Cholecystectomy Criteria Audit - Case Study Example

7.0 RESULTS AND RECOMMENDATIONS Cholecystectomy has been noted to reduce pain and discomfort from gallstones. Notably, conservative treatments like the dietary modifications generally can't stop recurring of gallstones. As such, cholecystectomy has been noted to be the only way of preventing gallstones. According to research some people experience mild diarrhea after cholecystectomy; however this usually fades of with time. Since, the gallbladder is not essential to healthy digestion; most people won't experience digestive complications after cholecystectomy. How fast one returns to normalcy after cholecystectomy depends on the procedure used by the surgeon and a person's overall health. Individuals undergoing laparoscopic cholecystectomy can resume to their duties in a matter of days. However, those who undergo open cholecystectomy may stay for a whole week or so before recovering fully to their duties. 7.1 Patient Age Distribution As illustrated in the table below samples were taken from both men and women. Men took 55% of the total sample while women took the rest 45%. The table further illustrates that 90% of all the patients ranged from 60-89 years. Notably, there were only 4 respondents who were below 50 years of age the youngest patient being 34 years old. Sr. No Age group Male Female Total 1 90yr 1 0 1   Total 55 45 100 Table 1 Actual verses Expected Figure 1. Demographic Distribution of Age Based On Gender 7.2 Clinical Data As illustrated above 100 patients underwent elective cholecystectomy procedure between 2010 and 2011; that is 55 men and 45 women. All the patients recorded participated in the procedure where 4 had earlier been used as pilot patients. Before taking the 100 patients in the study, 12 patients had postoperative complications 8 of them who underwent conversion to open procedure while the rest 5 refused return the postoperative registration questionnaire. In the 100 patient who underwent cholecystectomy their median age was 70.70 (age range, 34-95 years). The median stay in the hospital was 1 night after surgery and the range of duration stayed was 0-5 nights. Duration of Convalescence The data on convalescence is provided in the table below and it has the reasons for failure to follow recommendations to resume work and recreation activities. During this time those patients who were returning to work took more time compared those who were returning to frivolous activity. Convalescence from work (n=57) and recreation activity (n=13) was 5 days ranged from 0-28 days including days of surgery and 2 days on the range of 0-22 days respectively for patients recommended for convalescence of 2 days. The overall convalescence was 3 days range of 0-28 days. Convalescence Data Activity level Variable Moderate Strenuous Total Work No. of days of work (range) 6 (0-28) 10 (0-52) 7 (0-52) Patients Number 70 30 100 Not following Recommendations No. 52 13 65 Main Contributory factors for not following n=85 Pain 16 Fatigue 13 Planned vacation 15 Weekend 14 Table 2: convalescence data for working patients Activity level Variable Moderate Strenuous Total Recreation Activity No. of days of activity (range) 2 (0-24) 8(5-11) 10 (0-24) Patients Number 54 5 59 Not following Recommendations No. 31 2 33 Main Contributory factors for not following n=67 Pain 16 Fatigue 11 Planned vacation 9 Weekend 7 Table 3: convalescence data for recreation activity patients 7.1 Recommendation for Convalescence A convalescence of one week is recommended in case of construction or strenuous workload; this is inclusive of the day of surgery. Two days of convalescence or three day inclusive of the day of surgery in case of other types of sedentary or moderate work lie journalism, poster worker or recreation activity. All patients were told that there would be no post operative restriction and work or recreation was fundamental from postoperative day one. Patients were given recommendation and information at the first preoperative ambulatory examination before and after surgery at the time of discharge. Per-Operative Complications While treating acute cholecytitis remains debatable; laparoscopic cholecystectomy has gradually been employed as the primary surgical approach in patients who has acute cholecystitis. In keeping with Lai et al (2013) Laparoscopic cholecystectomy has also been used for management of acute cholecystitis. This procedure is tricky and challenging. Some favourable and unfavourable situations may be prevailing and this may influence the rate of conversion and complication. Lai et al (2013) further indicates that Laparoscopic cholecystectomy has been preferred on emergency basis as soon as the diagnosis has been done. In this study, 21.9% of the patients had acute cholecytitis. Compared with another study by Lai et al (2013) 120 of 132 patients were recorded with cholelithiasis had acute cholecytitis. Laparoscopic cholecystectomy was performed within 24 hrs this conformed with Lai et al (2013) study. In our study majority of the patients who were investigated presented with oedematous gall bladder, empyema and mucocele. In our study, most of patients presented with oedematous gall bladder, mucocele and empyema. Per-operative finding principally included adhesion of gallbladder with the surrounding structure i.e. the Calot's triangle, colon, stomach as well as omentum in 47% of the cases and the bile duct injury was recorded to be at 4.71% of the cases. Preoperative complications recorded in the study included bleeding in 7 cases, the CBD injury in 5 cases and minor liver injury in 5 cases distorted anatomy of Calot's triangle recorded on 10 cases. As illustrated by Abdelkader (2013) early recognition and quick repair has a positive result. Male gender above the age of 60 is liable to more complications. According to the study all the cases accept a single case of the CBD injury. The study also depict that 5% of 100 patients were converted due to bleeding, perforated gallbladder with biliary, dense adhesion of the gallbladder and pasted adhesion. In keeping with Abdelkader (2013) Emergency laparoscopic cholecystectomy can be defined as a reliable and safe modality in managing acute cholecystitis with or without cholelithiasis. Factors that are responsible for conversion include patients with empyema, delayed and perforated gallbladder. 