46 research outputs found
Operating Room Setup and Patient Positioning for Laparoscopic Adrenalectomy and Donor Nephrectomy
No full textRe: Utility of inguinal incision in retroperitoneoscopic live donor nephrectomy
No full textIn article “Cheng CT, Deitch JM, Haines IE, Porter DJ, Kilbreath SL. Do medical procedures in the arm increase the risk of lymphoedema after axillary surgery? A review. ANZ J. Surg. 2014; 84: 510–4.”, the authors describe the use of Weck Hem-o-lok clips for ligature of the renal artery during what is effectively laparoscopic donor nephrectomy.1 Yet the manufacturer,Teleflex Medical, issued a product warning in June 20062 contraindicating the use of these clips on the renal artery during laparoscopic donor nephrectomy. The U.S. Food and Drug Administration (FDA) issued a Medical Device Safety Communication3 to the same effect in 2011. Teleflex’s action followed at least three donor deaths that occurred in similar circumstances: after uncomplicated laparoscopic donor nephrectomy, sudden death in the recovery room from exsanguination occurred which was thought to be due to clip dislodgement
Implementation of electronic health records systems in surgical units and its impact on performance
No full textElectronic health records (EHR) systems have been utilized in New South Wales for more than a decade; however, there is no agreement as to what clinical benefits they provide. This study aims at determining whether the introduction of EHR systems resulted in changes in documentation quality and other markers of clinical performance such as post-operative length of stay (PO LOS), use of imaging modality, rates of readmission and morbidity.A before and after study was conducted utilizing both written and electronic patient documentation in a single surgical ward. Patients who underwent appendicectomy at Blacktown Hospital had inpatient documentation collated at three distinct time-points. Documentation was then assessed against the QNOTE assessment criteria. Other markers of clinical performance assessed included PO LOS, ultrasound use, computed tomography use, rate of readmission, rate of morbidity and rate of positive histological findings.There was a significant (P = 0.001) improvement in QNOTE score between group 1 (6 months prior to the implementation of EHR) and group 3 (12 months after the implementation of EHR) of 9 points. PO LOS was reduced following the implementation of EHR from 1.94 to 1.37 days (P = 0.001).This study demonstrated that following the implementation of EHR system in an inpatient surgical ward, notation quality improved. It was also found that the implementation of EHR was associated with a decrease in PO LOS
Implementation of electronic health records systems in surgical units and its impact on performance
No full textBackground: Electronic health records (EHR) systems have been utilized in New South Wales for more than a decade; however, there is no agreement as to what clinical benefits they provide. This study aims at determining whether the introduction of EHR systems resulted in changes in documentation quality and other markers of clinical performance such as post-operative length of stay (PO LOS), use of imaging modality, rates of readmission and morbidity. Methods: A before and after study was conducted utilizing both written and electronic patient documentation in a single surgical ward. Patients who underwent appendicectomy at Blacktown Hospital had inpatient documentation collated at three distinct time-points. Documentation was then assessed against the QNOTE assessment criteria. Other markers of clinical performance assessed included PO LOS, ultrasound use, computed tomography use, rate of readmission, rate of morbidity and rate of positive histological findings. Results: There was a significant (P = 0.001) improvement in QNOTE score between group 1 (6 months prior to the implementation of EHR) and group 3 (12 months after the implementation of EHR) of 9 points. PO LOS was reduced following the implementation of EHR from 1.94 to 1.37 days (P = 0.001). Conclusion: This study demonstrated that following the implementation of EHR system in an inpatient surgical ward, notation quality improved. It was also found that the implementation of EHR was associated with a decrease in PO LOS
Adherence to surgical antibiotic prophylaxis guidelines in New South Wales, Australia : identifying deficiencies and regression analysis of contributing factors
No full textBackground: Surgical antibiotic prophylaxis is frequently reported in the literature to be suboptimal, a finding having both clinical and public health implications. This study aimed to calculate rates and patterns of adherence to guidelines at two sites and identify extrinsic contributing factors. Methods: A retrospective analysis was conducted over two 12-mo periods during 2013–2014 at the metropolitan Blacktown Hospital and regional Lismore Base Hospital, New South Wales, Australia. A group of 400 patients undergoing abdominal general surgery was selected via simple random sampling (n = 200 per site). Medical records were reviewed, and prophylactic antibiotic regimens were compared with the Australian guideline, Therapeutic Guidelines: Antibiotic (v. 14) with respect to drug choice, dosage, timing of administration, and duration of administration. Results: The overall rate of adherence to the guidelines was 16.5% at Blacktown Hospital and 19.5% at Lismore Base Hospital. At