The assessment of usefulness of the qualification card and ultrasonographic consultation.

The result of therapeutic success is always the effect of medical professionals cooperation. The creation of adequate mechanisms of cooperation of these teams demands time and appropriate examples. In the understanding of differentiated behaviors in the line patient - diagnostician - surgeon, particularly the mechanism of the cascade of errors formation, giving simple examples may help - their awareness will facilitate the formation of an adequate pattern of diagnostic-therapeutic chain. The therapeutic team formed in this way provides optimal forms of cooperation and positive result. One of the elements of the cooperation is the surgical procedure qualification card which is an example of the communication between surgeon and diagnostician. The propagation of proven examples seems to be justified by practical reasons. The introduction of the surgical procedure qualification card enabled maintaining of the preoperative and postoperative diagnoses in the range from 88.4% to 89.29%, the barrier of 90% however is still not achieved. The diagnoses discrepancy is still the most often occurring patient safety incident and our results should head towards its mineralization. In particularly complicated cases we come back to a well-known form of medical consultation, that is the form of examination and treatment establishment basing on simultaneous physical and ultrasound examination - hence the colloquial name of ultrasound consultation. The universality of medical consultation makes out of it an excellent tool, particularly in cases of significant discrepancy between physical and ultrasound examination. This is excellent form of the experience exchange and learning about mutual possibilities. We believe that the mechanisms presented will influence the improvement of patient security.

Introduction

Bearing in mind that therapeutic success is always a result of cooperation of many medical professionals, medical centers create therapeutic teams enabling, thanks to close cooperation, achieving a good result. It is important to understand the needs of each side which without an appropriate form of communication must remain only a dream. In order to demonstrate communication forms, we are going to build the smallest model of therapeutic team (actually still diagnostic) consisting of surgery representative, referred to as “surgeon” and imaging diagnostic specialist referred to as “diagnostician”. In our opinion this is a training example which can be referred to different medical fields. The result of the cooperation of this team is a correct diagnosis qualifying, or not, for operative treatment. It results from our studies that the discrepancy between preoperative and postoperative diagnosis is the most often occurring patient safety incident. As a result it may cause serious consequences for a patient(.

In everyday practice we can observe a series of patient safety incidents. Let us analyze them beginning from the most extreme one.

A patient with complaints comes to a surgeon. After examining the patient the doctor sends them to “some” diagnostician, usually with no referral, in order to have ultrasound examination done and to come back in order to establish appropriate treatment. A little bit better situation is in National Health Fund centers in which there has to be a referral, however the diagnosis written on it usually does not explain anything. There are also concrete diagnosticians, that is the ones with whom a contract for medical service had been signed. Unfortunately, they know nothing about the result of the physical examination and the expectations of the surgeon referring the patient. Both examples illustrate incorrect (wrong) form of cooperation. Incorrectly written referral or lack of it leads to incorrectly performed examination. A cascade of errors is formed: incorrect referral gives incorrect diagnosis and this in turn gives incorrect therapeutic decisions. This sounds ominously, however this is how the reality, in which the patient lives, often looks like.

This situation leads to the formation of repair mechanisms, still non-systemic, but individually solving the given problem:

A diagnostician understanding the problem tries to take medical history on his own and to examine the patient before performing diagnostic examination. This practice is taught by MD Zbigniew Czyrny on his authorial lectures. Not only does he take medical history but also he thoroughly examines the patient and often is present in the operating theatre in order to confront difficult diagnostic examination with the picture of the surgery. He also teaches dynamic (functional) ultrasound examination which includes basic elements of orthopedic examination.

The patient makes his way shorter and goes first to the diagnostician in order to have an examination performed including physical and ultrasound examination. After obtaining the result he goes to a surgeon indicated by a diagnostician.

Surgeons, trying to save their position, buy ultrasound equipment to their surgeries and perform the examination by themselves although they do not have a lot of experience in this aspect.

As far as the first mechanism, propagated by MD Czyrny is universal, the efficacy of the remaining ones is not going to be great without basing on the first one. The effect must lead to the understanding of the role and competences of each side: surgeon must examine and then operate and diagnostician has to perform preoperative and postoperative examination. Basing on the therapeutic team a diagnostic-therapeutic process should be formed. Without it the efficacy of the actions of each side decreases. We observe the formation of these teams, both formal and informal. This created new forms of communication, the examples of which we are going to show below.

Qualification card for arthroscopic treatment in children

The skill of the correct interpretation of physical examination often does not sit well with the competence of the correct interpretation of imaging examination. The result of this is very often incorrect qualification for operative treatment or not performing it.

Incorrect qualification is also incorrectly obtained informed consent for the surgical procedure and also incorrectly prepared and often incorrectly performed surgical procedure.

The example given will explain this complicated argument.

