cycle data collection involving quantitative analysis of clerking against RCSEng domains was conducted before (n = 23) and after (n = 25) intervention. Fisher’s exact test was performed to calculate the statistical significance of our data. A qualitative survey was performed to gain feedback on the pro-forma. Results Observations, allergies, and smoking history were omitted in over half of freehand documentations. Medical/surgical history and management plans were well documented regardless. Intervention resulted in statistically significant increases in 7 out of 12 RCSEng clerking domains, most notably allergies (p < 0.00001). Qualitative feedback was positive; 100% of those surveyed stated that the pro-forma ‘improved quality of clerking‘ and ‘benefited clinical decision making’. Conclusions Our study demonstrated that implementing an Orthopaedic pro-forma improved adherence to RCSEng best practice clerking guidelines compared to freehand documentation and standardised the process improving the level and quality of documentation.

Challenges of oral medicine specialists at the time of COVID-19 pandemic.

Challenges of oral medicine specialists at the time of COVID-19 pandemic.

Effectiveness of a multi-session combined near-peer and faculty-led surgical skills course on self-perceived ability to perform basic surgical skills

BackgroundNewly qualified UK doctors report feeling unprepared to perform basic practical procedures. The Royal College of Surgeons of England (RCSEng) responded to this concern by developing a national surgical curriculum, however, a national survey of UK medical schools identified that surgical skills teaching is inconsistent throughout the UK.Peer assisted teaching sessions are delivered by senior students to junior peers and have been demonstrated to be effective in a number of settings. We aimed to develop a peer-led surgical skills course for medical students and assess its efficacy in teaching surgical skills. MethodsCombined near-peer and faculty-led teaching sessions were delivered to medical students (N = 14). We assessed for confidence in these skills using pre- and post-course Likert scale questionnaires to determine self-perceived benefit. ResultsOverall, student confidence in all skills improved by +1.254 (p < 0.0001). Individually, confidence in every skill increased significantly, including continuous suturing, knot tying and excision and closure, which improved by +1.45 (p < 0.001), +1.22 (p < 0.05) and +1.59 (p < 0.0001), respectively. DiscussionThis study demonstrates that teaching provided through near-peer faculty improves medical student confidence in basic surgical skills. A similar course design could be implemented in other UK medical schools to improve the surgical skills of newly graduated doctors

Training of children’s surgical teams at district level in low- and middle-income countries (LMIC): from concept to reality—a south to south initiative

Training of children’s surgical teams at district level in low- and middle-income countries (LMIC): from concept to reality—a south to south initiative

A historical perspective on the introduction of laparoscopic basic surgical training in the Caribbean and factors that contribute to sustainability of such training.

To report the development of minimally invasive training courses and workshops in the Caribbean and specifically the establishment of the Basic Surgical Skills Course of the Royal College of Surgeons of England (RCSEng) in Trinidad with respect to their value toward Surgical laparoscopic or minimally invasive training in the Caribbean. & Methods: The literature written on laparoscopy in the region was reviewed and in particular that related to the minimally invasive training courses provided over the period 2004 to 2019 and the development of laparoscopic surgical training described from a historic perspective. The factors that contribute to sustainability of courses were identified. Laparoscopic surgical training courses were sporadically introduced into the Caribbean over the period 2004 to 2019 in countries including Barbados, Curacao, Guyana, St. Lucia, Jamaica and Trinidad & Tobago. These were timed and closely related to the establishment of the Caribbean College of Surgeons (CCOS) with the help of the Royal College of Surgeons of England. However, the only certified course introduced was the Basic Surgical Skills (BSS) course of the RCSEng into Trinidad in 2012. This has now been established as a recognised overseas centre by the RCSEng and provides the Intercollegiate BSS course annually forming a solid basis for trainees to learn safe surgical and laparoscopic skills prior to commencing formal surgical training. This has resulted in the sustainable development of minimally invasive training in Trinidad in particular. Laparoscopic skills courses and workshops have been established in the Caribbean for 15 years beginning circa. 2004 to 2019 and have grown in number and locations throughout the Caribbean. The RCSEng and the CCOS have been instrumental in the development process. Of note, the only recognised overseas training centre for Basic Surgical Skills Course was established in Trinidad & Tobago with the support of the RCSEng and seems to be the main contributor to the successful, regular maintenance of these and other minimally invasive courses in General Surgery, ENT, Gynaecology and other fields on an annual, sustainable basis.