each site, prophylaxis was administered to more than 95% of patients and was inappropriately withheld in 4%. Drug choice was the most frequent error type, specifically involving inappropriate omission of metronidazole and use of newer-generation cephalosporins. Errors in the timing of administration also were frequent, with prophylaxis typically occurring excessively early. Logistic regression identified emergency surgery as independently associated with prophylactic errors in both the Blacktown Hospital (p < 0.001) and the Lismore Base Hospital cohorts (p = 0.020). Conclusions: Adherence to antibiotic prophylactic guidelines was poor at both the metropolitan and regional sites. Choice of antibiotic and timing of administration were identified as major error types. Consideration should be given to multidisciplinary involvement of anesthetists, implementation of focused interventions with an emphasis on emergency settings, and further research correlating antibiotic use with clinical significance
Interhospital transfer delays emergency abdominal surgery and prolongs stay
No full textBackground: Interhospital transfer of patients requiring emergency surgery is common practice. It has the potential to delay surgical intervention, increase rate of complications and thus length of hospital stay. Methods: A retrospective cohort study was conducted of adult patients who underwent emergency surgery for abdominal pain at a large metropolitan hospital in New South Wales (Hospital A) in 2013. The impact of interhospital transfer on time to surgical intervention, post-operative length of stay and overall length of stay was assessed. Results: Of the 910 adult patients who underwent emergency surgery for abdominal pain at Hospital A in 2013, 31.9% (n=290) were transferred by road ambulance from a local district hospital (Hospital B). The leading surgical procedures performed were appendicectomy (n=299, 32.9%), cholecystectomy (n=174, 19.1%), gastrointestinal endoscopy (n=95, 10.4%), cystoscopy (n=86, 9.5%), hernia repair (n=45, 4.9%), salpingectomy (n=19, 2.1%) and oversewing of perforated peptic ulcer (n=13, 1.4%). Overall, interhospital transfer (n=290, 31.9%) was associated with increases in mean time to surgical intervention (14.2h, P<0.001), post-operative length of stay (1.1days, P=0.001) and overall length of stay (1.6days, P<0.001). Delayed surgical intervention was observed across all procedure types except surgery for perforated peptic ulcer, where transferred patients underwent surgery within a comparable timeframe to direct admissions. Conclusion: Interhospital transfer delays surgical intervention and increases length of hospital stay. This mandates attention due to the implications for patient outcomes and added burden to the healthcare system. The system did, however, show capability to appropriately expedite surgery for acutely life-threatening cases
Educational antimicrobial stewardship intervention ineffective in changing surgical prophylactic antibiotic prescribing
No full textBackground: High rates of inappropriate use of prophylactic antibiotics in surgery continue to be reported in the literature, with many institutions designing interventions aimed at improving prescription. This study evaluates the surgical arm of a clinician-focused educational antimicrobial stewardship program implemented in February 2014 at Blacktown Hospital, Australia. Methods: A before-after analysis of the surgical antibiotic prophylaxis intervention was conducted at Blacktown Hospital, New South Wales, Australia. Two hundred abdominal general surgical patients were selected via simple random sampling and categorized into pre-intervention (n = 100) and post-intervention (n = 100) groups. Antibiotic prophylaxis regimens were compared with the Australian guideline, Therapeutic Guidelines: Antibiotic (v14) with respect to drug choice, dosage, timing of administration, and duration of administration. Results: Overall adherence rates in the pre- and post-intervention periods were 18% and 15% respectively, demonstrating no substantial change (p = 0.568). No patients in either group were administered antibiotics without an appropriate indication. There were no substantial decreases in error rates across any category, including drug choice, dosage, timing of administration, duration of administration, or re-dosing. The apparent decrease in the rate of inappropriate broad-spectrum cephalosporin usage was not statistically significant (29.3% vs. 18.8%; p = 0.16). Conclusions: The educational intervention studied demonstrated no substantial change to overall adherence. Given the frequent failure of such interventions, stronger and more directly mandated adoption of prescribing guidelines is recommended for surgical services. Future consideration should be given to focused computer-based solutions, integrated with electronic medical records where possible
Reversal of endoscopic sleeve gastroplasty and conversion to sleeve gastrectomy : two case reports
No full textINTRODUCTION: With the advent of more minimally invasive procedures like endoscopic sleeve gastroplasty (ESG) for weight loss and metabolic disorders, we are seeing more cases of patients presenting with sub-optimal results for consideration of alternative weight loss surgery. The report aims to describe our experience in converting ESG to laparoscopic sleeve gastrectomy and highlight our suggested technique, challenges and pitfalls.
