- Email: [email protected]
Standardization of Laparoscopic Operative Reporting: Improving Gynaecological Surgeon Communication
GYNAECOLOGY
Standardization of Laparoscopic Operative Reporting: Improving Gynaecological Surgeon Communication Rachel J. Pope, MD, MPH;1 Ahmed Y. Abdelbadee, MBBCh, MS;2,3 Amy J. Armstrong, MD;3 Prakash R. Ganesh, MD, MPH;4 Mohamed A. Bedaiwy, MD, PhD;5 Kristine M. Zanotti, MD3 1
Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX
2
Department of Obstetrics and Gynecology, Women’s Health Hospital, Assiut University, Egypt
3
Department of Obstetrics and Gynecology, University Hospitals, Case Western Reserve University, Cleveland, OH
4
Department of Family Medicine and Community Health, University Hospitals, Case Western Reserve University, Cleveland, OH
5
Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC
Abstract
Résumé
Objective: No standardization of quality of operative reporting currently exists, and this represents a missed opportunity for communication among health care providers. This study proposed a method to improve operative notes by structuring the findings by six anatomical zones of the pelvis. Objective I was to validate the method of documenting six zones of the pelvis by using intraoperative photography. Objective II was to compare this method with dictations from operative reports created before introducing this method.
Objectif : À l’heure actuelle, il n’existe aucune norme de qualité pour la production de rapports opératoires; pour les fournisseurs de soins de santé, cela constitue une occasion manquée de communiquer efficacement. La présente étude suggère une façon d’améliorer les notes opératoires en organisant les données selon six zones anatomiques prédéterminées dans le pelvis. Le premier objectif était de valider la consignation des données des six zones du pelvis à l’aide de photographies prises durant l’intervention. Le deuxième objectif était de comparer les rapports ainsi produits à des rapports dictés avant la détermination des six zones.
Methods: This retrospective cohort study evaluated pre- and postintervention results of using six zones to guide operative reporting. Reports were collected from participating surgeons and were scored using a validated scoring tool. Each participant was taught to photograph six zones and use the zones in the operative report. Pre- and post-intervention cases were compared using generalized linear mixed models. Results: Scores of study participants using the zones were significantly higher than those without (P < 0.0001). Surgeons showed an ability to improve their reporting. The detail illustrated in the cases was qualitatively richer, and the anatomy within the six zones was referenced more frequently. Conclusion: Compared with reports without the technique, incorporating the six zones greatly enhances operative reporting and likely would improve communication among care providers. More reliable communication of intraoperative findings has the potential to enhance the value of laparoscopy greatly as a diagnostic tool across gynaecological subspecialties. Key Words: Operative reporting, dictations, gynaecological surgery, laparoscopy, surgeon communication Corresponding Author: Dr. Rachel Pope, One Baylor Plaza, Houston, TX 77030. [email protected] Competing interests: See Acknowledgements. This paper was presented at the XXI FIGO World Congress of Gynecology and Obstetrics, Vancouver, British Columbia, October 9, 2015; and at the Cleveland Society of Obstetricians and Gynecologists, Cleveland, OH, May 20, 2015. Received on March 19, 2017 Accepted on July 31, 2017
Méthodologie : Cette étude de cohorte rétrospective a évalué les rapports produits avant et après la mise en place de la méthode des six zones. Les rapports ont été recueillis auprès de chirurgiens participants, et ont été notés au moyen d’un outil de notation validé. Les participants ont appris à photographier les six zones et à se servir de celles-ci pour produire leurs rapports opératoires. La comparaison des résultats obtenus avant et après la mise en place de la méthode des six zones a été faite au moyen de modèles linéaires mixtes généralisés. Résultats : Les notes obtenues par les participants s’étant servis des six zones étaient significativement plus élevées que celles des autres participants (P < 0,0001). Les chirurgiens ont réussi à améliorer la qualité de leurs rapports : les renseignements qu’ils contenaient étaient qualitativement plus riches, et les structures anatomiques à l’intérieur des six zones y étaient plus souvent mentionnées. Conclusion : Le recours aux six zones améliore grandement les rapports opératoires et améliorerait fort probablement l’efficacité des communications entre les fournisseurs de soins. Une meilleure communication des données peropératoires a le potentiel d’améliorer considérablement la valeur de la laparoscopie comme outil diagnostic dans les sous-spécialités de la gynécologie. Copyright © 2017 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.
J Obstet Gynaecol Can 2017;■■(■■):■■–■■ https://doi.org/10.1016/j.jogc.2017.07.023
■■ JOGC ■■ 2017 • 1
GYNAECOLOGY
INTRODUCTION
Figure. Six zones of the pelvis.
L
aparoscopic pelvic anatomical assessment and reporting of intraoperative findings are often performed in a non-standardized fashion and at the surgeon’s discretion. Although some surgeons are attentive to detail and make every effort to communicate their findings, omissions of surgical results represent critical missed opportunities to communicate important diagnostic information that could improve patient care, assist with medical-legal discrepancies, and aid in medical billing. In general surgery, deficiency in operative reporting has been identified as a weakness, especially in training post-graduates.1–3 In a review of operative reports in the surgical literature, only 46% of information considered important was included, and superfluous information was identified 97% of the time.4 For many in both the surgical and gynaecological fields, when reviewing patient records, this issue is a daily frustration.
