Orthopaedic surgical documentation: pre-templated operation notes significantly improve documentation of surgical procedures.

OBJECTIVES: The Royal College of Surgeons of England (RCS) Good Surgical Practice guidance identifies essential criteria for surgical operation note documentation. The current quality improvement project aims to identify if using pre-templated operation notes for documenting fractured neck of femur surgery results in improved documentation when compared to freehand orthopaedic operation notes. METHODS: A total of fourteen categories were identified from the RCS guidance as required across all the operations identified in this study. All operations for the month of October 2021 were identified and the operation notes analysed. Pre-templated operation notes were compared to freehand operation notes. RESULTS: Ninety-seven cases were identified, of which 74 were freehand operation notes and 23 were pre-templated fractured neck of femur operation notes. All fourteen categories were completed in 13 (57%) of the templated operation notes versus 0 (0%) in the freehand operation notes (odds ratio 0.0052, 95% CI 0.0003 to 0.0945, p < 0.001). The median total number of completed categories was significantly higher in the templated op-note group compared to the freehand op-note group (templated median 14, range 12-14, vs. freehand median 11, range 9 to 13, p < 0.001). Logistic regression analysis of operation notes written by consultants or trainees identified trainees as more likely to document the antibiotic prophylaxis given (p = 0.025). CONCLUSIONS: Use of pre-templated operation notes results in significantly improved documentation. Adoption of generic pre-templated operation notes to improve surgical documentation should be considered across all operations.

The Activitrax rate responsive pacemaker system.

Bipolar Medtronic Activitrax rate responsive pacemakers were implanted in 31 patients for ventricular (28) or atrial (3) pacing. Mean follow-up was 16 months (range 10 to 26). Twenty pacemakers were implanted after catheter ablation of the His bundle, 7 for sick sinus syndrome. 1 for atrioventricular block and 3 for sick sinus syndrome with atrioventricular block. A rate response value was selected that gave a pacing rate of about 100 pulses/min during walking. Of the 31 patients, all had 24-hour ambulatory electrocardiographic monitoring with diary, 11 walked a 20-minute circuit, including a flight of stairs, and 20 had a treadmill exercise test. In 9 patients the pacing rate could be compared with the underlying sinus rate during exercise and was seen to match it very closely. In 12 patients the pacing rate during car driving was found to be similar to the sinus rate of 5 volunteers under similar conditions (mean minimum and maximum rate was 80 and 99 pulses/min, respectively). No pacing-induced arrhythmias were seen during ambulatory electrocardiographic monitoring. At high pacing rates slightly irregular pacing intervals were sometimes observed, which was due to polarization sensing. Sporadically, 1 pacing interval shortened to the upper rate value, because of a known and now resolved timing anomaly. Neither anomaly was of clinical consequence and the first could be resolved by reprogramming.(ABSTRACT TRUNCATED AT 250 WORDS)

Continuous recording of neck rotation: preliminary observations.

An instrument is described that allows continuous recording of neck rotation for periods of up to 12 hours. This allows analysis of how the neck actually is used rather than its range of positions on static testing. This technique will be helpful in evaluating the severity of disorders of the neck and the effectiveness of treatment.

The management of recurrent croup in children.

OBJECTIVE: To review the aetiology, investigation, diagnosis, treatment and clinical outcome of children with recurrent croup. METHOD: Retrospective case note review of all children with recurrent croup referred to the otolaryngology service at our hospital from November 2002 to March 2011. RESULTS: Ninety children with recurrent croup were identified. Twenty-five children (28 per cent) had anatomical airway abnormalities, of which 16 (18 per cent) demonstrated degrees of subglottic stenosis. Twenty-three children (26 per cent) had positive microlaryngobronchoscopy findings suggestive of reflux. Eleven children were treated for gastroesophageal reflux disease, 10 (91 per cent) of whom responded well to anti-reflux medication (p = 0.006). No cause was identified for 41 (45 per cent) of the children; this was the group most likely to continue having episodes of croup at follow up. One death occurred in this group. CONCLUSION: Airway anomalies are common in children that present with recurrent croup. Laryngobronchoscopy allows identification of the cause of croup and enables a more accurate prognosis. In the current study, laryngobronchoscopy findings that indicated reflux were predictive of benefit from anti-reflux medications, whereas the clinical presentation of reflux was not. Routine measurement of immunoglobulin E and complement proteins did not appear to be helpful.

