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. 2023 May;133(5):1234-1238.
doi: 10.1002/lary.30286. Epub 2022 Jul 16.

Documentation in Pediatric Microlaryngoscopy/Bronchoscopy: International Modified Delphi Consensus

Penelope Neocleous  1 , Agnieszka Dzioba  1   2 , Julie Strychowsky  1   2 , Murad Husein  1   2 , Evan J Propst  3 , Lily Hp Nguyen  4 , Nikolaus E Wolter  3 , Peng You  1   2 , Sukgi Choi  5 , Michele Torre  6 , George Zalzal  7 , Sanjay Parikh  8 , Deepak Mehta  9 , M Elise Graham  1   2 ; Pediatric Bronchoscopy Working Group
Affiliations

Documentation in Pediatric Microlaryngoscopy/Bronchoscopy: International Modified Delphi Consensus

Penelope Neocleous et al. Laryngoscope. 2023 May.

Abstract

Background: Complete and accurate documentation of surgical procedures is essential for optimizing patient care, yet significant variation in operative notes persists within and across institutions. We sought to reach consensus on the most important components of an operative note for pediatric microlaryngoscopy and bronchoscopy.

Methods: A modified Delphi consensus process was used. A checklist for operative documentation, created by fellowship-trained pediatric otolaryngologists-head and neck surgeons, was sent to surgeons identified as experts in pediatric laryngoscopy and bronchoscopy. In the first round, items were rated as "keep" or "remove". In the second round, each item was rated on a 7-point Likert scale for importance. The mean score of each item was calculated to determine if consensus was reached.

Results: Overall, 43/74 (58.1%) surgeons responded to our survey. After two rounds of editing, 28 components reached consensus, 24 were near consensus, and 26 did not reach consensus. Items that reached final consensus had mean (SD) ratings of 6.12 (0.94) (range, 5.31-6.72).

Conclusion: Pediatric otolaryngologists identified as bronchoscopy experts were able to create a checklist of essential components of an operative note for pediatric laryngoscopy and bronchoscopy using a Delphi method. Items reaching consensus included procedure name, description of breathing, grade of airway view, description of normal anatomic structures, grade of subglottic stenosis if present, presence and description of tracheobronchomalacia, presence of fistulae, cleft and rings, and several special cases including foreign body and tracheostomy management, as well as end of procedure disposition and complications.

Level of evidence: 5 Laryngoscope, 133:1234-1238, 2023.

Keywords: Delphi; bronchoscopy; documentation; laryngoscopy; operative note.

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References

BIBLIOGRAPHY

    1. Peterson K, Ginglen JG, Desai NM, et al. Direct laryngoscopy. Ncbi.nlm.nih.gov. Updated October 27, 2021. Accessed January 12, 2022. https://www.ncbi.nlm.nih.gov/books/NBK513224/
    1. Novitsky YW, Sing RF, Kercher KW, Griffo ML, Matthews BD, Heniford BT. Prospective, blinded evaluation of accuracy of operative reports dictated by surgical residents. Am Surg. 2005;71(8):627-632.
    1. Smyth NA, Sabeh KG, Meiyappan K, Conway SA, Dodds SD. Operative reports in Orthopaedic surgery: the need for assessment and education. J Surg Educ. 2020;77(1):229-234. https://doi.org/10.1016/j.jsurg.2019.08.013.
    1. Leotsakos A, Zheng H, Croteau R, et al. Standardization in patient safety: the WHO high 5s project. Int J Qual Health Care. 2014;26(2):109-116. https://doi.org/10.1093/intqhc/mzu010.
    1. Hyde GA, Biderman MD, Nelson EC. Resident operative reports before and after structured education. Am Surg. 2018;84(6):987-990.

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