Nigist Eleni Mohammed Memorial Referral

Hospital
Department of Surgery

AUDIT REPORT OF
September, 2020 G.C

Dr Habtamu M
09/01/2021 1
 OUTLINE
 Objectives

 ESOPD, cold opd and SRC activities

 Admissions and OR activities
 Major morbidities of the month
 Mortalities of the month
 Chart review
 Strength and Problems identified
 Recommendation

09/01/2021 2
 The team

 G. SURGEONS= 4  GPs= 14
 URO-SURGEON= 1
 ENDOCRINE  INTERNS= 8
SURGEON= 1
 ANESTHETISTS= 21
 ORTHOPEDIC l
SURGEON= 1  WARD NURSES= 32
 ANESTHESIOLOGIST=1
 SCRUB NURSES= 30
 GSRs= 3  CLEANERS
 OSR= 1 (WARD/OR)= 8 t
09/01/2021 3
 Objectives
• To evaluate overall surgical activity in the month of
September.
• To improve quality of surgical care.
• To identify and discuss factors associated with
morbidities and mortalities
• To keep the data as a source for future academic and
research purpose
• To use the data as a tool for planning and allocation
of budget

09/01/2021 4
 Extraction Period and source
• Data Extraction Period
- September 1-30/2020 G.c
• Source of Data:

– OPD & referral clinic log books

– Ward admission and discharge registers

– Major & minor OR log books

– Patient charts
– Morning session report forms

– Previous month audit report

09/01/2021 5
 ESOPD Activities
Cases sept
1, General surgery 101
2, Orthopedics (#s, infection….) 55
3, Soft tissue injury 276
4, Burn 8
5, Neurosurgery 13
6, Referred cases(TBI=3 , Cervical spine injury=4 , basal skul1 #=1,STI 12
R/O retroperitoneal injury=1, L3 and L4 compression#=1, R posterior
acetabular + lower ram #=1, AKI + sever hydronephrosis =1
7, bites 9
Total 474

09/01/2021 6
 ESOPD Activities
EOPD cases
EOPD cases
514
503

474
466

439

May June July Aug sept

09/01/2021 7
 Emergency consultations

• Pediatrics (ETAT)= 42 – Fracture=3

– Burn = 9 – Breast abscess = 1
– STIs = 11 – Submandibular abscess=
– Bite(dog, human)=4 1?
– Appendicitis=2 – pyomyosities= 1
– Foreign body( ear, – L pnemothorax= 1
nose)= 5 – Gluteal abscess=1
– TBI=2
– Tongue laceration = 1

09/01/2021 8
 COLD S.OPD ACTIVITIES
• The number of cases, seen at surgical cold
OPD in the month of September 2020:

* ROOM-11 = 278
* ROOM-12 = 226
TOTAL = 504

09/01/2021 9
 COLD S.OPD ACTIVITIES
Month OPD11 OPD12 Total

May 263 136 399

June 292 295 587
July 335 279 614
August 298 259 557

September 278 226 504

09/01/2021 10
 COLD S.OPD ACTIVITIES
700
600
500
400
OPD
300 11
OPD
200 12
100
0
May June July August semptember

09/01/2021 11
 SRC/ ORC ACTIVITIES
Units of the
department Cases Total
New cases Repeat uncategorized
cases

General 114 201 16? 331

Surgery

Orthopedic 60 97 3? 160

09/01/2021 12
 SRC/ORC activity in the past 5 months
Month SRC ORC
May 269 137
June 366 152
July 414 168
August 425 173
September 331 160

09/01/2021 13
 Trends of SRC/ORC activity in
450
the past 5 months…
400
350
300
250
SRC
200 ORC
150
100
50
0
May June july August semptember