Our group proposed a novel method for systematic pelvic assessment on the basis of six anatomical landmark zones that has the potential to enhance intraoperative diagnostic accuracy and provide better communication of operative findings among care providers.5 The pelvis is divided into two midline zones (zone I and II) and four lateral zones (right and left zones III and IV). More reliable communication of intraoperative findings has the potential to enhance the value of laparoscopy greatly as a diagnostic tool across gynaecological subspecialties. The six zones would serve as a guide for reporting operative findings. To determine the potential usefulness of this technique, we sought to validate these findings in an academic gynaecological practice. We hypothesized that operative reports using the six zones would result in more comprehensive communication of relevant anatomical findings identified at surgery, defined as higher scores on the Structure Assessment Format for Evaluating Operative Reports (SAFE-OR), a validated surgical report scoring tool.1 The SAFE-OR includes two major components: the structured assessment and the global score. The structured assessment includes descriptions of the actual operative findings. We expanded this to include the six zones specifically used in our study. The global score is a subjective evaluation of the coherence, reproducibility, and overall quality of the dictated operative report. Scores are determined on the basis of a percentage of what was dictated compared would what a thorough report should dictate. Therefore, a score of 100% in both the structured and global sections would mean that not only are all of the objective descriptions fulfilled, but also the report subjectively reads well and makes sense to the reader. METHODS
Gynaecological surgeons at University Hospitals Case Medical Center in Cleveland, OH were invited to participate on the
2 • ■■ JOGC ■■ 2017
basis of the following inclusion criteria: (1) the surgeon must be a fellow or attending surgeon; (2) the surgeon must regularly perform laparoscopic surgical procedures; and (3) the surgeon would be willing to dictate the cases himself or herself. Exclusion criteria were as follows: any non–attendinglevel surgeon and any individual already familiar with SAFEOR. Participants were instructed on dictation using the six zones and were asked to incorporate their surgical findings in a structured manner according to the six anatomical landmark zones of the pelvis, described by Bedaiwy et al.5 and illustrated in the Figure. The zones include (1) the anterior uterus and bladder, (2) the posterior uterus and culde-sac, (3) the left adnexa, (4) the right adnexa, (5) the left pelvic sidewall and (6) the right pelvic sidewall (see Figure). Participants were also asked to obtain six photographs at the beginning of each laparoscopic or robotic procedure corresponding to the six anatomical landmark zones of the pelvis. Cases were collected from the participating surgeons, de-identified, and independently scored by three judges, who also were all gynaecological surgeons, using the SAFE-OR.1 The photographs were printed and submitted to the study coordinator by depositing them into a locked box kept in each operating room. The photographs were then de-identified, given a study number, and used by the judges to verify the anatomy witnessed during the case. Therefore, if the posterior cul-de-sac truly showed no pathological features, for example, a normal-appearing sigmoid colon and no free fluid according to the operative report, the photograph of zone II would validate that. Surgeon participants were naïve to the SAFE-OR as a measuring tool. A priori, the investigators defined a high-quality operative report as scoring ≥80% on the SAFE-OR. We hypothesized that at least 60% of the dictated cases using the six zones technique would have this level of detail. Post hoc
Standardization of Laparoscopic Operative Reporting: Improving Gynaecological Surgeon Communication
power analysis was greater than 0.90 given our sample size, assuming a correlation of 0.25 between fixed effects, and an alpha level of 0.05. Therefore, the study was adequately powered. Pre-analysis of our data was assessed for normality of all continuous variables using quantile-quantile plots and frequency distributions. The comparison of scores of pre- and post-intervention reports was carried out using generalized linear mixed models with fixed and random effects. The fixed effect was whether the scores were pre- or post-intervention, and the random effects were the surgeon, the surgery type, and the interaction between the two. Convergence was met using the Restricted Maximum Likelihood (REML) method, and the best overall model for comparing usage of the covariates was decided by the Akaike information criteria (AIC) using a significance level of .05. All statistical analyses were performed using Stata software version 14.1 (StataCorp College Station, TX). All significance tests were 2-tailed, and those with a P value less than 0.05 were considered statistically significant. This study was approved by the Institutional Review Board of University Hospitals Case Medical Center, protocol number 02-13-44. RESULTS
Fifteen surgeons participated in the study, including three gynaecology oncologists, five reproductive endocrinologists, and seven general obstetrician/gynaecologists. Sixtynine pre-intervention cases were collected and matched to surgeon and surgery of 80 post-intervention cases. Although 100 cases were submitted for the post-intervention analysis, 20 cases were excluded from the final analysis for the following reasons: five cases were dictated by a resident and not the participating surgeon, and 15 cases did not incorporate all six zones in the photographs or were not visually clear enough to allow objective judging. Surgery types were grouped into the following categories: minor laparoscopy (n = 26; diagnostic cases, excision of small endometrial implants, lysis of adhesions, fimbrioplasty), bilateral or unilateral oophorectomy (n = 20), total laparoscopic hysterectomy (n = 32), and myomectomy (n = 2). Average scores were grouped on the basis of these categories. All three judges found >60% of the reports using the six zones as having an acceptable level of detail; (judge 1 found 61.2%, judge 2 found 90%, and judge 3 found 79%). Not using the six zones, few surgeons scored above 80% in the structured assessment. None of the judges found >60% of the pre-intervention reports as having an acceptable level of detail. Specifically, the three judges found 10%, 29%, and
Table 1. Bivariate analysis of scoring components for all participantsa Scoring system
Mean score (95% CI) Pre-intervention Post-intervention
Structured score
71.1 (69.4–72.8)
86.5 (84.9–88.2)
Operative finding
48.8 (45.7–51.9)
79.2 (75.9–82.5)
Global score
83.7 (82.1–85.2)
91.8 (90.7–93.0)
a
Using two sample unpaired t tests with 95% level of confidence (CI) with unequal variance.
