Improving operation notes and postoperative care: an audit of current practice

Surgical reporting for laparoscopic cholecystectomy based on phase annotation by a convolutional neural network (CNN) and the phenomenon of phase flickering: a proof of concept

Purpose

Surgical documentation is an important yet time-consuming necessity in clinical routine. Beside its core function to transmit information about a surgery to other medical professionals, the surgical report has gained even more significance in terms of information extraction for scientific, administrative and judicial application. A possible basis for computer aided reporting is phase detection by convolutional neural networks (CNN). In this article we propose a workflow to generate operative notes based on the output of the TeCNO CNN.

Methods

Video recordings of 15 cholecystectomies were used for inference. The annotation of TeCNO was compared to that of an expert surgeon (HE) and the algorithm based annotation of a scientist (HA). The CNN output then was used to identify aberrance from standard course as basis for the final report. Moreover, we assessed the phenomenon of ‘phase flickering’ as clusters of incorrectly labeled frames and evaluated its usability.

Results

The accordance of the HE and CNN was 79.7% and that of HA and CNN 87.0%. ‘Phase flickering’ indicated an aberrant course with AUCs of 0.91 and 0.89 in ROC analysis regarding number and extend of concerned frames. Finally, we created operative notes based on a standard text, deviation alerts, and manual completion by the surgeon.

Conclusion

Computer-aided documentation is a noteworthy use case for phase recognition in standardized surgery. The analysis of phase flickering in a CNN’s annotation has the potential of retrieving more information about the course of a particular procedure to complement an automated report.

Operation notes in orthopaedics: Beliefs and practices in a developing country

Maintaining accurate and complete operation notes is an essential metric of the quality of surgical care. While developed countries have implemented electronic health records to improve documentation, financial constraints prevent this realisation in the Caribbean. Somewhat paradoxically, previous studies in this area have focussed on 'process' while neglecting the key role of the surgeon. We conducted a 25-item Knowledge, Attitudes and Practices survey of orthopaedic doctors to identify any culturally unique health-related behaviours. Our results indicate that while most doctors understand the importance of operation notes, many are unaware of international note-keeping recommendations. Legibility was identified as a significant issue by 92% of doctors. A disturbing and previously unreported finding from the study revealed that 72% of surgeons would occasionally write the operation notes, although they were not scrubbed in for the procedure. We suggest that future studies examine this peculiar behaviour in greater detail.

Improving the quality and speed of access to operation notes

INTRODUCTION

Operation notes are often poorly completed, potentially compromising patient care. This project was undertaken to improve the quantity, quality and clarity of information included in operation notes, and make them easier to locate within a set of patient notes.

METHODS

Operation notes were audited against standards laid out in national guidelines. The time taken for staff to locate an operation note, and information within it, was then measured. The layout was re-designed, followed by a re-audit.

RESULTS

The number of operation notes with all measured domains completed rose from 4% to 34% (P<0.001). The mean time to locate the operation note fell from 30 to 4 seconds, and the mean time to locate all requested pieces of information within the operation note fell from 35 to 20 seconds.

CONCLUSIONS

The interventions have improved quality and speed of access of operation notes, but there is still room for improvement.