PRESENTATION OF CASES: We described two bariatrics cases detailing our findings on initial endoscopy along with methods used to reverse ESG hardware, followed by issues encountered during sleeve gastrectomy 1 month later. Case 1 being of a 33 year old female (BMI – 50.7) with previous laparoscopic band removal and 2 ESG attempts, while case 2 is a 31 year old female (BMI 44.6) with previously failed gastric balloon and ESG. DISCUSSION: ESG reversal was performed without difficulty via endoscopy with visible sutures cut and hardware removed with snares. In both cases, the stomach was easily endoscopically distensible. During sleeve gastrectomy, extra-gastric adhesions along with more gastro-gastric sutures were encountered in case 1. In case 2, ESG hardware was noted on the external surface of stomach with misfiring of 3rd stapler reload during sleeve gastrectomy likely related to unidentified retained hardware. No post-operative complications occurred in either of the cases with adequate weight loss on one month follow up. CONCLUSION: In our experience, ESG conversion to sleeve gastrectomy is feasible and for the most part, uncomplicated. In our case series, we described a two staged approach to conversion although a single staged conversion is theoretically feasible
Necrotising soft tissue infection in western Sydney: An 8‐year experience
No full textBackground: This study aimed to assess the risk factors, management, imaging validity, Laboratory Risk Indicator for Necrotising infection (LRINEC) score and outcomes of necrotising soft tissue infection (NSTI) at a western Sydney tertiary hospital. Methods: A retrospective study was conducted of all patients with NSTI from 2012 to 2019 at our institution. Patient characteristics, imaging, microbiology and site, LRINEC score, surgical management and outcomes/disposition were collected. Results: Thirty-six patients met the inclusion criteria with mean age of 52 years and body mass index of 38.1; 55.6% were male, 48% of Polynesian descent and 55.6% were diabetic. The most frequent sites of NSTI were perineal (30.6%), lower limb (30.6%), perianal (19.3%) and trunk (11.1%). A total of 64% of patients underwent computed tomography radiological imaging with diagnostic accuracy of 50%. The mean LRINEC score was 7 (1–20). A total of 52.8% were transferred from another facility or non-surgical teams which delayed surgical review by 11.4 h (P < 0.03) and operating time by 12.4 h (P < 0.04) compared with direct emergency department referrals to the on-call surgical team. There was no statistical difference in outcomes in both groups. The overall average time to surgical debridement was 16.2 h (standard deviation 19.6, range 3.4–105.1). The mean hospital length of stay was 20.9 days; 44.4% of patients were transferred for rehabilitation or plastic reconstruction with a single mortality from multi-organ failure. Conclusion: The optimal management of NSTI requires a high index of suspicion and LRINEC score is a useful adjunct in aiding a clinician's decision. Early surgical debridement within 24 h of diagnosis and a multidisciplinary approach is associated with a lower mortality rate