12%, respectively, of the pre-intervention cases each as scoring >80%. The global scores were similarly low. In the pre-intervention group, items such as surgical team and method of entry were often included in detail, whereas the actual anatomical findings were noted in less detail. In addition, pertinent negative findings were mentioned more frequently in the post-intervention group. The scores of participating surgeons are summarized in Table 1 and identify performance both before and after the implementation of the structured operative reporting method using the six zones. The scores for the post-intervention cases were statistically significantly higher than the scores for the pre-intervention cases by all three judges in all categories of structured assessment, operative findings, and global score at a P value of <0.0001. Participants’ scores increased in all areas when using the six zones. The outcome with the largest score increase after the intervention was in the operative findings section of the structured assessment, which included the six zones. In comparing the scores of post-intervention reports matched to pre-intervention reports and surgery type, it was found that surgeons improved their scores in all three categories when using the six zones technique. Post-intervention scores were statistically higher than pre-intervention reports for all types of surgery (Table 2). Structured assessment scores increased on average by 20.25 points, operative finding scores increased on average by 39.1 points, and global scores increased on average by 10.75 points. Minor laparoscopic procedures (diagnostic cases, excision of small endometrial implants, lysis of adhesions, fimbrioplasty) resulted in the highest operative scores, with a high margin of improvement compared with pre-intervention scores. Although there was no obvious trend on the basis of surgeons’ experience, subspecialists such as oncologists and reproductive endocrinologists were more likely to give greater detail to anatomy, especially in describing pertinent negative findings. The results of the generalized linear mixed model are seen in Table 3. For the overall model we can see that the preintervention group had a score of 71.9, 48.7, and 84.8 for
■■ JOGC ■■ 2017 • 3
GYNAECOLOGY
the structure score, operative findings, and global score, respectively. Post-intervention scores were approximately 16, 30, and 8 points higher than pre-intervention scores in the structured score, operative findings, and global scores, respectively, controlling for all other variables. All results were statistically significant. Of note, in the overall models for the various scoring components, the surgeon, type of surgery, and their cross-effect also had impacts on the overall linear mixed model, resulting a lower pre- and post-intervention difference. Generalized linear mixed modeling results for each judge can also be seen in Table 3.
Table 2. Mean scores on the basis of surgery typea Surgery type
Mean score (95% CI) Pre-intervention Post-intervention
Laparoscopy minors (n = 26) Structured
70.7 (67.5–73.9)
89.8 (87.6–91.9)
Operative
51.4 (45.0–57.8)
90.1 (86.2–94.1)
Global
82.0 (79.7–84.3)
92.8 (91.1–94.5)
Structured
73.1 (69.3–76.9)
87.7 (84.8–90.6)
Operative
47.6 (41.2–54.1)
79.0 (72.6–85.3)
Global
88.1 (84.9–91.4)
94.0 (92.3–95.7)
Salpingooophorectomy (n = 20)
DISCUSSION
Hysterectomy (n = 32) Structured
70.9 (68.6–73.2)
82.8 (79.7–85.9)
Operative
48.3 (44.5–52.0)
70.0 (64.0–76.0)
Global
82.8 (80.1–85.5)
89.4 (87.3–91.5)
Myomectomy (n = 2) Structured
57.7 (45.1–70.3)
93.1 (86.2–99.9)
Operative
22.2 (−1.6 to 46.0)
86.8 (68.4–105.2)
77.0 (68.5–85.5)
96.7 (90.3–103.1)
Global a
Using two sample unpaired t tests with 95% level of confidence with unequal variance.
This study validates a method of standardizing dictation of laparoscopic operative findings by objectively demonstrating an increase in the clarity and quality of the content in the dictation of relevant anatomical findings identified at laparoscopic surgery. The photographs validate the use of the six zones when using the SAFE-OR to score the quality of operative report. Compared with previous reports by the same surgeons, the reported data are richer and include more pertinent negative findings when incorporating the six pelvic zones. The scores for reports in which the six zones technique was not used were much lower than their matched pre-intervention cases because they failed to provide optimal detail in the structured
Table 3. Analysis of generalized linear mixed model with fixed and randoma effects for the structured score, operative findings, and global score Structure score β (95% CI)
P Value
Operative findings β (95% CI)
P Value
Intercept
67.2 (63.6–70.7)
<0.001
41.7 (32.5–50.9)
<0.001
80.6 (76.9–84.2)
<0.001
Post (vs. Pre)
15.9 (11.9–19.9)
<0.001
27.3 (19.7–34.9)
<0.001
13.7 (10.4–17.0)
<0.001
Parameter
Global score β (95% CI)
P Value
Judge 1
Random effects
b
b
0.2196
0.2286
b
0.0226
Judge 2 Intercept
70.9 (67.4–74.4)
<0.001
45.4 (36.1–54.7)
<0.001
Post (vs. Pre)
14.8 (11.0–18.7)
<0.001
33.3 (26.1–40.5)
<0.001
Random effects
b
b
0.7073
0.1692
86.2 (83.5–89.0) 1.95 (−0.77 to 4.7) b
<0.001 <0.001 0.5029
Judge 3 Intercept
76.7 (74.0–79.4)
<0.001
59.0 (52.1–65.8)
<0.001
86.7 (84.7–88.6)
<0.001
Post (vs. Pre)
15.6 (12.5–18.8)
<0.001
31.0 (24.2–37.7)
<0.001
9.2 (7.1–11.4)
<0.001
Random effects
b
b
0.1473
0.4669
b
0.0176
Overall model Intercept
71.9 (69.7–74.1)
<0.001
48.7 (41.6–55.8)
<0.001
84.8 (82.4–87.3)
<0.001
Post (vs. Pre)
15.5 (13.3–17.7)
<0.001
30.4 (26.1–34.8)
<0.001
8.3 (6.6–10.0)
<0.001
b
<0.001
Random effects
b
a
Random effects are surgeon, surgery type, and interaction between the two. Constant and β-coefficient of random effects not included in table, given the number of iterations.