Evaluation and comparison of two Stuart's liquid swab transport systems tested by the CLSI M40 method.

The Copan Diagnostics HealthLink Transporter swab and the Remel Bacti-Swab were evaluated by the Clinical and Laboratory Standards Institute M40-A quantitative swab elution method for maintenance of bacterial viability of six ATCC and six clinical strains. Acceptable levels of viability according to Clinical and Laboratory Standards Institute criteria were maintained for all organisms tested with the HealthLink Transporter swab and for 8 of 12 organisms tested with the Bacti-Swab. In this study, the HealthLink Transporter swab maintained organism viability better than the Bacti-Swab.

Use of an implantable cardioverter defibrillator in a patient with a rate responsive pacemaker.

A patient dependent on a pacemaker and with a rate responsive unit presented with symptomatic ventricular tachycardia despite drug treatment. He was managed with a third generation implantable cardioverter defibrillator, while rate responsive pacing was maintained.

Benefit of single setting rate responsive ventricular pacing compared with fixed rate demand pacing in elderly patients.

In order to assess the value of a simple, single setting rate response option to VVI pacing, 12 patients (mean age 75.1 +/- 6.2, range 62-83 years, seven males, five females) with symptomatic complete heart block were entered into a double-blind, randomized crossover trial of VVI versus VVIR (single setting rate responsive) pacing using Medtronic Activitrax pacemakers. Assessment was by time taken in seconds (sec) and Borg scale symptom score (6-20) for simple activities (standing from chair x 30; walking 800 meters; 52 steps on stairs [slow and fast pace], and incremental, noninclined maximal treadmill exercise), performed after a 4-week period with the patient in each pacing mode. Times were significantly improved in VVIR mode for standing from chair [mean +/- SD] (78.7 +/- 22.5 vs 70.7 +/- 19.5 sec; P less than 0.05), for 800 m walk (1032 +/- 80 vs 885 +/- 59 sec; P less than 0.05), fast ascent of stairs (29.5 +/- 7.7 vs 26.5 +/- 5.6 sec; P less than 0.02), and treadmill exercise (626.7 +/- 189.5 vs 741.0 +/- 170.2 sec, P less than 0.005) although no difference in time for slow stair ascent was demonstrated. Symptom scores were significantly less in VVIR for standing from chair (12.7 +/- 2.8 vs 10.3 +/- 1.8; P less than 0.01), 800 m walk (10.9 +/- 2.7 vs 9.0 +/- 2.4; P less than 0.01), slow ascent of stairs (11.6 +/- 2.1 vs 10.0 +/- 2.0; P less than 0.01), and fast ascent of stairs (13.0 +/- 2.0 vs 11.7 +/- 1.9; P less than 0.02) but unchanged for treadmill exercise.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical experience with an activity sensing pacemaker.

During clinical evaluation of the Medtronic Activitrax pacemaker in a worldwide multicenter study, implant and follow-up data were provided by 61 investigators on 222 patients. Pacing indications included two- and three-degree AV block in 149 and atrial arrhythmias in 174 patients; 16 patients received atrial pacing. Average and longest documented follow-up periods were 7.5 and 16 months respectively. Paired treadmill tests, one in Activity mode and one in VVI/AAI mode, were performed by 120 patients. At peak exercise, average heart rate was 95 bpm in VVI/AAI mode and 118 bpm in Activity mode (p less than 0.0001). Average exercise time was 9.4 minutes in VVI/AAI mode and 10.8 minutes in Activity mode (p less than 0.0001). In 54 patients who exclusively had paced rhythm during both treadmill tests, average heart rates and exercise times were 70 ppm and 8.1 minutes in VVI/AAI mode and 111 ppm and 10.3 minutes in Activity mode respectively (p less than 0.0001). 24-hour Holter recordings typically demonstrated pacing at or near basic rate during periods of rest and appropriate increase in pacing rate during daily activities. Patients had significantly fewer problems with physical effort in daily life during a week of Activity mode pacing than during a week of VVI/AAI mode pacing (p less than 0.05) as assessed from the symptom scores recorded by 62 patients in special diaries.