University of Michigan Medical School, Ann Arbor, MI, USA.
Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA.
Surg Endosc. 2022 May;36(5):3610-3618. doi: 10.1007/s00464-021-08614-8. Epub 2021 Jul 14.
Variable approaches to intraoperative communication impede our understanding of surgical decision-making and best practices. This is critical among hernia repairs, where improved outcomes are reliant on understanding the impact of different patient characteristics and surgical approaches. In this context, a hernia-specific synoptic operative note was piloted as part of an effort to create a statewide hernia registry. We aimed to understand the impact of the synoptic operative note on variable missingness and evaluate barriers and facilitators to improved intraoperative communication and note adoption.
In January 2020, the Michigan Surgical Quality Collaborative (MSQC) registry was expanded to capture hernia-specific intraoperative variables. A synoptic operative note for hernia repair was piloted at 8 hospitals. The primary outcome was change in hernia variable communication, measured by missingness. Using a sequential explanatory mixed-methods design, we performed semi-structured interviews with data abstractors (n = 4) and surgeons (n = 4) at 5 pilot sites to assess barriers and facilitators of implementation. Interviews were iteratively analyzed using content analysis with both deductive and inductive approaches.
From January to June 2020, 870 hernia repairs were performed across 8 pilot and 53 control sites. Pilot sites had significantly less missingness for all hernia-specific variables. At pilot sites, 46% of notes were fully complete in regard to hernia variables, compared to 21% at control sites (p value < 0.001). While collection of intraoperative variables improved after synoptic note implementation, low note adoption was reported. Facilitators of improved variable collection were (1) communication with data abstractors and (2) stakeholder acknowledgment of widespread benefit, while barriers included (1) surgeon resistance to practice change, (2) EMR/technology, and (3) interruptions to communication and implementation.
This mixed-methods evaluation of a synoptic operative note implementation suggests that sustained communication, particularly with abstractors, was the most impactful intervention. Future implementation efforts may have improved effectiveness with interventions supplementary to surgeon-level direction.
术中沟通方式的差异阻碍了我们对手术决策和最佳实践的理解。在疝修补术中，这一点尤为关键，因为提高手术效果依赖于对不同患者特征和手术方法影响的理解。在此背景下，我们尝试采用特定于疝的摘要手术记录，作为建立全州疝登记系统的一部分。我们旨在了解摘要手术记录对变量缺失的影响，并评估改善术中沟通和记录采用的障碍和促进因素。
2020 年 1 月，密歇根手术质量协作组织（MSQC）登记处扩大范围，纳入疝特定的术中变量。在 8 家医院试行疝修复的摘要手术记录。主要结局是疝变量沟通的缺失程度变化，以此衡量缺失情况。我们采用序贯解释性混合方法设计，对 5 个试点医院的 4 名数据录入员和 4 名外科医生进行半结构式访谈，以评估实施的障碍和促进因素。使用基于归纳和演绎的内容分析法对访谈进行迭代分析。
2020 年 1 月至 6 月，在 8 个试点和 53 个对照医院进行了 870 例疝修补术。试点医院的所有特定于疝的变量缺失率显著降低。在试点医院，46%的记录完全完整地记录了疝变量，而对照组为 21%（p 值<0.001）。虽然摘要记录实施后术中变量的采集有所改善，但记录的采用率较低。变量采集改善的促进因素包括（1）与数据录入员的沟通，（2）利益相关者对广泛受益的认可，而障碍包括（1）外科医生抵制实践改变，（2）电子病历/技术，以及（3）沟通和实施的中断。
这项对摘要手术记录实施的混合方法评估表明，持续的沟通，特别是与录入员的沟通，是最具影响力的干预措施。未来的实施工作可能会通过补充外科医生层面的指导的干预措施来提高效果。