b
4 • ■■ JOGC ■■ 2017
<0.001
b
<0.001
Standardization of Laparoscopic Operative Reporting: Improving Gynaecological Surgeon Communication
assessment and failed to produce coherent and easily understood descriptions on the basis of the global score. The findings of the generalized linear mixed model demonstrate that although surgeons are able to learn a new technique, their personal styles always play a role. However, standardization improves detail to operative reports because the average surgeon does not include basic anatomical information that can easily be included with the aid of a systematic evaluation, as has been noted in other surgical fields.2 This represents a missed opportunity for effective communication of patient information. Therefore, the six zones technique not only demonstrates statistical significant difference compared with a non-standardized technique, but also suggests the potential for clinical significance. The understanding of a surgical procedure and a patient’s anatomy is clearer and more thorough when using the six zones technique, and therefore, future clinical and surgical planning could be positively influenced. For example, in a patient with pelvic pain who has undergone a diagnostic laparoscopy at an outside hospital, a standardized operative report using the six zones technique will note the extent and location of endometrial implants or the absence of lesions. Our findings are similar to those in the literature and point to the need to include a high standard of operative reporting when training gynaecologists. The need for residents’ training in operative reporting and the potential for improvement through training have been demonstrated in general surgery.2,3,6 Although there are clear benefits of improving operative reports, there are also challenges in implementing a change of habit. For example, Gillman et al.2 noted that junior residents improved with the introduction of a dictation template, whereas senior residents did not. Therefore, training in a new standardized technique should begin early in one’s surgical career. The simplicity of our intervention may enhance adoption of the technique. In general surgery, implementation of structured operative reporting also demonstrated improved quality in a variety of procedures studied.2,7,8 One study involving obstetric and gynaecological surgeons noted increased comprehensiveness of operative documentation and found that including particular information could improve thoroughness for medical-legal and billing purposes.9 The strengths of this study are that it was appropriately powered, and although it was retrospective, it matched surgeon and surgery types for the pre- and post-intervention arms in an effort to reduce confounding. A major weakness of this study is that we could not ask surgeons to take photographs during pre-intervention cases because of the
retrospective nature of the investigation and in an effort to avoid introducing the concept of six the zones or systematic laparoscopic photography. We also noted difficulty in identifying controls because of many of the reports were dictated by residents and not by participating surgeons. This finding, however, demonstrates that future implementation of structured evaluation should be directed towards residents, especially when teaching quality operative reporting. CONCLUSION
Using the six zones technique, operative documentation and photographic documentation can be standardized. Photographing the six zones greatly adds to the reported information because photographs can be easily incorporated into electronic medical records, and more detailed reporting can be used to enhance medical billing. This simple technique does not add greatly to cost or time to the surgeon but can greatly add to patient care. ACKNOWLEDGEMENTS
The authors report no conflict of interest. No financial support was given to this study. The authors acknowledge Jarrod Harding for components of the statistical analysis. REFERENCES 1. Vergis A, Gillman L, Minor S, et al. Structured assessment format for evaluating operative reports in general surgery. Am J Surg 2008;195:24–9. 2. Gillman L, Vergis A, Park J, et al. Structured operative reporting: a randomized trial using dictation templates to improve operative reporting. Am J Surg 2010;199:846–50. 3. Dumitra S, Wong S, Meterissian S, et al. The operative dictation: a review of how this skill is taught and assessed in surgical residency programs. J Surg Educ 2015;72:321–9. 4. Edhemovic I, Temple WJ, de Gara CJ, et al. The computer synoptic operative report—a leap forward in the science of surgery. Ann Surg Oncol 2004;11:941–7. 5. Bedaiwy M, Pope R, Henry D, et al. Standardization of laparoscopic pelvic examination: a proposal of a novel system. Minim Invasive Surg 2013;2013:153235. 6. Gillman L, Vergis A, Hardy K, et al. Resident training and the dictated operative report: a national perspective. Can J Surg 2010;53:246–50. 7. Chambers A, Pasieka J, Temple W. Improvement in the accuracy of reporting key prognostic and anatomic findings during thyroidectomy by using a novel Web-based synoptic operative reporting system. Surgery 2009;146:1090–8. 8. Harvey A, Zhang H, Nixon J, et al. Comparison of data extraction from standardized versus traditional narrative operative reports for databaserelated research and quality control. Surgery 2007;141:6. 9. Laflamme M, Dexter P, Graham M, et al. Efficiency, comprehensiveness and cost-effectiveness when comparing dictation and electronic templates for operative reports. AMIA Annu Symp Proc 2005;425–9.