09/01/2021 14
 Emergency minor OR cases
No. cases Number of cases

1 Soft tissue injury repair 75

2 I and D 16

3 Fb removal 7

4 POP application 17

5 Circumcision ( corrective) 3

Total 118

09/01/2021 15
 The trend of Er-minor OR cases…
140
122 118
120
108
100

80 76 78

60

40

20

0
May June July August september
Emergency MOR
09/01/2021 16
 Elective minor OR cases
N cases July August SEPTE
o MBER
1 POP application , removal, 4 7 7

2 Circumcision 14 14 22
3 Foreign body removal 2 - 1
4 Mass excision (LIPOMA,f.adenoma,cysts…) 16 17 11
5 Wound closure 9 5 3
6 I&D 5 2 5
7 Suprapubic catheterization 1 2
8 Tendon repair 1
9 Epigastria Hernia - 3 1
10 Pin removal 1 3 2
11 Chest tube - 2 2
TOTAL 53 57 55

09/01/2021 17
 The trend….
cold cases at MOR

57 55
53

22 21

09/01/2021 18
May June July August september
 Admissions to Surgical Ward,
September,2013
Month General surgery Ortho

Emergency Elective

May 83 35 44

June 61 38 69

July 64 34 44

august 66 34 49

September
09/01/2021 58 20 51???? 19
 Admission trend….
Emergency Elective Ortho

83

69
64 66
61
58
49 51
44 44
38
35 34 34

20

May June July August september

09/01/2021 20
 Major OR Activities…
May June July Aug September

Emergency 57 33 64 51 35

Elective 19 25 34 22 19

Ortho 30 69 51 76 62

09/01/2021 21
 Emergency Procedures
No. Procedure August
1 I and D 13
2 Appendectomy 6
3 Appendectomy + lavage(abscess, perforation) 3
4 Laparatomy + apendectomy + lavage 2

5 Laparotomy + R-I-T-E-S-A(I-I knotting) 1

6 Ex LAP + enbloc resection+E-E-I-I-A(I-I-I) 1
7 Colostomy + rectal and colonic biopsy 1
8 LAP + R-I-T-E-S-A (SBO 2 gangrenous internal hernia) 1
9 Ex laparatomy +R-I-I E-E-A(?typhoid perforation) 1
10 Lap + illo- transverse anastomosis(ilo-sigmoid knotting)
11 tracheostomy 1
12 Grahams patch 1
11 FB removal(FBS , nasal) 2
14 supra pubic cystotomy) 2

09/01/2021 total 35 22
 G. surgery Emergency OR procedures
Emergency major OR procedures
emergency major OR Procedures

64
57
51

33 35

09/01/2021 23
May June July August september
 Elective general surgery procedures
No. Procedure August

1 TVP 2
2 Thyroidectomy (STT,NTT, TT with LLD) 5
3 Hernia repair (MBR, mesh….,) 5

4 Haemorrhoidectomy 1

5 Sigmoid resection and E-E-A 1

6 Colostomy reversal 1
7 Tongue mucocele excision 1
8 cholecystectomy 2
10 MRM 1
Total 19
09/01/2021 24
 Trends of G. surg elective procedures
40

35
34
30

25 25
22
20
19 19
15

10

0
May June July August sept
09/01/2021 25
Elective Major OR general surgery
 Major Ortho. procedures
No. Procedure August

1 I and D 21
2 ORIF ( Inc. IMN) 21
3 Pinning 7
4 Tendon repair 3
5 Graft (STSG, FTSG) & Flap 2
6 osteotomy 1
7 Flap division 2
8 Hip spica 1
9 Contracture release 2
10 cyst excision 1
11 Ex fix 1
Total 62
09/01/2021 26
 The trend of major ortho. procedures
Major orthopedics procedures
76
69
62
50

30

May June JULY August septe

09/01/2021 major Orthopedics procedures 27

 OR cancellations, September 2020

• 04 cases were cancelled.

