The George Hospital theatre documentation and information system

Abstract

George Hospital is a secondary level hospital in the Garden Route district of the Western Cape. Its theatre complex consists of five theatres and an endoscopy suite. The main stakeholders in the theatre complex are the surgical disciplines, the nursing staff and anaesthesiology. The thread that connects all stakeholders of theatre is the documentation requirements of every case that passes through the complex. This process has historically been associated with two specific frustrations: the legibility of notes and the duplication of information evident in creating the necessary documents for the surgeon, anaesthetist and nursing staff. The information recorded was often illegible, uncoded and incomplete. This resulted in concerns about inappropriate patient care as a result of misinterpretation of notes, insufficient data surrounding pending medico-legal cases or for morbidity and mortality review, and the inability to review individual and theatre complex performance. These issues were not unique to our hospital but when I arrived in 2010, the frustration they engendered was enough for me to try and create a solution – an automated documentation and information system. The clinicians needed a tool to make their work easier, and management needed an operational tool that would provide them with clinician-created data reflecting the efficiency of the theatre environment. The ultimate aim was to create a user-friendly digital platform for clinicians to engage with in theatre to assist in patient care.