Improving the documentation of intraoperative use of tourniquets using an operation note template in a single centre.

AIM: Tourniquet use is common practice in operative theatres, specifically in trauma and orthopaedic surgery. Documentation is important for having postoperative records in case of a complication. Having a system in place can ensure consistency of documentation. Our aim was to improve the documentation surrounding tourniquet use in our department.

METHODS

This is a prospective, two-stage, closed-loop audit of departmental operative notes against the British Orthopaedic Association Standard for Trauma standards for tourniquet use. Our intervention was the introduction of a specific tourniquet section in the operative note template along with departmental teaching sessions. A second cycle audit was performed post-intervention.

RESULTS

Substantial improvements in documentation across all domains were found during the second cycle audit.

DISCUSSION: Surgeons were aware of their low rate of documentation, although this only improved after the first cycle. Similar audits have shown comparable shortcomings and subsequent promising results following the implementation of an electronic template.

CONCLUSIONS

Operative templates improved the completeness of documentation regarding tourniquet use across all domains.

RECOMMENDATIONS: Continuation of this audit nationwide, with the introduction of an electronic template, can be beneficial, both departmentally and for patient safety.