• The reasons identified were
– Unavailability of blood products in the blood bank.
– Incomplete preoperative preparation of the pt.
– Due to emergency procedure.
– Referral

09/01/2021 28
 Morbidities, G. surgery

No Age/ Admission Procedure Complication Outcome

sex diagnosis
1 40/F AA 2 SBO 2 ileo Laparotomy + enbloc HAP(aspiration Taken antibiotics
-ileal resection +E-E ileo-ileal pnemonia) for 14days
intuscusseption (? anastomosis Hypocalcemia Loaded with
Paraneoplastic Hypokalemia Calcium gluconate
syndrome) Prerenal AKI Kcl 1.8g po tid
UTI
SSSI In the ward
Calcium carbonate
1 gm po tid
Ciprofloxacin 400
mg iv bid
Wound care daily

2 70/m AA 2 gangrenous Laparatomy + enbloc HAP discharged

SBO 2 ileoileal resection + ileo-transverse Partial wound
knotting end to side anastomosis Dehiscence
Pre renal AKI

09/01/2021 29
 Morbidities, G. surgery cont’nd….
No Age/se Admission Procedure Complica outcome
x diagnosis tion

3 50/M foreigner’s gangrene • Extensive - Bowel completed Iv

+ severe necrotizing debridement Eviscera antibiotics
soft tissue infection • Re-debridement tion Silo-bag
involving the anterior (9times) - Hypoalb High protein diet
abdominal wall. uminem
ia(1.43) In the Ward.
- Post op On wound care
ileus High protein diet

4 2O/M GP2 gangrenous ileo- • lap+ I-T-E-S-A Septic

sigmoid knotting shock ICU .
Out of shock
On ceftriaxone 1gm
iv bid
Metronidazole
500mg iv tid
09/01/2021 Tramadol 500 mg iv30
tid
 Mortality Report

No Age/Sex Admission Dx. Intervention Complicatio Cause of

n death

1 30/M GP 2 viscous Put on face mask MOF 2

perforation 2 BAT adrenaline septic
SEPTIC SHOCK 0.1µg/kg/min shock
Bilateral Ceftazidime 1gm iv
Hemothorax bid
Prerenal AKI Vancomycin750 mg
daily
Metronidazole 500
mg iv tid
R side chest tube
inserted
09/01/2021 31
 Mortalities
No Age/Sex Admission Dx. Intervention Complicatio Cause of
n death
2 65/F Sever TBI to r/o neck colar Increased
ICH Ng tube ICP 2 ?
Increased ICP Mechanical Expandin
ventilation g ICH
Phyntion 1gm,
100mg tid
Manitol1gm/kg iv ,
0.5g/kg iv tid

3 55/F GP 2 small bowl Exploratomy Septic MOF 2

perforation(? laparatomy + ileal shock septic
typhoid R-E-E-A hypoglyce shock
perforation) mia

09/01/2021 32
 Mortality / case 1

30 , M, MVA of 2 days duration. hit on front side by a bajaji and fall on his back. has abdominal
distension, vomiting of ingested matter 3 times, and failure to pass faces and flatus
stayed at primary hospital for 1 day and rescucitated with 5 bag of n/s and started antibiotics.
no loc , bleeding from any site
PE
GA: - ASL
V/S: - BP= 66/40 PR=feable RR= 28 spo2= 74% on atms air,
HEENT; PC , NIS
CHEST; decreased air entry on posterior lower 1/3 bilaterally
dullness on the same area
abdomen; distended, suprapubic skin bruise, diffuse tenderness
guarding and rigidity,
+ve sign of fluid collection.
GUS; catheter insitu draining minimal urine
MSS; cold extermity, delayed capilary refill
CNS: - COTPP

09/01/2021 33
 WBC: 4.1k( neu=68%)
HGB: 16.2 g/dl
HCT: 44%
PLT: 107K
OFT; CR= 3.46; UREA= 84.2 ALT= 45.7 AST =194.7(4.46), ALP= 55
ABDOMINAL U/S
. There is hypo echoic collection in the peritoneal cavity having numerous
large echogenic particle
• bilateral anechoic free fluid collection in the pleural cavity larger on right side.

conclusion; intra peritoneal hypoechoic free fluid collection likely

heamoperitonium
bilateral hydrothorax(likely hemothorax) larger on the right.

