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Surgical audit system
334
British
Journal
of Oral
and Maxillofacial
Surgery
Although not directly comparable with the data considered so far, it is interesting to look at the incidence of carcinoma of the tongue in Scotland in men and women under the age of 50 for the period 1980-1992 (Fig. 1). This confirms the increasing incidence in both sexes, but the trend (Fig. 2) shows that the rise is much steeper in men than women. In contrast to England and Wales, the incidence of carcinoma of the alveolus in Scotland has changed little between the two periods. We wonder about the significance of the apparently large increase in alveolar carcinoma reported by Worrall.’ There are problems in the coding of alveolar carcinoma because there is a degree of overlap between the ICD9 codes 143 and 145. ICD9 143 codes for ‘malignant neoplasm of gum’ and includes alveolar ridge mucosa, upper gum, lower gum and gum, unspecified. ICD9 145 codes for ‘malignant neoplasm of other and unspecified parts of mouth’ including upper and lower buccal sulci, hard palate and retromolar area. This can make precise classification difficult. For example, what might be recorded as a lower alveolar ridge carcinoma (ICD9 143) by one clinician might be coded as a retromolar area tumour (ICD9 145) by another. This latitude in coding together with the relatively small number of alveolar carcinomas compared with the much larger number of unspecified carcinomas, means that these data should be interpreted with caution. Carcinoma of the floor of mouth has increased in both sexes in Scotland. Again the numbers are small but there appears to have been a striking increase in incidence in young males. The data from the Scottish Cancer Registry show some interesting changes in the incidence of oral cancer in No. PATIENTS I
T\Jl I%30
1981 1982 1983 -
1984 1986
MALES
+
Fig. 1 - Incidence of tongue Scotland 1980-1992.
1986 1967 1988 FEMALES
cancer
+
in patients
1989 1990
1991 1992
TOTAL
under
R. Mitchell ChM, FRCS Consultant Department of Maxillofacial City Hospital Edinburgh
Surgery
References 1. Worrall SF. Oral J Oral Maxillofac
cancer incidence between Surg 1995; 33: 195-196.
A MODIFIED MINIPLATE COMPLEX FRACTURES
1971 and 1989. Br
FOR USE IN MALAR
Sir, I was interested to read Mr Smyth’s paper published in the June edition of The British Journal of Oral and Maxillofacial Surgery.’ It shows some remarkable similarities to my own publication regarding such modifications to miniplates which was published in 1994,’ although I note the variations in the technique he describes. It is unclear from the text, and indeed from the photographs, whether the plate has been constructed by modifying a plate of a different variety or whether it has been cut to shape from a piece of titanium plate. In either case I would counsel against such modifications since the reproducibility and, therefore, consistency of the plate must be highly dubious. An almost identical modified mini-plate is available to the design I described and is manufactured in titanium by De Puy Ltd.* Although it is not currently listed in their standard catalogue it is available on request and not only facilitates the reduction of zygomatic fractures but is useful in the fixation of osteotomies and in reducing mandibular fractures under direct vision. C. M. Hill Consultant Department of Oral and Maxillofacial University Dental Hospital Cardiff
Surgery
References 1. Smyth AG. A modi6ed miniplate for use in malar complex fractures. Br J Oral Maxillofac Surg 1995; 33: 169-170. 2. Hill CM. A modification to miniplates to allow adjustment in position of the bone fragments. Br J Oral Maxillofac Surg 1994; 32: 52-53. *De Puy Healthcare, Millshaw House, Manor Mill Lane, Leeds, LSll SLQ.
No. PATIENTS
I li60
R. Crasher FDS, FRCS Registrar
50 years in
20
”
Scotland and some apparent differences between Scotland and England and Wales. We present the Scottish data without being able to explain either the changes or the differences.
SURGICAL
+ + +. + + + + + ( 1961 1962 1983 IS84 -
Fig. 2 -Tongue cancer trend 1980-1992.
1985 1936
MALES
in patients
+
1 I 1997 1988 1989
/ 1990
I 1 I 1991 1992
FEMALES
under
50 years in Scotland:
AUDIT
SYSTEM
Sir, Three years ago, with the support of the Faculty of Dental Surgery at the Royal College of Surgeons and funding provided from the Department of Health, two locally networked surgical audit systems were introduced to two major teaching hospitals-The Royal London Hospital and Leeds Dental Institute/General Infirmary.