Increasing efficiency in emergency surgical care

In response to increases in emergency surgical admissions, the Royal College of Surgeons of England (RCSE) published guidelines on ways to separate inpatient emergency and elective surgery with the creation of the surgical assessment unit (SAU). This study aimed to evaluate the impact of a new SAU on acute surgical patient pathways in a busy district general hospital and compare it with the RCSE standard for emergency care. Data were retrospectively extracted from records for all patients attending the SAU over an 8-week period. Patient demographics, methods of referral, rate of discharge, time spent in the SAU, imaging, diagnosis and the requirement for emergency surgical intervention were looked at. During the period studied there were 956 attendees, who spent an average time of 5 hours 48 minutes in the unit. Forty nine percent were admitted and of these, 41% required emergency surgery, with a further 18% of patients (60) re-attending the next day for emergency surgery. A total of 316 radiological investigations were conducted on the SAU patients. The average waiting time for a scan was 5 hours and 3 minutes. The majority of referrals were from GPs (38.5%). The SAU at Watford hospital is meeting the majority of the RCSE's guidelines, however there are several areas in which the unit can continue to improve. With hospitals under increasing pressures, this unit highlights a service where patients can be diverted from A&amp;E to a dedicated assessment area, which is key to the future efficiency of emergency surgical care.

A thorough note: Does a procedure-specific operation note proforma for laparoscopic appendicectomy improve compliance with the Royal College of Surgeons of England Guidelines?

IntroductionOperation notes provide an insight into the operative process and stand as a legal document of a surgical procedure occurring. Maintaining accurate, complete and legible notes is fundamental for post-operative patient care and medico-legal purposes. This study aimed at comparing the quality of laparoscopic appendicectomy operation notes prior-to and after the introduction of a procedure-specific proforma consistent with the Royal College of Surgeons of England (RCSEng) guidelines, 2014. MethodsNineteen parameters based on the RCSEng ‘Good Surgical Practice’ 2014 guidelines were used to audit laparoscopic appendicectomy operation notes. The study consisted of a retrospective audit of 43 consecutive laparoscopic appendicectomy operation notes and a prospective audit of 57 consecutive operation notes following the introduction of a procedure-specific proforma (existing in both hard copy and electronic versions) for laparoscopic appendicectomy.We assessed: (i) the overall compliance with the RCSEng guidelines, (ii) whether each parameter of RCSEng guidelines recommendations were clearly recorded in the operation notes, and (iii) legibility of operation notes. Statistical analysis for difference between the two groups was performed using the independent sample t-test. ResultsAfter introduction of a procedure-specific profroma for laparoscopic appendicectomy, average compliance with RCSEng guidelines increased from 66% retrospectively to 94% prospectively (p < 0.00001). In 8 of the 19 parameters assessed there was significant improvement in adherence to guidelines. DiscussionThe implementation of a procedure-specific operation significantly increased compliance with RCSEng guidelines. Such proformas may help reduce variability and standardise operation notes for the same procedure and improve post-operative care.

