Haddad Joseph, Anderson Christopher, Heinlen Jonathan, Stratton Kelly, Mellis Adamantios, Herr Harry, Cookson Michael, Patel Sanjay
Department of Urology, University of Oklahoma, Oklahoma City, Oklahoma, USA.
Can J Urol. 2017 Oct;24(5):8976-8981.
To assess the quality of resident dictations for transurethral resection of bladder tumor (TURBT). One indicator of surgical quality is the completeness of the operative report. Surprisingly, there is a paucity of standardized operative templates for TURBT and little formalized instruction for learners. The quality of TURBT dictations was assessed and areas of improvement were determined after implementation of a 10 item TURBT checklist.
A retrospective review of the last 50 TURBT operative reports dictated by residents was performed. A 'TURBT checklist' was used assessing 10 key factors in documentation. A formal training session regarding TURBT dictations was given with TURBT checklists handed out to each trainee. Fifty TURBT dictations were subsequently analyzed.
TURBT dictations improved across the board following checklist implementation. Total number of checklist items dictated increased to 7.0 from 2.6 prior (p < 0.05). When stratified by resident experience, TURBT dictations improved across different resident years (p < 0.05). Junior resident dictations statistically improved in every checklist item (p < 0.05). Senior resident dictations improved in almost every category but only two reached statistical significance. A regression model demonstrated checklist implantation to be a significant predictor of improvement in mean number of checklist items dictated independent of PGY level.
Our study demonstrates that prior to implementation, TURBT operative dictations performed by residents lacked many of the critical components required for a quality TURBT. However, once properly instructed, a relatively simple 'checklist' can be easily implemented and serve as a teaching tool for residents in training to ensure critical procedural elements are documented.
评估住院医师关于经尿道膀胱肿瘤切除术（TURBT）的病历记录质量。手术质量的一个指标是手术报告的完整性。令人惊讶的是，TURBT缺乏标准化的手术模板，且对学习者的正规指导很少。在实施一份包含10项内容的TURBT检查表后，对TURBT病历记录的质量进行了评估，并确定了改进的方面。
对住院医师最近记录的50份TURBT手术报告进行回顾性分析。使用一份“TURBT检查表”来评估记录中的10个关键因素。针对TURBT病历记录进行了一次正式培训课程，并向每位学员发放了TURBT检查表。随后对50份TURBT病历记录进行了分析。
在实施检查表后，TURBT病历记录全面得到改善。检查表项目的记录总数从之前的2.6项增加到了7.0项（p < 0.05）。按住院医师经验分层时，不同年份住院医师的TURBT病历记录均有改善（p < 0.05）。初级住院医师的病历记录在每个检查表项目上均有统计学意义的改善（p < 0.05）。高级住院医师的病历记录在几乎每个类别中都有改善，但只有两项达到统计学意义。回归模型表明，检查表的实施是检查表项目记录平均数改善的一个重要预测因素，与住院医师培训年数无关。
我们的研究表明，在实施之前，住院医师进行的TURBT手术记录缺乏高质量TURBT所需的许多关键要素。然而，一旦得到适当指导，一个相对简单的“检查表”就可以很容易地实施，并作为培训住院医师的教学工具，以确保记录关键的手术步骤要素。