Letters to the Editor The purpose of the exercise was to evaluate surgical audit system with respect to its:
the use of a
1. Acceptability by departmental staff. 2. Ability to act as a suitable tool for development of audit within the individual departments specifically and the Specialty in general. 3. Ability to capture the departmental inpatient workload accurately including both routine and acute admissions. It was never the intention of the British Association of Oral and Maxillofacial Surgeons to endorse the use of any particular commercially available software and we have not made any conscious effort to evaluate the system in comparison with other available software. Since initial installation of the networked systems in April 1991 both departments have increased the networking by adding strategically placed satellite terminals consistent with the individual working practices at each Unit. Currently each Unit has four terminals (including the central PC). At the Royal London these are sited on the dedicated ward, one in the registrars room and two within the secretarial complex. At the Leeds Dental Institute they are sited in the dedicated Day Stay Unit and within the secretarial offices. Following installation a staged educational programme was introduced, with the support of the software house, to ensure that the secretarial staff could both competently and confidently manage the programme. The system holds the waiting lists and is used to generate admission episodes and create operating lists. It also creates customised letters for each firm in each sphere of activity. It is envisaged, at the Royal London Hospital, that further developments of the system will include a PAS link which will hopefully overcome the problems associated with duplication of effort between the stand alone and the central PAS systems. One of the requirements of the system is that a patient following an admission episode can only be removed from the waiting list by completion of the inpatient diagnostic and treatment details. There is therefore a powerful incentive, quite apart from the audit aspect, to complete the patients treatment record. Running parallel to the secretarial tutorials were those aimed at those members of the clinical staff who would be ensuring that the clinical data was entered both accurately and at an appropriate time. The consultants, being the only permanent members of the professional staff, were the first target. All members of clinical staff within the department, from consultants to senior house officers, are now competent in the entering of data into the system and all take part in the exercise. In Leeds we have found that by distributing the task between all members of staff no patient remains unrecorded. As the data is used to support our contracts the end of month deadline ensures that no appreciable backlog develops and consequently the data available is always up to date. At the Leeds Dental Institute the clinical details are entered directly from the medical records and not via an intermediate card and this allows routine evaluation of the medical records for the presence of the required information. The regular reading of records by members of staff to extract the required information is in itself an excellent educational exercise and continual audit of the record keeping process. During the first year of operation all the clinical data was input by the consultant staff and by so doing a highly accurate database of patient activity was developed. At the Leeds Dental Institute this data was used not only to examine critically the throughput of the department but it was also made available to the Trust for the purpose of contract negotiations with the various local purchasing authorities.
335
The data supplied by the system was regarded by the Trust as the most accurate available and has subsequently been used to support internal debate regarding bed usage and bed requirement. The data is now entered by all the clinical staff members and random checks by senior staff indicate an extremely high degree of accuracy. We are able to supply accurate casemix data the system has been invaluable in the setting up of subdivisions of activity (bands) within the contract process and oral and maxillofacial surgery, in Leeds, piloted such a system, based on the systems database, in 1993/4 ahead of all other specialities. The banding system thus developed is being continued in 199415 but will probably undergo modification in response to the introduction of the Healthcare Resource Groupings. We have been fortunate to be involved in the development of the Healthcare Resource Groupings for our speciality and the previously identified bands developed through the audit system were used as the building blocks which were subjected to analysis against known national data at the National Casemix Office. At present contracts are supported by the data obtained via the Audit system and have been accepted as the most accurate source of data currently available. The ability to identify all inpatients has been tested against the current PAS within the Trust and it was the PAS that was found to be deficient! There is no doubt that as Information Technology develops the mainframe hospital system will subsume the role of the current PC based network system and to avoid duplication of effort we shall be expected and required to link with the central system. At the Royal London Hospital two practical problems have resulted in less than complete case recording. These are (i) the failure, to date, to complete the link with a somewhat idiosyncratic PAS system and (ii) a modem problem which has delayed the best use of the ‘slave’ link on Edward VII ward. These are currently in the process of upgrading. The original aim was to assess the usefulness of a surgical audit system within the speciality. We feel that the introduction of the system has allowed us to accurately record the in-patient activity, to audit that activity and to take an active part in the management processes involved in the local development of our speciality. With few exceptions the clinical menus within the system have allowed accurate recording of all clinical activity and in those areas where procedures have not been identifiable the customisation of the system allows inclusions to the menus consistent with working practice. The system has been accepted by both the secretarial and clinical staff alike and the system will continue to be used and developed in accordance with the local requirements of each of the involved Units. Finally we would suggest that all Units would benefit from the systematic collection of appropriate clinical data. Until such time as the Read Coding System is introduced such data should be referenced to the standard OPCS and ICD coding systems and this should allow comparative audit between units irrespective of the software used to collect the data. We are indebted to the Faculty of Dental Surgery at the Royal College of Surgeons of England and the British Association of Oral and Maxillofacial Surgeons for their support and the Department of Health for providing the grant for the provision of the equipment during the 3year period. A. M. Corvigan Department of Oral and Maxillofacial Surgery, Leeds Dental Institute, Leeds. S. L. B. Carter Department of Oral and Maxillofacial Surgery, The Royal London Hospital, London.