Improving the quality of orthopaedic elective and trauma operative notes: A completed audit loop study

IntroductionGood medical practice dictates that comprehensive documentation of all surgical procedures is paramount in maintaining a high standard of patient care. This study audited the quality of operative note keeping for elective and trauma procedures against the standards set by the British Orthopaedic Association (BOA) and The Royal College of Surgeons of England (RCSE) guidelines. Patients and methodsA retrospective assessment of the operative notes of every patient undergoing a total knee and hip replacement (elective cases) was carried out over a period of 2 months. Data recorded were compared against BOA guidelines. Within this time a randomised selection of trauma operative notes were also assessed, and the recorded data were compared against RCSE guidelines. Change in practice was implemented and the audit cycle completed. A total of 173 operative notes were evaluated. ResultsThere was a significant improvement (p-value < 0.05) in the quality of total knee replacement notes, with an increase in the percentage of data points from 68.6% to 93%. Similarly the quality of total hip replacement notes showed significant improvement (p-value < 0.01) with an increase in the percentage of data points from 67.5% to 86%. However trauma operative notes showed minimal improvement. DiscussionThis study showed that the quality of elective operative notes was improved through surgeon education and the circulation of a guideline based electronic operative note. We have further plans to implement procedure specific notes for the most common types of trauma cases to help improve the quality of trauma operative notes.

An exploration of the use of social media by surgical colleges

Background: Social media use has become common for organisations in surgery, however the nature and reach of these communications is unknown. This study aimed to characterise and compare the use of “Twitter” by five prominent organisations in surgery. Study Design: Data were collected from Twitter and the scale, reach, nature and sentiment of messages analysed. Message influence was determined and content analysed by frequency and association using hierarchical clustering and network analysis. Poisson regression was used to compare institutional message and “re-tweet” counts. Results: 7712 messages were analysed from a four-year period up to 13th April 2013. The American College of Surgeons (ACS) had tweeted most and posted the greatest number of messages per day (3.3/day). The number of followers reflects social reach and the Royal College of Surgeons of England (RCSEng) had the greatest number (11,600) followed by the ACS (7320). The number of “retweets” a message receives is a measure of influence with the RCSEng (2.0) demonstrating a significantly greater count than the Royal College of Surgeons of Ireland (RCSI; 0.8, p < 0.001) and the ACS (1.3, p < 0.001). Followers of the RCSEng and ACS appeared most influential. Terms relating to education feature prominently in messages posted by the RCSEng and RCSEd, but less so in those from the RCSI and ACS. Education and training terms were highly correlated with “events”. Conclusions: Surgical colleges have significant international reach through social media. UK colleges frequently communicate about education/training opportunities while the ACS focuses on patient-related matters. Only one organisation was found to have an explicit social media policy, which would be considered best practice and can focus on-line activity.

Tonsillectomy discharge information - An improvement in both patient safety and satisfaction

Approximately 20,000 adult and 25,000 paediatric tonsillectomies are performed each year in England. 0.9% of these patients return to theatre for post-tonsillectomy bleeding. The Royal College of Surgeons of England (RCSEng) have produced guidelines regarding emergency surgery, with standards for tonsillectomy discharge information. We audited our compliance with these guidelines and patient satisfaction regarding the information currently provided.Theatre records identified all tonsillectomies carried out between December 2012 and February 2013. 71 patients and their electronic discharge information were reviewed for post-operative bleeding information. Each patient was contacted, with a second call made to those who did not answer. 35 patients took part in our telephone questionnaire. Only 35% of patients had post-operative bleeding information on their discharge summary. 51% received no written information either in clinic or on the day of surgery, 66% recalled a verbal explanation. Only 54% knew to go to A&E if they experienced bleeding. 40% were not satisfied with their discharge information, stating that they wanted to know about bleeding, recovery expectations, and information regarding oral intake.A focus group was formed to discuss potential solutions to the audit outcomes and a tonsillectomy leaflet was produced inline with the trust patient information template. It contained specific instructions regarding bleeding and the nearest A&E contact details. It was reviewed by three tonsillectomy patients and their feedback regarding further information on post-operative diet, throat appearance and pain expectations was incorporated. A second cycle of the audit took place between August and September 2013. Results showed improvement, with 83% receiving an information leaflet and 100% a verbal explanation. 100% of patients were satisfied with their discharge information and 100% knew what to do if they bled. As a result we now meet the standards set out by the RCSEng and have increased our patient safety and satisfaction rates.