■■ JOGC ■■ 2017 • 5
Standardization of Laparoscopic Operative Reporting: Improving Gynaecological Surgeon Communication Rachel J. Pope, MD, MPH;1 Ahmed Y. Abdelbadee, MBBCh, MS;2,3 Amy J. Armstrong, MD;3 Prakash R. Ganesh, MD, MPH;4 Mohamed A. Bedaiwy, MD, PhD;5 Kristine M. Zanotti, MD3 1
Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX
2
Department of Obstetrics and Gynecology, Women’s Health Hospital, Assiut University, Egypt
3
Department of Obstetrics and Gynecology, University Hospitals, Case Western Reserve University, Cleveland, OH
4
Department of Family Medicine and Community Health, University Hospitals, Case Western Reserve University, Cleveland, OH
5
Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC
Abstract
Résumé
Objective: No standardization of quality of operative reporting currently exists, and this represents a missed opportunity for communication among health care providers. This study proposed a method to improve operative notes by structuring the findings by six anatomical zones of the pelvis. Objective I was to validate the method of documenting six zones of the pelvis by using intraoperative photography. Objective II was to compare this method with dictations from operative reports created before introducing this method.
Objectif : À l’heure actuelle, il n’existe aucune norme de qualité pour la production de rapports opératoires; pour les fournisseurs de soins de santé, cela constitue une occasion manquée de communiquer efficacement. La présente étude suggère une façon d’améliorer les notes opératoires en organisant les données selon six zones anatomiques prédéterminées dans le pelvis. Le premier objectif était de valider la consignation des données des six zones du pelvis à l’aide de photographies prises durant l’intervention. Le deuxième objectif était de comparer les rapports ainsi produits à des rapports dictés avant la détermination des six zones.
Methods: This retrospective cohort study evaluated pre- and postintervention results of using six zones to guide operative reporting. Reports were collected from participating surgeons and were scored using a validated scoring tool. Each participant was taught to photograph six zones and use the zones in the operative report. Pre- and post-intervention cases were compared using generalized linear mixed models. Results: Scores of study participants using the zones were significantly higher than those without (P < 0.0001). Surgeons showed an ability to improve their reporting. The detail illustrated in the cases was qualitatively richer, and the anatomy within the six zones was referenced more frequently. Conclusion: Compared with reports without the technique, incorporating the six zones greatly enhances operative reporting and likely would improve communication among care providers. More reliable communication of intraoperative findings has the potential to enhance the value of laparoscopy greatly as a diagnostic tool across gynaecological subspecialties. Key Words: Operative reporting, dictations, gynaecological surgery, laparoscopy, surgeon communication Corresponding Author: Dr. Rachel Pope, One Baylor Plaza, Houston, TX 77030. [email protected] Competing interests: See Acknowledgements. This paper was presented at the XXI FIGO World Congress of Gynecology and Obstetrics, Vancouver, British Columbia, October 9, 2015; and at the Cleveland Society of Obstetricians and Gynecologists, Cleveland, OH, May 20, 2015. Received on March 19, 2017 Accepted on July 31, 2017
Méthodologie : Cette étude de cohorte rétrospective a évalué les rapports produits avant et après la mise en place de la méthode des six zones. Les rapports ont été recueillis auprès de chirurgiens participants, et ont été notés au moyen d’un outil de notation validé. Les participants ont appris à photographier les six zones et à se servir de celles-ci pour produire leurs rapports opératoires. La comparaison des résultats obtenus avant et après la mise en place de la méthode des six zones a été faite au moyen de modèles linéaires mixtes généralisés. Résultats : Les notes obtenues par les participants s’étant servis des six zones étaient significativement plus élevées que celles des autres participants (P < 0,0001). Les chirurgiens ont réussi à améliorer la qualité de leurs rapports : les renseignements qu’ils contenaient étaient qualitativement plus riches, et les structures anatomiques à l’intérieur des six zones y étaient plus souvent mentionnées. Conclusion : Le recours aux six zones améliore grandement les rapports opératoires et améliorerait fort probablement l’efficacité des communications entre les fournisseurs de soins. Une meilleure communication des données peropératoires a le potentiel d’améliorer considérablement la valeur de la laparoscopie comme outil diagnostic dans les sous-spécialités de la gynécologie. Copyright © 2017 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.
J Obstet Gynaecol Can 2017;■■(■■):■■–■■ https://doi.org/10.1016/j.jogc.2017.07.023
■■ JOGC ■■ 2017 • 1
GYNAECOLOGY
INTRODUCTION
Figure. Six zones of the pelvis.
L
aparoscopic pelvic anatomical assessment and reporting of intraoperative findings are often performed in a non-standardized fashion and at the surgeon’s discretion. Although some surgeons are attentive to detail and make every effort to communicate their findings, omissions of surgical results represent critical missed opportunities to communicate important diagnostic information that could improve patient care, assist with medical-legal discrepancies, and aid in medical billing. In general surgery, deficiency in operative reporting has been identified as a weakness, especially in training post-graduates.1–3 In a review of operative reports in the surgical literature, only 46% of information considered important was included, and superfluous information was identified 97% of the time.4 For many in both the surgical and gynaecological fields, when reviewing patient records, this issue is a daily frustration.