09/01/2021 34
 ASS
p1: Hypovolemic shock 2 GI loss
p2: GP 2 to viscus perforation 2 to BAT
p3: bilateral hemothorax
• put on ino2, Iv line secured, resuscitated with 4 bag of N/S,NG
tube and urinary catheter inserted.
• ceftriaxone 1 gm iv BID and metronidazole 500mg iv TID started.
After resuscitation , with 4 bag of N/S
BP=85/30,PR=130 SPO2 87% with 5l in o2, uop=10ml/2hr
With the assesment of =same +septic shock, admitted to ICU for
vasopressor

09/01/2021 35
 ICU
• ASS= Generalized peritonitis + bilateral hemothorax
septic shock
hypoglycemia(RBS=49)
• V/s; bp=63/32, PR=94,RR=28,SPO2=80 with ino2
• hx, RTA of 2 days duration
• HEENT; PC NIS
• CHEST; decreasd air entery on posterior lower 1/3 bilaterally
• abdomen; difuse abdominal tenderness
• GUS; Catheterized no uop
• CNS; GCS 15/15, pupil midsized and bilaterally reactive

09/01/2021 36
• kept NPO
• 20 ml of 40 % iv bolus given,
• put on facemask and
• ceftazidime 1gm iv tid
• vancomycin 750 mg iv daily
• metronidazole 500mg iv tid
• adrenaline 0.1µg/kg/min, with 60drops/min started, maintened at 90
drops/min with BP=100/60 and the patient was followed but after 2hrs BP
become 85/57 and no action taken for 6hrs(escalate the dose or second
presser)

on 26/12/12, at 10:40 local time , patient passed away.

Cause of death, MOF 2 SEPTIC SHOCK

09/01/2021 37
 pitfalls
• delayed ICU admission
• no progress note in ICU
• no procedure note for chest tube insertion.
• Incomplete assessment
• ?? Revision of antibiotics
• Suboptimal management(shock , pain….)

09/01/2021 38
 Case 2
• 65/F, MVA of 4hrs duration. Hit on R side by a motor bike and she fall on her left side.
has 4 episode of vomiting of ingested mater, LOC since then and urinary incontinence.
no bleeding from any site
no ABM
no hx of DM ,HTN
P/E
V/S: BP=180/89, PR =64 , SPO 2=97%at ATM
HEENT: PC , NIS
Chest ; clear , vesicular , bilateral good air entry
CVS: s1 and s2 well heard
Abdomen ; flat moves with respiration , no organomegally , no sign of fluid collection
GUS ; kideny is not bimanually palpable
Is; no skin bruize
Mss; no bony deformity or bone creptious
CNS ; GCS;5/15(E=1,M=2,V=2), pupil, R=constricted, L= dilated.
ASS , SEVER TBI, increased ICP 2 to? ICH

-
09/01/2021 39
 Ctnd…
 patient put on neck collar and INO2
 oral airway , NG tube, urinary catheter inserted
 Loaded with Phyntoin 1gm and Manitol lgm/kg
 admitted to ICU

09/01/2021 40
 ICU
 Ass= same
BP=170/108 PR=78, SPO2=99% T=36.8
DONE
 Put on MV
 Manitol 25 g iv qid
 Phyntoin 100 mg po tid
 Morphine 4 mg iv qid
 Diazepam 5 mg iv prn
 Cimetidine 200 mg iv bid
 NG tube feeding

0n 11/1/13 at 1pm patient passed away

Cause of death=increased ICP2 to ? Expanding ICH

09/01/2021 41
 PITFALLS
• In ideal set up patient need brain CT scan and
management accordingly.