Surgery 1913: The genesis of the British Journal of Surgery

Shortly after lunch on 13 February1913, eight surgeons met in anupstairs room at the Royal Collegeof Surgeons of England (RCS) onLincoln’s Inn Fields. In the Chairsat Sir Berkeley Moynihan, Professorof Clinical Surgery at Leeds—freshlyknighted and elected to RCS Council.Robert Jones of Liverpool, whosefame as an orthopaedic pioneer wasbeginning to spread, also representednorthern expertise. More local wereSt George’s surgeons Sir WilliamBennett and Thomas Crisp English(like Jones, later knighted), EdredMoss Corner of St Thomas’s, CharlesHerbert Fagge of Guy’s (not to beconfused with his uncle, the Guy’sphysician Charles

Emergency Laparotomy in High Risk General Surgical Patients: A Review of Perioperative Care

High risk general surgical patients account for the largest proportion of surgical deaths. There is concern from the Royal College of Surgeons of England (RCSEng) and National Confidential Enquiry into Patient Outcome and Death (NCEPOD) that these patients may receive suboptimal care. Patients undergoing an emergency laparotomy were identified and the notes reviewed; patients had high observed and predicted mortalities. Consultant involvement, patient consent and nutritional planning were all assessed. An agreed method of patient identification and quantification of risk was recommended. The use of an emergency laparotomy proforma was suggested.

Is There Adequate Information on Operation Notes? the Application of the Royal College of Surgeons of England Guidelines

An audit was performed to review the compliance and applicability of the Royal College of Surgeons of England (RCSEng) guidelines for operation notes in a regional plastic surgery department. 137 operation notes were initially audited revealing a variable quality when compared to the guidelines. An aide-memoire (Figure 1) was used to detail each of the ten guidelines and allowed the surgeon to record if any of the guidelines were not applicable. 151 operation notes were subsequently reviewed, and showed an improvement in the recording of the operative note and the varied applicability of the guidelines to this particular speciality. It is concluded that the RCSEng guidelines are not universally applicable to plastic surgery. The difference between 'not applicable' and 'failure to record' is potentially important if these guidelines are used by non-clinical audit staff in a target driven environment.

Are patients referred for NHS-funded dental implant treatment being selected in accordance with national guidelines and subsequently funded by their primary care trust?

The Faculty of Dental Surgery, The Royal College of Surgeons of England (RCSE), published a national guideline document in 1997 detailing specific selection criteria for National Health Service (NHS) funded dental implant treatment. The aim of this audit was to assess whether patients selected for NHS-funded dental implants at Bristol Dental Hospital (BDH) met the RCSE national criteria for treatment and received funding from their primary care trust (PCT). A retrospective audit over a period of 2 years was undertaken using medical records and an existing Microsoft Excel database. All patients who had an application submitted to their local PCT for NHS-funded dental implants by BDH were included in this audit. A total of 82 applications for dental implant funding were made by BDH and 100% met the RCSE criteria. Fifty-one patients (62.2%) in total had their application for funding approved. Thirty-one patients (37.8%) that met the RCSE guidelines for NHS-funded dental implant treatment had their applications refused. Twenty-five (49%) out of 51 cases in the partially dentate category and six (27.3%) cases in the edentulous group were unsuccessful in their application for NHS-funded dental implants. However, all applications for patients with acquired maxillofacial defects were successful. Patient selection by the BDH for NHS-funded implants complied with the RCSE guidelines. However, there was significant variation in funding between PCTs for those patients who apparently fulfilled the RCSE guidelines. NHS resources are not being allocated equitably for dental implant 'high-priority' patients and it would appear that a so-called 'postcode lottery' exists between PCTs.