Our group proposed a novel method for systematic pelvic assessment on the basis of six anatomical landmark zones that has the potential to enhance intraoperative diagnostic accuracy and provide better communication of operative findings among care providers.5 The pelvis is divided into two midline zones (zone I and II) and four lateral zones (right and left zones III and IV). More reliable communication of intraoperative findings has the potential to enhance the value of laparoscopy greatly as a diagnostic tool across gynaecological subspecialties. The six zones would serve as a guide for reporting operative findings. To determine the potential usefulness of this technique, we sought to validate these findings in an academic gynaecological practice. We hypothesized that operative reports using the six zones would result in more comprehensive communication of relevant anatomical findings identified at surgery, defined as higher scores on the Structure Assessment Format for Evaluating Operative Reports (SAFE-OR), a validated surgical report scoring tool.1 The SAFE-OR includes two major components: the structured assessment and the global score. The structured assessment includes descriptions of the actual operative findings. We expanded this to include the six zones specifically used in our study. The global score is a subjective evaluation of the coherence, reproducibility, and overall quality of the dictated operative report. Scores are determined on the basis of a percentage of what was dictated compared would what a thorough report should dictate. Therefore, a score of 100% in both the structured and global sections would mean that not only are all of the objective descriptions fulfilled, but also the report subjectively reads well and makes sense to the reader. METHODS
Gynaecological surgeons at University Hospitals Case Medical Center in Cleveland, OH were invited to participate on the
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basis of the following inclusion criteria: (1) the surgeon must be a fellow or attending surgeon; (2) the surgeon must regularly perform laparoscopic surgical procedures; and (3) the surgeon would be willing to dictate the cases himself or herself. Exclusion criteria were as follows: any non–attendinglevel surgeon and any individual already familiar with SAFEOR. Participants were instructed on dictation using the six zones and were asked to incorporate their surgical findings in a structured manner according to the six anatomical landmark zones of the pelvis, described by Bedaiwy et al.5 and illustrated in the Figure. The zones include (1) the anterior uterus and bladder, (2) the posterior uterus and culde-sac, (3) the left adnexa, (4) the right adnexa, (5) the left pelvic sidewall and (6) the right pelvic sidewall (see Figure). Participants were also asked to obtain six photographs at the beginning of each laparoscopic or robotic procedure corresponding to the six anatomical landmark zones of the pelvis. Cases were collected from the participating surgeons, de-identified, and independently scored by three judges, who also were all gynaecological surgeons, using the SAFE-OR.1 The photographs were printed and submitted to the study coordinator by depositing them into a locked box kept in each operating room. The photographs were then de-identified, given a study number, and used by the judges to verify the anatomy witnessed during the case. Therefore, if the posterior cul-de-sac truly showed no pathological features, for example, a normal-appearing sigmoid colon and no free fluid according to the operative report, the photograph of zone II would validate that. Surgeon participants were naïve to the SAFE-OR as a measuring tool. A priori, the investigators defined a high-quality operative report as scoring ≥80% on the SAFE-OR. We hypothesized that at least 60% of the dictated cases using the six zones technique would have this level of detail. Post hoc
Standardization of Laparoscopic Operative Reporting: Improving Gynaecological Surgeon Communication
power analysis was greater than 0.90 given our sample size, assuming a correlation of 0.25 between fixed effects, and an alpha level of 0.05. Therefore, the study was adequately powered. Pre-analysis of our data was assessed for normality of all continuous variables using quantile-quantile plots and frequency distributions. The comparison of scores of pre- and post-intervention reports was carried out using generalized linear mixed models with fixed and random effects. The fixed effect was whether the scores were pre- or post-intervention, and the random effects were the surgeon, the surgery type, and the interaction between the two. Convergence was met using the Restricted Maximum Likelihood (REML) method, and the best overall model for comparing usage of the covariates was decided by the Akaike information criteria (AIC) using a significance level of .05. All statistical analyses were performed using Stata software version 14.1 (StataCorp College Station, TX). All significance tests were 2-tailed, and those with a P value less than 0.05 were considered statistically significant. This study was approved by the Institutional Review Board of University Hospitals Case Medical Center, protocol number 02-13-44. RESULTS
Fifteen surgeons participated in the study, including three gynaecology oncologists, five reproductive endocrinologists, and seven general obstetrician/gynaecologists. Sixtynine pre-intervention cases were collected and matched to surgeon and surgery of 80 post-intervention cases. Although 100 cases were submitted for the post-intervention analysis, 20 cases were excluded from the final analysis for the following reasons: five cases were dictated by a resident and not the participating surgeon, and 15 cases did not incorporate all six zones in the photographs or were not visually clear enough to allow objective judging. Surgery types were grouped into the following categories: minor laparoscopy (n = 26; diagnostic cases, excision of small endometrial implants, lysis of adhesions, fimbrioplasty), bilateral or unilateral oophorectomy (n = 20), total laparoscopic hysterectomy (n = 32), and myomectomy (n = 2). Average scores were grouped on the basis of these categories. All three judges found >60% of the reports using the six zones as having an acceptable level of detail; (judge 1 found 61.2%, judge 2 found 90%, and judge 3 found 79%). Not using the six zones, few surgeons scored above 80% in the structured assessment. None of the judges found >60% of the pre-intervention reports as having an acceptable level of detail. Specifically, the three judges found 10%, 29%, and
Table 1. Bivariate analysis of scoring components for all participantsa Scoring system
Mean score (95% CI) Pre-intervention Post-intervention
Structured score
71.1 (69.4–72.8)
86.5 (84.9–88.2)
Operative finding
48.8 (45.7–51.9)
79.2 (75.9–82.5)
Global score
83.7 (82.1–85.2)
91.8 (90.7–93.0)
a
Using two sample unpaired t tests with 95% level of confidence (CI) with unequal variance.