09/01/2021 42
 Case 3
55/F, crampy lower quadrant abdominal pain, abdominal
distension, 4 episode of vomiting of ingested matter and failure to
pass faeces and flatus of 2 days duration.
P/E:
V/S BP= 96/60, PR=120; RR=20, T= ATT
HEENT: PC, NIS
Wbc=13.3k
CHEST: clear, resonant (Neu=82.5%)
CVS: s1 and s2 well heard
Abdomen: distended HGB=13.2g/dl
hypertypanic
generalized tenderness HCT=39.2%
PR=formed stool
Gus: prolapsed mass per vagina
Plt=209k
CNS: COTPP

09/01/2021 43
 DONE
 kept NPO
 IV line secured and resuscitated with 02 bag of N/S
 NG tube and urinary catheter inserted
 ceftriaxone 1 gm iv BID, metronidazole 500 mg iv
TID and cemitidine 200 mg iv BID given.
 prepared for emergency laparatomy.

09/01/2021 44
 Operation
On next day , after written consent was taken patient taken to OR and under general
ansthesia explaratory laparatomy was done.

IOF; 0.75 x 0.75 cm perforation 80 cm from ileocecal valve on antimesenteric border.

500 ml thin pus in generalized peritoneum. Palpable lymph node at mesentery on
perforation site.

Done; resection of small bowel , proximal and distal to perforation site with palpable
lymph node. Ileo-ileal E-E anastomosis was done, mesenteric defect was
approximated. Abdomen washed with warm saline thoroughly and abdominal wall
closed in layers. Sample sent for biopsy.
Patient transferred to ICU with
V/S
PR=104, BP=112/69,SPO2=70% when she was out of mechanical ventilator.

09/01/2021 45
 Day 1, immediate post op day
P1:Immidate post op after exploratory laparotomy+ ileal resection and E- E
ileo-ileal anstomosis was done for GP 2 small bowel perforation(? Typhoid
perforation)
P2; grade IV UVP

V/S: PR=98,RR=18, BP=80/62 T= 36.7, spo2 =98%

DONE Cbc
PUT on MV, SIMV mode Wbc=21.7k
 Kept NPO, resuscitated with 02 bag of N/S Neu=83.1%
Ceftriaxone 1gm iv BID Hct=34.8%
Hgb=11.6g/dl
Metronidazole 500 mg iv TID Plt=167k
tramadol 50 mg iv tid Cr=0.54
transfused with 01 unit of cross matched whole blood.

09/01/2021 46
 2 day, first postop
nd

• Ass=same + ? Septic shock

bp=87/59, pr=feable, RR=32 SPO2=96%, Cbc
Wbc=??
done Neu=83.1%
Hct=41.5%
 Kept NPO Hgb=11.4g/dl
Plt=112k
 Ceftriaxone 2gm iv BID Cr=1.18
 Metronidazole 500 mg iv TID
 Adrenaline 0.1µg/kg/min, start from 10 drop
 Tramadol 50 mg iv qid
 Cimitidine 200 mg iv bid
 UFH 7500 SC BID
09/01/2021 47
 2 day, first postop
nd

• Ass=same + prerenal azotemia

V/S; bp =109/60, pr =110, RR=30 SPO2=90%,
UOP=200ML/6hrs
• Done
 ceftriaxone discontinued and ceftazidime 2gm iv TID
and Ciprofloxacin 400 mg iv TID started.
 Maintenance dose of adrenaline drip (65 drops/min)
 Other management continued

09/01/2021 48
 3 day, 2 post op
rd nd

 P1:Immidate post op after exploratory laparotomy+ ileal resection and E-

E ileo-ileal anstomosis was done for GP 2 small bowel perforation(?
Typhoid perforation)
 P2; grade IV UVP
 P3, septic shock
 P4, AKI 2 to sepsis
Wbc=19.2k
V/S, BP=111/68,PR=110. RR=30, SPO2=82%, UOP=0/6HRS
Neu=61.9
 Ceftazidime 1gm/24hrs Hg=10.4
 Ciprofloxacine 400mg/24hr Hct=36
Plt=96k
 Vancomycin 750 mg /24hr
 Dopamine 5µg/kg/min started Urea=80
Cr=2.84
 lasix 20 mg iv escalate, by 20 mg unti there is uop
AST=129
 Other management continued ALT=80
09/01/2021
ALP=147 49
ALB=1.49
 4 day, 5 post op day
th