British
Journal
of Oral
and Maxillofacial
Surgery
Although not directly comparable with the data considered so far, it is interesting to look at the incidence of carcinoma of the tongue in Scotland in men and women under the age of 50 for the period 1980-1992 (Fig. 1). This confirms the increasing incidence in both sexes, but the trend (Fig. 2) shows that the rise is much steeper in men than women. In contrast to England and Wales, the incidence of carcinoma of the alveolus in Scotland has changed little between the two periods. We wonder about the significance of the apparently large increase in alveolar carcinoma reported by Worrall.’ There are problems in the coding of alveolar carcinoma because there is a degree of overlap between the ICD9 codes 143 and 145. ICD9 143 codes for ‘malignant neoplasm of gum’ and includes alveolar ridge mucosa, upper gum, lower gum and gum, unspecified. ICD9 145 codes for ‘malignant neoplasm of other and unspecified parts of mouth’ including upper and lower buccal sulci, hard palate and retromolar area. This can make precise classification difficult. For example, what might be recorded as a lower alveolar ridge carcinoma (ICD9 143) by one clinician might be coded as a retromolar area tumour (ICD9 145) by another. This latitude in coding together with the relatively small number of alveolar carcinomas compared with the much larger number of unspecified carcinomas, means that these data should be interpreted with caution. Carcinoma of the floor of mouth has increased in both sexes in Scotland. Again the numbers are small but there appears to have been a striking increase in incidence in young males. The data from the Scottish Cancer Registry show some interesting changes in the incidence of oral cancer in No. PATIENTS I
T\Jl I%30
1981 1982 1983 -
1984 1986
MALES
+
Fig. 1 - Incidence of tongue Scotland 1980-1992.
1986 1967 1988 FEMALES
cancer
+
in patients
1989 1990
1991 1992
TOTAL
under
R. Mitchell ChM, FRCS Consultant Department of Maxillofacial City Hospital Edinburgh
Surgery
References 1. Worrall SF. Oral J Oral Maxillofac
cancer incidence between Surg 1995; 33: 195-196.
A MODIFIED MINIPLATE COMPLEX FRACTURES
1971 and 1989. Br
FOR USE IN MALAR
Sir, I was interested to read Mr Smyth’s paper published in the June edition of The British Journal of Oral and Maxillofacial Surgery.’ It shows some remarkable similarities to my own publication regarding such modifications to miniplates which was published in 1994,’ although I note the variations in the technique he describes. It is unclear from the text, and indeed from the photographs, whether the plate has been constructed by modifying a plate of a different variety or whether it has been cut to shape from a piece of titanium plate. In either case I would counsel against such modifications since the reproducibility and, therefore, consistency of the plate must be highly dubious. An almost identical modified mini-plate is available to the design I described and is manufactured in titanium by De Puy Ltd.* Although it is not currently listed in their standard catalogue it is available on request and not only facilitates the reduction of zygomatic fractures but is useful in the fixation of osteotomies and in reducing mandibular fractures under direct vision. C. M. Hill Consultant Department of Oral and Maxillofacial University Dental Hospital Cardiff
Surgery
References 1. Smyth AG. A modi6ed miniplate for use in malar complex fractures. Br J Oral Maxillofac Surg 1995; 33: 169-170. 2. Hill CM. A modification to miniplates to allow adjustment in position of the bone fragments. Br J Oral Maxillofac Surg 1994; 32: 52-53. *De Puy Healthcare, Millshaw House, Manor Mill Lane, Leeds, LSll SLQ.
No. PATIENTS
I li60
R. Crasher FDS, FRCS Registrar
50 years in
20
”
Scotland and some apparent differences between Scotland and England and Wales. We present the Scottish data without being able to explain either the changes or the differences.
SURGICAL
+ + +. + + + + + ( 1961 1962 1983 IS84 -
Fig. 2 -Tongue cancer trend 1980-1992.
1985 1936
MALES
in patients
+
1 I 1997 1988 1989
/ 1990
I 1 I 1991 1992
FEMALES
under
50 years in Scotland:
AUDIT
SYSTEM
Sir, Three years ago, with the support of the Faculty of Dental Surgery at the Royal College of Surgeons and funding provided from the Department of Health, two locally networked surgical audit systems were introduced to two major teaching hospitals-The Royal London Hospital and Leeds Dental Institute/General Infirmary.
