Development and evaluation of an electronic hospital referral system: a human factors approach.

Coordinating care across hospitals has been identified as a patient safety risk as referrals are often paper-based and poorly documented. Electronic referral systems have the potential to improve the situation but can fail to gain uptake. We applied a human factors/ergonomics (HFE) approach to place analysis of local workflow and user engagement central to the development of a new regional electronic referral system. The intervention was evaluated with a before-and-after study. Referral quality improved, referrals containing sufficient clinical information for continuation of care increased from 36.9% to 83.5% and completeness of referral information significantly improved. There was a 35.7% reduction in the number of calls to the on-call specialist, and the mean period between admission and surgery for expedited transfers was reduced. Applying HFE informed design with use-based evidence; the system maintains sustained uptake three years after implementation. Reliable recording of information translates to better patient safety during inter-hospital transitions. Practitioners summary: This study developed, implemented and evaluated a clinical referral system using a human factors approach. Process analysis and usability studies were used to inform the application requirements and design. Region-wide implementation in hospitals resulted in the improved quality and completeness of clinical referral information and efficiencies in the referral process.

Cerebrospinal fluid leaks after transsphenoidal surgery - Effect of a polyethylene glycol hydrogel dural sealant.

To investigate cerebrospinal fluid (CSF) leak rates after mainly endoscopic endonasal transsphenoidal surgery with and without polyethylene glycol hydrogel dural sealant (DuraSeal®), we prospectively collected data from a single-centre consecutive case series over four years from January 2007 to December 2010 inclusive. 250 patients were identified (135 male, 115 female; median age 52years, range 14-83). 180 patients received DuraSeal® (72%). 85 (34%) had intra-operative dural breach and 13 (5.2%) developed post-operative CSF leaks (3 without intra-operative dural breach) requiring lumbar drainage or formal repair. Of this group 5/251 (2.0%) patients required a formal repair. Post-operative CSF leak was seen in 5/189 (2.7%) of patients with pituitary adenoma, of which 2/5 (40%) were in cases undergoing revision surgery. 5/13 (38.4%) patients who developed a CSF leak presented with either Rathke's cleft cyst or craniopharyngioma. 3/71 patients not receiving DuraSeal® leaked (4.2%) and 10/180 patients receiving DuraSeal® leaked (5.6%). 11/234 patients without Tisseel (4.7%) and 2/16 receiving Tisseel (12.5%) leaked. 54 patients (22%) received intra-operative lumbar drains, one of whom developed subsequent CSF leak (1.9%), in contrast to 12/197 (6.1%) of patients without intra-operative lumbar drains who later developed CSF leak. The rate of post-operative CSF leak requiring re-exploration and nasoseptal flap repair was low (2.0%) in this mainly endoscopic case series without statistically significant benefit from either DuraSeal® or Tisseel. Intra-operative and post-operative lumbar drainage appears beneficial in patients at higher risk of post-operative CSF leak.

Evaluation of a newly introduced tonsillectomy operation record for the analysis of regional post-tonsillectomy bleed data: a quality improvement project at the London North West Healthcare NHS Trust.

The primary objective of this audit and quality improvement project was to retrospectively analyse regional post-tonsillectomy haemorrhage data as per national recommendations. However, this process highlighted the need for high-quality routinely collected data; something that was not always available via retrospective audit and thus does not enable formal aetiological factor analyses. We therefore created further secondary objectives to facilitate our primary audit objective. These secondary objectives were (1) to introduce a standardised tonsillectomy operation proforma to improve completeness and quality of routinely collected data and (2) to evaluate and validate proforma use and usefulness in improving using routine data collection to help with a repeated audit of post-tonsillectomy haemorrhages with the eventual aim to help improve operative outcomes by identifying potential associated factors. The retrospective audit component, the prospective audit and the quality improvement component were all carried out at the Northwick Park Hospital and Central Middlesex Hospital (London North West Healthcare NHS Trust). First, 642 tonsillectomy records (2012-2014) were retrospectively reviewed. Free-text operative documentation and, where possible, potential factors associated with post-tonsillectomy haemorrhages were analysed. In addition, completeness of data available before and after the introduction of (A) a new paper-based and (B) electronic surgical record proforma was reviewed (2014-2015). Over a 2-year period, 62 of the 642 (9.7%) audited tonsillectomy patients had a post-tonsillectomy haemorrhage, and 19 of these (2.9%) had to return to theatre for surgical arrest of the haemorrhage. Bipolar diathermy was the most commonly used technique. During this period, data available from routine operative documentation in the surgical operation notes were variable and thus did not allow identification of potential factors associated with post-tonsillectomy haemorrhage. The completeness and quality of data significantly improved after the introduction of a standardised paper-based proforma with sections for required details based on known risk factors for post-tonsillectomy haemorrhage and required operative details. Quality and completeness of data was further improved after the introduction of an electronic version. This electronic proforma will allow prospective spiral auditing results, early identification of raised bleeding rate, and provide individual surgeon audit results.

Secreting Follicle-Stimulating Hormone Pituitary Carcinoma with Cervical Metastasis.

BACKGROUND: Pituitary carcinoma is defined by either metastases outside the central nervous system or noncontiguous foci within the central nervous system. This case report details the first documented case of a pathologically isolated follicle-stimulating hormone-secreting pituitary carcinoma and its presentation of metastasis. CASE DESCRIPTION: A 63-year-old man developed intrascapular pain radiating up his neck to his occiput. He had undergone a transsphenoidal hypophysectomy 2 years previously for an atypical pituitary macroadenoma. Subsequent magnetic resonance imaging identified a focal, solitary, well-circumscribed, homogeneous T2 high-signal intradural, extramedullary enhancing mass at C2-3 in a right ventral parasagittal location, extending toward the exit foramina. On surgical excision with a laminectomy, the mass demonstrated a morphologic appearance of a malignant neuroendocrine tumor with an immunoprofile similar to the original atypical pituitary adenoma. This was in keeping with metastatic disease secondary to a follicle-stimulating hormone-secreting pituitary carcinoma. CONCLUSIONS: Although rare, metastatic spread is recognized in patients with atypical pituitary adenoma. This should form the differential diagnosis for such patients presenting with symptoms that could be attributed to metastatic lesions within the neuraxis. In these patients, who undergo regular surveillance in joint neuroendocrine clinics, more urgent investigation of new spinal pain should be instigated to exclude metastatic disease.