7.3 Incidence of exploration of common bile duct It has been studied that incidences of mortality and morbidity after common bile duct exploration do not justify its use in a patient with gallbladder situation. As such, endoscopic sphincterotomy has often been advocated to remove duct stones before cholecystectomy in some patients. Indications of duct exploration in this study included; dilated common bile duct, jaundice, multiple small stones, gallstone pancreatitis and abdominal intraoperative cholangigram. In the study it was discovered that exploration was done though choledochoscopy (manual technique) in accordance with the surgeon's preference. In our study it was only 2 patients who required duodenotomy to extract difficult stones and there were no deaths in the series of successive common duct exploration. The study records 15.7% rate of morbidity which included 5.3% incidences of held common duct stones. 7.4% major complication rate inclusive of deep vein thrombosis, pneumonia, and bleeding gastric ulcer. The rest were minor complications that did not prolong hospitalization. The study recorded one wound infection but no postoperative pancreatitis. In the study, none of the complications were directly attributable to duct exploration or choledochotomy. In keepin with the analysis attained, all conserved common duct stones were cleared through angiographic basket or retrograde cholangiopancreatography hence they did not require reoperation as such it is conclusive that common duct exploration that does not require duodenotomy is safe and no incidences of complications can be experienced after cholecystectomy. As such, endoscopic sphinterotomy continues to be the most preferable alternative for any operative common duct exploration for those patients with retained common duct stones. Surgical exploration of the common bile duct Common Bile Duct    Positive Total Percentage Surgical exploration of common Bile duct 43 100 43 Evidence of disease in common bile duct 40 3 94 Table 4: Surgical exploration of Common Bile Duct and evidence of disease Above table shows 45% of the patients have got surgical exploration of common bile duct. And out of there 45, 39 have got proof of disease of common bile duct. Figure 2: Surgical exploration of common bile duct Figure 2 shows the exploration of common bile duct The figure indicates examination of 43 patients which translates to 43% who showed positive and the remaining 57% did not. Figure 3: Evidence of disease in common bile duct 40 patients out of 43 were diagnosed with the disease the number is not common bile duct. This number is not high and is in much accordance with the safety norms that are followed within the hospital setting. 7.4 Presentation of Acute and Chronic Cholecystitis Cholecystitis Type Male Female Total Acute 32 26 58 Chronic 23 19 42 Total 55 45 100 Table 4: Type of cholecystitis based on gender Figure 4: Type of cholecystitis based on gender The figure above illustrates the types of Cholecystitis based on patients’gender. Acute and chronic diseases are almost in the ratio of 3:2 irrespective of the gender. The number of men in the sample was more compared to women. 8.0 FINDINGS AND ANALYSIS This study represents the level of care provided by Curtin hospital for acute and chronic diseases. It includes a simple sample size of 100 patients 55 of whom are males and the remaining 45 are females. On the total 100 patients 11 audit criteria have been defined. It is then on the basis of these criteria that the patients have been surveyed. This study focuses on the amount of care the hospital has accorded in carrying out cholecytectomy. Some of the areas that are of concern for the hospital are its strength as resolutely analysed below. 8.1 Clinical decision making process Curtin Hospital’s greatest strength is their clinical decision making process since it suggests the criteria to be followed, signs and symptoms investigations on pre-cholecystectomy to give 100% justification for surgery operations in the hospital. This is in agreement with RACS rules and guidelines. All the surgeries recorded in our study were justified and this boosts patients confidence when they are admitted in the hospital, 8.2 Antibiotic prophylaxis protocol In the figure 5 below 58% of the total cases established that patients had been issued with prophylaxis protocol. This result is significantly misrepresent since in the sample that was surveyed 32% of the sample did not have applicable results. Prophylaxis protocol is given to prevent infections that are related to microbial activity. Figure 5: Patients issued with prophylaxis antibiotics as per the given protocol. 