12%, respectively, of the pre-intervention cases each as scoring >80%. The global scores were similarly low. In the pre-intervention group, items such as surgical team and method of entry were often included in detail, whereas the actual anatomical findings were noted in less detail. In addition, pertinent negative findings were mentioned more frequently in the post-intervention group. The scores of participating surgeons are summarized in Table 1 and identify performance both before and after the implementation of the structured operative reporting method using the six zones. The scores for the post-intervention cases were statistically significantly higher than the scores for the pre-intervention cases by all three judges in all categories of structured assessment, operative findings, and global score at a P value of <0.0001. Participants’ scores increased in all areas when using the six zones. The outcome with the largest score increase after the intervention was in the operative findings section of the structured assessment, which included the six zones. In comparing the scores of post-intervention reports matched to pre-intervention reports and surgery type, it was found that surgeons improved their scores in all three categories when using the six zones technique. Post-intervention scores were statistically higher than pre-intervention reports for all types of surgery (Table 2). Structured assessment scores increased on average by 20.25 points, operative finding scores increased on average by 39.1 points, and global scores increased on average by 10.75 points. Minor laparoscopic procedures (diagnostic cases, excision of small endometrial implants, lysis of adhesions, fimbrioplasty) resulted in the highest operative scores, with a high margin of improvement compared with pre-intervention scores. Although there was no obvious trend on the basis of surgeons’ experience, subspecialists such as oncologists and reproductive endocrinologists were more likely to give greater detail to anatomy, especially in describing pertinent negative findings. The results of the generalized linear mixed model are seen in Table 3. For the overall model we can see that the preintervention group had a score of 71.9, 48.7, and 84.8 for
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GYNAECOLOGY
the structure score, operative findings, and global score, respectively. Post-intervention scores were approximately 16, 30, and 8 points higher than pre-intervention scores in the structured score, operative findings, and global scores, respectively, controlling for all other variables. All results were statistically significant. Of note, in the overall models for the various scoring components, the surgeon, type of surgery, and their cross-effect also had impacts on the overall linear mixed model, resulting a lower pre- and post-intervention difference. Generalized linear mixed modeling results for each judge can also be seen in Table 3.
Table 2. Mean scores on the basis of surgery typea Surgery type
Mean score (95% CI) Pre-intervention Post-intervention
Laparoscopy minors (n = 26) Structured
70.7 (67.5–73.9)
89.8 (87.6–91.9)
Operative
51.4 (45.0–57.8)
90.1 (86.2–94.1)
Global
82.0 (79.7–84.3)
92.8 (91.1–94.5)
Structured
73.1 (69.3–76.9)
87.7 (84.8–90.6)
Operative
47.6 (41.2–54.1)
79.0 (72.6–85.3)
Global
88.1 (84.9–91.4)
94.0 (92.3–95.7)
Salpingooophorectomy (n = 20)
DISCUSSION
Hysterectomy (n = 32) Structured
70.9 (68.6–73.2)
82.8 (79.7–85.9)
Operative
48.3 (44.5–52.0)
70.0 (64.0–76.0)
Global
82.8 (80.1–85.5)
89.4 (87.3–91.5)
Myomectomy (n = 2) Structured
57.7 (45.1–70.3)
93.1 (86.2–99.9)
Operative
22.2 (−1.6 to 46.0)
86.8 (68.4–105.2)
77.0 (68.5–85.5)
96.7 (90.3–103.1)
Global a
Using two sample unpaired t tests with 95% level of confidence with unequal variance.
This study validates a method of standardizing dictation of laparoscopic operative findings by objectively demonstrating an increase in the clarity and quality of the content in the dictation of relevant anatomical findings identified at laparoscopic surgery. The photographs validate the use of the six zones when using the SAFE-OR to score the quality of operative report. Compared with previous reports by the same surgeons, the reported data are richer and include more pertinent negative findings when incorporating the six pelvic zones. The scores for reports in which the six zones technique was not used were much lower than their matched pre-intervention cases because they failed to provide optimal detail in the structured
Table 3. Analysis of generalized linear mixed model with fixed and randoma effects for the structured score, operative findings, and global score Structure score β (95% CI)
P Value
Operative findings β (95% CI)
P Value
Intercept
67.2 (63.6–70.7)
<0.001
41.7 (32.5–50.9)
<0.001
80.6 (76.9–84.2)
<0.001
Post (vs. Pre)
15.9 (11.9–19.9)
<0.001
27.3 (19.7–34.9)
<0.001
13.7 (10.4–17.0)
<0.001
Parameter
Global score β (95% CI)
P Value
Judge 1
Random effects
b
b
0.2196
0.2286
b
0.0226
Judge 2 Intercept
70.9 (67.4–74.4)
<0.001
45.4 (36.1–54.7)
<0.001
Post (vs. Pre)
14.8 (11.0–18.7)
<0.001
33.3 (26.1–40.5)
<0.001
Random effects
b
b
0.7073
0.1692
86.2 (83.5–89.0) 1.95 (−0.77 to 4.7) b
<0.001 <0.001 0.5029
Judge 3 Intercept
76.7 (74.0–79.4)
<0.001
59.0 (52.1–65.8)
<0.001
86.7 (84.7–88.6)
<0.001
Post (vs. Pre)
15.6 (12.5–18.8)
<0.001
31.0 (24.2–37.7)
<0.001
9.2 (7.1–11.4)
<0.001
Random effects
b
b
0.1473
0.4669
b
0.0176
Overall model Intercept
71.9 (69.7–74.1)
<0.001
48.7 (41.6–55.8)
<0.001
84.8 (82.4–87.3)
<0.001
Post (vs. Pre)
15.5 (13.3–17.7)
<0.001
30.4 (26.1–34.8)
<0.001
8.3 (6.6–10.0)
<0.001
b
<0.001
Random effects
b
a
Random effects are surgeon, surgery type, and interaction between the two. Constant and β-coefficient of random effects not included in table, given the number of iterations.