Letters to the Editor The purpose of the exercise was to evaluate surgical audit system with respect to its:
the use of a
1. Acceptability by departmental staff. 2. Ability to act as a suitable tool for development of audit within the individual departments specifically and the Specialty in general. 3. Ability to capture the departmental inpatient workload accurately including both routine and acute admissions. It was never the intention of the British Association of Oral and Maxillofacial Surgeons to endorse the use of any particular commercially available software and we have not made any conscious effort to evaluate the system in comparison with other available software. Since initial installation of the networked systems in April 1991 both departments have increased the networking by adding strategically placed satellite terminals consistent with the individual working practices at each Unit. Currently each Unit has four terminals (including the central PC). At the Royal London these are sited on the dedicated ward, one in the registrars room and two within the secretarial complex. At the Leeds Dental Institute they are sited in the dedicated Day Stay Unit and within the secretarial offices. Following installation a staged educational programme was introduced, with the support of the software house, to ensure that the secretarial staff could both competently and confidently manage the programme. The system holds the waiting lists and is used to generate admission episodes and create operating lists. It also creates customised letters for each firm in each sphere of activity. It is envisaged, at the Royal London Hospital, that further developments of the system will include a PAS link which will hopefully overcome the problems associated with duplication of effort between the stand alone and the central PAS systems. One of the requirements of the system is that a patient following an admission episode can only be removed from the waiting list by completion of the inpatient diagnostic and treatment details. There is therefore a powerful incentive, quite apart from the audit aspect, to complete the patients treatment record. Running parallel to the secretarial tutorials were those aimed at those members of the clinical staff who would be ensuring that the clinical data was entered both accurately and at an appropriate time. The consultants, being the only permanent members of the professional staff, were the first target. All members of clinical staff within the department, from consultants to senior house officers, are now competent in the entering of data into the system and all take part in the exercise. In Leeds we have found that by distributing the task between all members of staff no patient remains unrecorded. As the data is used to support our contracts the end of month deadline ensures that no appreciable backlog develops and consequently the data available is always up to date. At the Leeds Dental Institute the clinical details are entered directly from the medical records and not via an intermediate card and this allows routine evaluation of the medical records for the presence of the required information. The regular reading of records by members of staff to extract the required information is in itself an excellent educational exercise and continual audit of the record keeping process. During the first year of operation all the clinical data was input by the consultant staff and by so doing a highly accurate database of patient activity was developed. At the Leeds Dental Institute this data was used not only to examine critically the throughput of the department but it was also made available to the Trust for the purpose of contract negotiations with the various local purchasing authorities.
335
The data supplied by the system was regarded by the Trust as the most accurate available and has subsequently been used to support internal debate regarding bed usage and bed requirement. The data is now entered by all the clinical staff members and random checks by senior staff indicate an extremely high degree of accuracy. We are able to supply accurate casemix data the system has been invaluable in the setting up of subdivisions of activity (bands) within the contract process and oral and maxillofacial surgery, in Leeds, piloted such a system, based on the systems database, in 1993/4 ahead of all other specialities. The banding system thus developed is being continued in 199415 but will probably undergo modification in response to the introduction of the Healthcare Resource Groupings. We have been fortunate to be involved in the development of the Healthcare Resource Groupings for our speciality and the previously identified bands developed through the audit system were used as the building blocks which were subjected to analysis against known national data at the National Casemix Office. At present contracts are supported by the data obtained via the Audit system and have been accepted as the most accurate source of data currently available. The ability to identify all inpatients has been tested against the current PAS within the Trust and it was the PAS that was found to be deficient! There is no doubt that as Information Technology develops the mainframe hospital system will subsume the role of the current PC based network system and to avoid duplication of effort we shall be expected and required to link with the central system. At the Royal London Hospital two practical problems have resulted in less than complete case recording. These are (i) the failure, to date, to complete the link with a somewhat idiosyncratic PAS system and (ii) a modem problem which has delayed the best use of the ‘slave’ link on Edward VII ward. These are currently in the process of upgrading. The original aim was to assess the usefulness of a surgical audit system within the speciality. We feel that the introduction of the system has allowed us to accurately record the in-patient activity, to audit that activity and to take an active part in the management processes involved in the local development of our speciality. With few exceptions the clinical menus within the system have allowed accurate recording of all clinical activity and in those areas where procedures have not been identifiable the customisation of the system allows inclusions to the menus consistent with working practice. The system has been accepted by both the secretarial and clinical staff alike and the system will continue to be used and developed in accordance with the local requirements of each of the involved Units. Finally we would suggest that all Units would benefit from the systematic collection of appropriate clinical data. Until such time as the Read Coding System is introduced such data should be referenced to the standard OPCS and ICD coding systems and this should allow comparative audit between units irrespective of the software used to collect the data. We are indebted to the Faculty of Dental Surgery at the Royal College of Surgeons of England and the British Association of Oral and Maxillofacial Surgeons for their support and the Department of Health for providing the grant for the provision of the equipment during the 3year period. A. M. Corvigan Department of Oral and Maxillofacial Surgery, Leeds Dental Institute, Leeds. S. L. B. Carter Department of Oral and Maxillofacial Surgery, The Royal London Hospital, London.