8.3 The safety of the Cholecystectomy procedures The safety of cholecystectomy procedures is one of the most fundamental provisions by Curtin Hospital. The hospital policy states that admission is free for any unplanned surgery. As such, a high of 98% of surgery are unplanned with the setting. In the study, 98% of surgical cases were in accordance with the expectation where only two cases of out the studied 100 were found. Figure 6: Free Admission of Unplanned Additional Surgery 8.4 Fatality rate In keeping with the study, Curtin Hospital’s fatality rate stands at 2%. This is much higher that the expected limit of 0.09 to 0.2%. Arguably, fatality rate in the hospital is alarming compared to the limit defined for cholecystectomy procedures. This is one area that the hospital must focus on to reduce this rate to norm and exected levels of fatality or to zero. Figure 7: Fatality Rate 8.5 Blood transfusions As shown in the figure below 2% (2 patients) of the patients surveyed (100) needed blood transfusions at the time of operation and after operations. The need for transfusion may be as a result of scantily performed operation. In reference to Fraxel (2009) only 0.05% patients of cholecystectomy procedures should require blood transfusion. However, in the case of Curtin hospital the percentage is at an alarming 2% though not as severe as the fatality late which also stands at 2%. Figure 8: Admission of both intra-operative and postoperative blood transfusion 8.6 Overall Results To begin with is the fatality rate of 2%. This is the most serious safety procedure that is not in accordance with the compliance rate. The safety norms provides for 0.09 to 0.2% fatality rate. The fatality rate in the hospital is alarming and calls for speed intervention. Secondly, is the blood transfusion rate which is 4 time higher that the normal rate. Though not as severe as the blood transfusion rate it can not be ignored. The most confident result compared with the RACS procedures is in the signs and symptoms investigations i.e. pre-cholecystectomy that justifies the surgery of 10% of the cases. This shown that the hospital is following the guideline and it is one of the strengths of Curtin Hospital. Lastly, for 58% of the patients to have been given prophylaxis protocol was in accordance to given protocol was a clear indication of good protocol follow though it was not the best safety. Figure 9: Overall Results 9.0 RECOMMENDATIONS The a fore mentioned findings and analysis helps us to find a common ground to consider how to handle all the issues pin pointed at Curtin Hospital that must be undertaken with caution. 9.1 Conduct studies into contemporary best practice cholecystectomy To begin with the hospital must put up a huge investment with regard to procedures in cholecystecomy. There is a great necessity to point the best practises and follow them to avoid direction non-compliance. On key issues pointed out is the need antibiotic prophylaxis in the hospital that must be done in accordance with the guidelines. It is one practise that would help the hospital to maintain superior quality and give best results to its patients. 9.2 Annual Audit Patients file in Curtin hospital must be audited annually. An audit would assist to identify risks before hand and control them. In this regard, various problems arising would be detected early. As a result, doctors in Curtin Hospital would get a chance to improve and explore thus develop safety norms. 9.3 Inquiry into cholecystectomy safety Procedures The study depicts the requirement for inquiry into safety procedures that must be followed on cholecystectomy in the hospital. As patient of cholecystitis increase, the impact of safety procedures is felt more. In reference to Lai et al (2013) this impacts more in a cyclic manner by if compliance procedures are not followed in the hospital. In this case, there is the need to understand and manage non-compliance of safety procedure within Curtin hospital. However, there is a need to control the patient with cholecystitis. Notably, cases of surgical wounds infection increase the levels of fatality and cholecystitis; this ands more pressure to non-safety and therefore a cause of concern for the hospital. 9.4 Implement new scheduling system On implementation and scheduling system, the hospital must come up with a critical plan. The initial move is following up procedures which will significantly increase the level of excellence and impart indispensable safety methods. A good example of such an approach is taking the patients into the ward hours before surgery. This approach will assist Curtin hospital in having a well organised and effective approach to safety procedures that must be followed. 10.0 DISSEMINATION OF CRITERIA AUDIT RESULTS Similar to discussion on what criteria are contrary the safety compliance and procedure; instant action must be taken by the hospital for all the non compliance results analyzed herein. The first step is training and developing competent hospital personnel who can communicate efficiently about various safety procedures and policies. The communication must be top-down to allow for efficient flow of leadership and efficiency. Different stakeholders and all board members must be informed of such policies and quality procedures that are vital to patients’ wellbeing. In addition, there should also be a record maintenance database that will allow for easy access to patients record through internal network. Such easy access of patients records electronically must be provided in accordance to Curtin Hospital policies. References Lai S., Jin-Ming Wu J., Chiung-Nien C., and Hong-Shiee M. (2013) Combined cholecystectomy in gastric cancer surgery. International Journal of Surgery, Volume 11, Issue 4, Pages 305-308 Abdelkader I., Hussein M and Houseni M. (2013). A medical school experience with three port laparoscopic cholecystectomy with a new modification in technique Original Research Article International Journal of Surgery, Volume 11, Issue 1, Pages 37-40 Read More