The result of the examination and preliminary diagnosis: joint sprain (the whole sac of diagnoses) and referral to ultrasound examination. The result of the examination is descriptive – because what else can a diagnostician do. According to their knowledge they describe particular elements of the joint which might have been damaged. The description formed is very extensive, full of doubts caused by lack of detailed clinical data. The conclusions made by surgeon are most often based on the notes from the preliminary clinical examination. The diagnostic value is therefore uncertain. Let us concentrate on the forming cascade of patient safety incidents (errors); as a result of incorrectly written referral we obtained “some” examination. This in turn gives some preoperative diagnosis. Neither of the doctors consults their diagnosis because they cannot communicate. One can have an impression that surgeon referred the patient to the diagnostician in order to check the result of their examination. The surgical procedure is also uncertain: diagnostic-therapeutic arthroscopy because of… sprained joint? After performing the surgery according to the general qualification we state e.g. anterior cruciate ligament damage. Diagnostic arthroscopy was performed and reconstruction was recommended in the later period. There was no patient's consent, operative equipment and so on. This means that the proper diagnosis is established only now.

There may be many questions but the cascade of errors still increases. The presented example is typical for all the medical fields. Lack of appropriate communication between professionals created diagnostic errors, the result of which is incorrectly performed therapeutic procedure – because it is ineffectual.

The construction of qualification card is based on a simple mechanism: the surgeon makes a preliminary diagnosis and refers the patient to the imagining examination, in this case ultrasound. The examination is performed by a diagnostician (it would be beneficial if at the beginning of the cooperation the surgeon was present during the examination) and establishes preliminary diagnosis. The preoperative diagnosis is made collaboratively basing on the surgeon's and diagnostician's examination. After performing the surgery the following diagnoses are assessed: preliminary, diagnostic, preoperative and final. This is important for both sides. The results may be surprising. Understanding of mutual relationships usually facilitates functioning of diagnostictherapeutic chain. Matching of these two necessary elements often takes a lot of time and the results might be different. This time, however, is not wasted because both surgeon and diagnostician mutually learn (figs. 1 and 2).

Fig. 1

Qualification card sample introduced by MD Leszek Bojarski in 1986

Fig. 2

Sample of the qualification card used in 2010. The division into surgical and diagnostic part and tables with diagnoses can be seen

In the preliminary stage of preoperative diagnosis making it is worth to turn to a well-known form of medical consultation, sanctioned in our country with jural acts(. Its form, called ultrasound consultation, was propagated by Polish eminent surgeon professor Józef Dzielicki. Consultation takes place in case of a discrepancy of diagnoses made by surgeon and diagnostician or in so-called “complicated cases”. The rule is the performance of ultrasound examination and physical examination in the presence of the therapeutic team member and the presentation of different examination results in order to establish the correct diagnosis and further treatment. Although this may seem a relic of the past, we have learned the advantages of this diagnostic tool many times, not only in orthopedic but also surgical cases. The result of a medical consultation was very often surprising for its members. We must admit that patients took part in the ultrasound consultation with a great understanding, with no qualms undergoing successive tests, often repeated many times.

The aim of the study

Presentation of the advantages of the qualification card for arthroscopic treatment in children.

Assessment of the use of the qualification card in diagnostic-therapeutic process.

Material and methods

The study included 728 children aged from 4 to 18 years old (average age 15.4) treated operatively in the period from January 2005 to March 2010.

The patient safety incidents were assessed according to the Rec 2006(7) Recommendation of the Committee of Ministers for the member states about patient safety management and the prevention of patient safety incidents (ZN) in healthcare, accepted by the Committee of Ministers of the Council of Europe during 95th meeting on 24th of May 2006.

The level of damage was assessed according to NPSA (National Patient Safety Agency) with the division into degrees and according to Dindo-Clavien classification.

The first assessment was made after performing 441 knee joint arthroscopies, the second – after 626 arthroscopies and the third – after 728 arthroscopies. The analyzed group is not homogenous because the percentage of performed reconstructive procedures and complex procedures on knee joint systematically increased. This was caused by organizational changes and the improvement of the skills of the operative team.

Results

The risk of patient safety incident occurrence on the particular stages of the assessment equaled: 26.30%, 29.61% and 29.53%. This is the sum of the detailed indicators: rearthroscopies – 1.81%, 3.19%, 3.71%; local and general infections – 1.36%, 1.78%, 1.79%; equipment damage – 0.68%, 1.12%, 1.65%; intraarticular hematomas – 5.44%, 5.91%, 5.77%; performed microarthrotomies – 0.68% to 0.96%, 0.82%; percentage of transient neurological and vascular disorders – 0.68%, 1.28%, 1.24%; so-called “anesthesiological complications”– 2.49%, 2.88%, 3.02%; ooze of the fluid beyond the joint – 0.45%, 0.48%, 0.69%; incorrect qualification for the surgical treatment – 11.56%, 10.86%, 10.71%.

