Introduction to surgery

Published on 10/04/2015 by admin

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Last modified 10/04/2015

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CHAPTER 1 Introduction to surgery

Evidence-based medicine 1
Clinical governance in surgical practice 2
Clinical audit 2
Consent 4
Medico-legal issues 6
Breaking bad news 6
Death and the certification of death 8
Bereavement counselling 8
Approach to the patient 9
Taking a history 9
Examination of a lump 11
Examination of an ulcer 12
Classification of disease 14

The practice of surgery today involves not only technical skills but a whole range of other skills, such as communication skills, delivery of informed consent, breaking bad news and bereavement counselling. Surgical practice must be evidence-based and surgeons must conduct regular audits as well as being aware of their accountability in patient care.

Evidence-based medicine

Evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. Evidence-based medicine combines the individual doctor’s expertise and the best available external evidence when making decisions about the patient’s healthcare.

Evidence-based medicine is a lifelong process which involves:

• Asking clinical questions
• Tracking down the best evidence
• Assessing the evidence
• Applying the results in practice
• Evaluating subsequent performance.

Evidence-based medicine has the following advantages:

• It offers an objective way to determine and maintain consistently high quality and safety standards in medical practice
• It helps speed up the process of transferring clinical research findings into clinical practice
• It has the potential to significantly reduce the cost of delivery of healthcare.

External evidence includes research from basic medical sciences, patient-centred clinical research, randomized trials and meta-analyses. Patient-centred clinical research looks at the accuracy and appropriateness of diagnostic tests, the use of prognostic indicators and the effectiveness and safety of treatments. External clinical evidence may invalidate previously accepted tests and treatments, replacing them with new ones that are more accurate, effective and safe. Without the current best evidence, surgical practice risks becoming out of date, to the detriment of patient care.

Evidence may be available from individual randomized trials or via meta-analysis of several trials such as those published in the Cochrane Database of Systematic Reviews.

Clinical governance in surgical practice

Clinical governance is – a framework through which healthcare organizations are accountable for continually improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish.

The purpose of clinical governance is to ensure a systematic approach to maintaining and improving the quality of patient care. It embodies three main areas:

1. Recognizable high standards of care
2. Transparent responsibility and accountability for those standards
3. A drive for improvement through constant monitoring of standards.

Clinical governance covers organizational systems and processes for monitoring and improving services including:

• Education and training
• Clinical audit
• Clinical risk management
• Clinical effectiveness
• Research and development
• Openness.

Effective clinical governance addresses those structures, systems and processes that ensure quality and accountability thus ensuring proper management of an organization’s operations and delivery of service in an open and transparent setting. In so doing, it ensures continual improvement of patient care with a commitment to quality and the prevention of clinical errors.

Clinical audit

Clinical audit is a continuous cycle of quality improvement that seeks to improve patient care and service delivery through systematic review of care against explicit criteria and the implementation of change. The clinical audit process is known as the audit cycle. This involves observation of existing practice, the setting of standards, comparison between observed and set standards, implementation of change and re-audit of clinical practice (Fig. 1.1). The main components of the audit cycle are:

• Choose a topic
• Review current standards or agree standards
• Accurate collection of data on current practice
• Use of data to compare with standards
• A system for implementing change to make improvement
• Re-audit to ensure practice has improved.
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Figure 1.1 The audit cycle.

Benefits of undertaking clinical audit:

• Improvements in clinical practice benefiting patient care and service delivery
• Meeting evidence-based best practice
• Minimizing error
• Developing local guidelines/protocols
• Reducing adverse clinical incidents, complaints and claims.

Clinical audit is used to compare current practice with evidence of good practice. It basically asks the question, ‘are we actually doing what we think we are doing?’. Clinical audit can:

• identify major risk, resource and service development implications
• reinforce implementation of evidence-based practice
• influence improvements to individual patient care
• provide assurance on the quality of care.

When considering topics to audit, the following may be a useful guide; high-risk practice, cost-effectiveness, patient concerns, local concerns, conforming to international guidelines, new treatments or procedures.

Types of audit vary from basic clinical audit, e.g. morbidity/mortality, to national audit, e.g. National Confidential Enquiry into Patient Outcome and Death (NCEPOD). Whatever the subject audited, the following are essential requirements:

• Accurate high quality data collection
• Recognition of variation in case mix
• Clearly defined outcome measures
• Appropriate statistical analysis
• A system for introducing change
• Re-evaluation of the system after change.

How does audit differ from research?

• Research:

— aims to establish best practice
— aims to generate new knowledge
— is theory driven
— may involve a completely new treatment.

• Audit:

— aims to evaluate how close actual practice is to best practice
— aims to improve service delivery
— is practice based
— never involves a completely new treatment.

Consent

Informed consent is required for all invasive procedures. Consent should be obtained by the person who is actually going to carry out the procedure or certainly by somebody who is suitably trained and qualified and has sufficient knowledge of the proposed treatment. It is probably best that consent for major procedures is obtained either by the consultant or with the consultant present. It is good practice that consent should be obtained for any procedure that can have a complication.

For consent to be valid, the patient must have the capacity to:

1. Be able to comprehend and retain the information relevant to the decision in question
2. Believe that information
3. Weigh that information in the balance to arrive at a decision.

Consent should be informed, i.e. the patient should be given the full information about:

• The procedure
• The reasons for carrying it out
• Any alternative treatments
• Benefits of the procedure
• Adverse effects or complications
• The outcome without any treatment.

Consent must be voluntary, i.e. not the result of coercion by medical staff, relatives or friends.

Minors between the ages of 16 and 18 are presumed to have capacity to consent in English law. If a doctor feels that a child under 16 has the intelligence and maturity to comprehend the risks and benefits of an intervention (Gillick competence), the patient may consent against parental wishes. Children under 16 who are not Gillick competent may not withhold or give consent; parents must act on their behalf. Patients over 16 with fluctuating capacity (e.g. under the influence of drugs affecting mental state) should be given the opportunity to consent when lucid, if their medical condition can wait until then. Otherwise, doctors may consent on their behalf.

Consent may be verbal or written. Consent forms provide some evidence that the process of consent has taken place, but are not themselves legal documents that prove that consent is valid.

Risks of operation may be general or specific to the operation. The general risks include the risks of anaesthesia and the risks of any operation, e.g. haemorrhage, wound infection, deep vein thrombosis. Examples of specific complications are recurrence after inguinal hernia repair, recurrent laryngeal nerve palsy after thyroid surgery, facial nerve palsy after superficial parotidectomy.

It is generally accepted that complications should be explained to the patient when they arise at a rate of 1% or greater. However, any devastating complication which may occur and has an incidence of less than 1% should be explained to the patient, e.g. paraplegia after aortic cross clamping.

The degree of information to be conferred to a patient continues to evolve through debate in English law. Consent issues challenged by a claimant are tested in English law against the elements of negligence. Rulings have been led by legal precedent. In Sidaway vs. Bethlem Royal Hospital (1985), a patient undergoing cervical cord decompression was not warned against a 1–2% risk of spinal cord injury, which she subsequently suffered. Although she claimed she would not have undergone surgery if she had been warned, a responsible body of surgical opinion would also not have warned a patient of the risk and therefore, the court ruled for the doctor of the basis of the Bolam test.

Since then, in Chester vs. Afshar (2004), surgery for back pain resulted in cauda equina syndrome, the possibility of which the patient was not informed prior to surgery. The judges ruled that failure to inform had violated her right to choose. She may, however, have still opted for this surgery, therefore it is debated that it is difficult to establish causation if the failure to inform may not have changed the outcome, i.e. the patients choice for surgery.

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