• Ass= same + non cardiogenic pulmonary edema

V/S; BP=119/58, PR=Feable, rr=28 ,spo2=75, uop=50 ml/12hrs
HEENT, PC, NIS
CHEST; transmitted sound
Cvs ; s1 and s2 well heard
Abdomen; clean mid line dressing, distended abdomen, no active bowl sound.
GUS; protruded mass per vagina
IS; edematous extermities
CNS; E1M1VT pupil ,dilated and fixed

done
 Lasix 100 mg iv tid , escalate by 20 mg iv until 160 mg if BP allows???
 Continue other mangement.

09/01/2021 50
 5 day, 6 post op day
th th

• Ass=same +recurrent hypoglycemia(RBS=26,28….)

• Bp=86/54,RR=feable, , UOP=20ml/6hr
 Start sips???
 Ceftazidime 500mg/24hr
 Hydrocortisone 50mg iv QID Urea=125.5
 Lasix 160 mg iv QID Cr=3.85
AST=613
 Continue adrenaline and dopamine drip ALT=182
ALP=128
 continue other mx. ALB=0.95
NA­=164
CL=3.7

09/01/2021 51
• Patient died on 07/01/2013 at?? Due to MOF
2 refractory septic shock.

09/01/2021 52
 pitfalls
 No progress note after admission
• Emergency laparotomy decided but operated next day
• Delayed presser treatment
• RBS is not properly monitored
• Hypoglycaemia is not properly managed
• High dose lasix given despite the patient is in shock
• Hpoalbuminemia is not managed
• frequent antibiotics revision(twice the same day)
• Poor V/S follow up despite on presser treatment

09/01/2021 53
 Chart review
• 26 charts reviewed from ortho and general surgery ward.
• All have no investigation summary
• All are not ordered properly
• All operated patients have no pre anesthetic evaluation
• 6 operated patients have no intraop anaesthesia
recording sheet
• All operated patients have safe surgical cheeklist , but not
properly recorded
• All operated patients have signed consent form.
• Post op order is written on operation note sheet

09/01/2021 54
 Strengths
• Morning sessions daily.

• Daily rounds by consultants and/or residents.

• SRC coverage 6x/week by consultants and residents.

• Good communication with in the team

• Separated MOR for Elective and Emergency cases.

• Monthly audit report.

09/01/2021 55
 Problems and limitations
• No disposable glove
• Poor coordination in trauma response
• Lack of trained supporting emergency team
• Lack of resuscitation material in the ER
• Problems regarding patient Referrals to other setup
• Under documented MOR, EOPD, and ETAT log books
• Poor chart keeping
• Pre anaesthetic evaluation is not done for all patients
• High attendant flow in the ward and ER, and security issue especially on duty
time
• Shortage of stitch, and equipment's are old and not properly working in MOR
• Shortage of drugs, roll bandage, and stitch materials in the emergency
pharmacy

09/01/2021 56
 recommendations
For the administrative
• Provide disposable glove at least at ER
• Control attendant flow
• Training the ER stuffs regarding trauma support
• Provide instruments for minor OR
• Availing drugs and materials in the ER pharmacy
• facilitate Catchment centre for Neurosurgery cases
• Avail Serum electrolyte and ???CT SCAN.

09/01/2021 57
 Recommendations…
FOR SURGICAL STAFFS
• Improve documentation and chart keeping
• Improve patient follow up , rounds 2x/day
• Improve registration in MOR
• Complete Ix for elective cases before
admitting for elective surgery
• Continue monthly audit report

09/01/2021 58
 THANK
YOU

09/01/2021 59