The probability of patient safety incident occurrence in correlation to incorrect qualification for the surgical procedure and rearthroscopies, that is performed one more time, unintentional arthroscopy because of the same reason, was significant for the assessment of the introduced mechanism (tab. 1, fig. 3).

Tab. 1

The comparison of patient safety incident, incorrect qualification for surgical treatment and rearthroscopies

Patient safety incident (%)	441 arthroscopies	626 arthroscopies	728 arthroscopies
Risk of occurrence	26,3	29,61	29,53
Incorrect qualification for surgical treatment	11,56	10,86	10,71
Rearthroscopies	1,81	3,19	3,71

Fig. 3

Comparison of patient safety incident, incorrect qualification for operative treatment and rearthroscopies

Most patient safety incidents did not do any harm to the patient. Only three of them caused transient undesirable effects.

Conclusions

The introduction of the qualification card for the arthroscopic treatment in children allows to improve the communication between the therapeutic team members.

As a result of the introduction of the qualification card the percentage of incorrectly qualified patients for the operative treatment decreased which positively influences the level of safety.

Discussion

The review of publications points to significant discrepancies between test results and preoperative examinations in their confrontation with the result of postoperative diagnosis. Searching for a new form of diagnostic solutions in the form of a purchase of more and more perfect equipment not always improves the existing condition because we must know what and where to look for. This forces searching for the forms of contact between surgeon and diagnostician.

The increase in the access to imaging diagnostics of knee joint – in particular magnetic resonance and high frequency ultrasound gives huge possibilities of the improvement of knee joint diagnostics. It is assumed that currently we should not qualify for arthroscopy patients who had not had an imaging examination performed which should confirm clinical indications in order to reduce the number of unnecessary arthroscopies similarly as the number of unnecessary arthrotomies was reduced(.

We think that the introduction of the qualification card before surgical procedure can improve the communication between the therapeutic team members. The card presented in this article is a result of the cooperation of the members of our team and applies only to the qualification for the arthroscopic treatment in children. Nevertheless, basing on it we proposed further forms of cooperation between the team kwalifimembers – further cards qualifying for successive operations/ surgeries.

Thanks to arthroscopy it was possible to verify established preliminary clinical and imaging diagnosis. Curran and Woodward analyzed 396 knee arthroscopies obtaining the compliance with the clinical assessment at the level of 71%(.

Vähäsarja et al. analyzed 138 arthroscopies in patients with acute knee trauma, stating 44% compliance of the clinical examination result with the arthroscopy result for children below 12 years of age and 67% compliance for older children(.

Eiskjaer and Larsen in the analysis of 182 arthroscopies confirm clinical diagnosis in 44%(. Similarly low efficacy of clinical study was stated by Hope basing on 67 arthroscopies in children aged 2–16. The clinical diagnosis was confirmed by the author in 45% of cases and in 51% arthroscopy extended preliminary diagnosis with significant elements. Hence the conclusion that an indication for arthroscopy is clinically significant pathology or chronic diseases which do not react to conservative treatment(.

Different results are obtained by other scientists. Analyzing 211 knee joint arthroscopies, Majkusiak et al. noted 83% compliance of the clinical study with ultrasound examination(.

Idzior and Walczak compared the material of 43 children aged 13–17 treated arthroscopically and they stated 74% compliance with ultrasound examination(.

One of the reasons of discrepancy is the lack of communication between surgeon and diagnostician, lack of knowledge about the expectations and possibilities of each side. But there are also praiseworthy exceptions, the example of which is proctology, a very difficult medicine discipline – a surgeon talks to a diagnostician about how to mutually communicate and what to expect of ultrasound examination. Articulation of the expectations and also possibilities should always be constructive. Medical professionals can loudly speak about what can and what cannot be shown or done(.

The surgical treatment qualification card is created in this purpose: in order to formalize diagnostic operations and show in a clear way diagnostic procedures performed in a patient. This is an important element of a larger whole. The effects of its processing are used for the construction of security system basing on the probability of the patient safety incident occurrence. The qualification card, taking part in patient safety program, is an excellent element complementing Perioperative Control Card used by our team and developed by CMJ in OZ in Cracow in cooperation with WHO(. Perioperative Control Card is an excellent example of perioperative communication of the operating team and its final result enables the improvement of patient safety proved in many clinical studies all over the world(.

The presented group of patients is characterized by currently stabilized parameters of patient safety incidents. Only the increasing number of rearthroscopies is alarming which yet seems to be a typical phenomenon for a developing population (the age of children in the range from 4 to 18 years old). This will be the subject of further studies.

Conclusion

The aim of the qualification card and ultrasound consultation is based on a simple rule: two pairs of eyes are not one pair, two heads are not one head. The condition, however, is a close cooperation because, as it is known, the efficacy of this process decreases with the square of distance and lack of communication. We must want the same thing – patient's welfare. Then the success is guaranteed.