b
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<0.001
b
<0.001
Standardization of Laparoscopic Operative Reporting: Improving Gynaecological Surgeon Communication
assessment and failed to produce coherent and easily understood descriptions on the basis of the global score. The findings of the generalized linear mixed model demonstrate that although surgeons are able to learn a new technique, their personal styles always play a role. However, standardization improves detail to operative reports because the average surgeon does not include basic anatomical information that can easily be included with the aid of a systematic evaluation, as has been noted in other surgical fields.2 This represents a missed opportunity for effective communication of patient information. Therefore, the six zones technique not only demonstrates statistical significant difference compared with a non-standardized technique, but also suggests the potential for clinical significance. The understanding of a surgical procedure and a patient’s anatomy is clearer and more thorough when using the six zones technique, and therefore, future clinical and surgical planning could be positively influenced. For example, in a patient with pelvic pain who has undergone a diagnostic laparoscopy at an outside hospital, a standardized operative report using the six zones technique will note the extent and location of endometrial implants or the absence of lesions. Our findings are similar to those in the literature and point to the need to include a high standard of operative reporting when training gynaecologists. The need for residents’ training in operative reporting and the potential for improvement through training have been demonstrated in general surgery.2,3,6 Although there are clear benefits of improving operative reports, there are also challenges in implementing a change of habit. For example, Gillman et al.2 noted that junior residents improved with the introduction of a dictation template, whereas senior residents did not. Therefore, training in a new standardized technique should begin early in one’s surgical career. The simplicity of our intervention may enhance adoption of the technique. In general surgery, implementation of structured operative reporting also demonstrated improved quality in a variety of procedures studied.2,7,8 One study involving obstetric and gynaecological surgeons noted increased comprehensiveness of operative documentation and found that including particular information could improve thoroughness for medical-legal and billing purposes.9 The strengths of this study are that it was appropriately powered, and although it was retrospective, it matched surgeon and surgery types for the pre- and post-intervention arms in an effort to reduce confounding. A major weakness of this study is that we could not ask surgeons to take photographs during pre-intervention cases because of the
retrospective nature of the investigation and in an effort to avoid introducing the concept of six the zones or systematic laparoscopic photography. We also noted difficulty in identifying controls because of many of the reports were dictated by residents and not by participating surgeons. This finding, however, demonstrates that future implementation of structured evaluation should be directed towards residents, especially when teaching quality operative reporting. CONCLUSION
Using the six zones technique, operative documentation and photographic documentation can be standardized. Photographing the six zones greatly adds to the reported information because photographs can be easily incorporated into electronic medical records, and more detailed reporting can be used to enhance medical billing. This simple technique does not add greatly to cost or time to the surgeon but can greatly add to patient care. ACKNOWLEDGEMENTS
The authors report no conflict of interest. No financial support was given to this study. The authors acknowledge Jarrod Harding for components of the statistical analysis. REFERENCES 1. Vergis A, Gillman L, Minor S, et al. Structured assessment format for evaluating operative reports in general surgery. Am J Surg 2008;195:24–9. 2. Gillman L, Vergis A, Park J, et al. Structured operative reporting: a randomized trial using dictation templates to improve operative reporting. Am J Surg 2010;199:846–50. 3. Dumitra S, Wong S, Meterissian S, et al. The operative dictation: a review of how this skill is taught and assessed in surgical residency programs. J Surg Educ 2015;72:321–9. 4. Edhemovic I, Temple WJ, de Gara CJ, et al. The computer synoptic operative report—a leap forward in the science of surgery. Ann Surg Oncol 2004;11:941–7. 5. Bedaiwy M, Pope R, Henry D, et al. Standardization of laparoscopic pelvic examination: a proposal of a novel system. Minim Invasive Surg 2013;2013:153235. 6. Gillman L, Vergis A, Hardy K, et al. Resident training and the dictated operative report: a national perspective. Can J Surg 2010;53:246–50. 7. Chambers A, Pasieka J, Temple W. Improvement in the accuracy of reporting key prognostic and anatomic findings during thyroidectomy by using a novel Web-based synoptic operative reporting system. Surgery 2009;146:1090–8. 8. Harvey A, Zhang H, Nixon J, et al. Comparison of data extraction from standardized versus traditional narrative operative reports for databaserelated research and quality control. Surgery 2007;141:6. 9. Laflamme M, Dexter P, Graham M, et al. Efficiency, comprehensiveness and cost-effectiveness when comparing dictation and electronic templates for operative reports. AMIA Annu Symp Proc 2005;425–9.
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