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Recordkeeping and reporting for trichiasis surgery

Watch this video to learn how to apply the principles and details of recording TT patient information, surgical output and surgical outcome.
Recordkeeping is carried out in order to manage: individual patient care, how much surgery has been done - this is measured through output and coverage figures, how good the surgical service was - this is measured through outcome figures. Good recordkeeping is an active process. A trained person collects the information and stores it correctly. The collected information is assessed at regular intervals by a manager or co-ordinator who prepares a report. This is known as monitoring. Monitoring can be carried out every month or even after every outreach. Ideally, the manager also sends feedback to the trichiasis surgery team on any trends or issues identified in the monitoring report. The team can use this information to improve their service.
It can often be challenging to ensure that suitable information is collected at the right time and that a complete and correct record is kept.
Poor recordkeeping examples include: incomplete or missing records, illegible information, records on loose paper that are not archived, incorrect data collected. Poor recordkeeping leads to serious consequences
for trichiasis surgery services, such as: Inadequate co-ordination and continuation of care. Poor decision making capacity. Lack of accountability, and inaccurate statistics in reporting. To monitor trichiasis surgery services,
three sets of individual patient records need to be kept: pre-surgical records, surgical records, and post-surgical records. All data are standardised. That is, the nature and format of information collected about each patient are the same. It is best to assign the responsibility of recording and collecting patient record information to one member of the trichiasis surgery team. Data can be recorded on paper or electronically. At the end of each outreach - within a day - all the information should be sent to the local health worker supporting the follow up. It is also sent to the team’s supervisor or manager within a week. The manager verifies and analyses the data before passing it on to national coordinators and sending feedback to the team.
Patient information is collected on location, age, gender, address and contact details for follow up.
Pre-surgical information is collected on: presence or absence of scar indicating previous surgery, on the upper eyelid. severity of trichiasis, that is the number of upper eyelid eyelashes touching the eyeball, evidence of epilation of in-turned eyelashes, presence or absence of lower eyelid trichiasis. It is important that the surgical team also obtain, record and archive each patient’s consent for surgery. Analysing the pre-surgical records. The supervisor or outreach manager analyses the pre-surgical records to generate information on the acceptance rate and coverage of the trichiasis surgery service. They do this for each community, sub-district and district. Coverage is calculated for persons. Coverage equals the number of trichiasis surgeries done, divided by the total number of patients with trichiasis, multiplied by 100.
The acceptance rate equals the number of patients who consented to have surgery divided by the total number of patients with trichiasis who were offered surgery, multiplied by 100. Acceptance can be further assessed by gender.
Managers use coverage and acceptance rate information to: Assess whether enough surgeries are being done to eliminate trachoma. Assess how successful community sensitisation activities can be sustained. Encourage the trichiasis team to carry on. The target for the elimination of trachoma in an area is a prevalence of trichiasis of less than 0.2% in adults aged 15 years and above. The generally accepted target for trichiasis surgery outreach campaigns is 15 surgeries per surgeon per day. This target may be different in your area as it relates to the local prevalence of trichiasis. If the number of surgeries being carried out is below target, managers discuss with the team whether this is due to inadequate community mobilisation or lack of sufficient manpower and materials.
They also consider ways to improve.
If the number of surgeries being carried out is above target, managers feed this information back to congratulate and motivate the team on the work done. Surgical records.
The information collected in the surgical record includes: the name of operating surgeon, eye being operated on, type of operation, that is bilamellar, or posterior lamellar, tarsal rotation, if a clamp was used, type of suture used. Information on any surgical complications
is also collected: excessive bleeding, if the margin fragment severed, if globe puncture occurred, or other. Finally, information is collected on whether oral azithromycin or topical tetracycline are given to the patient. The surgical record informs surgeons about their own complication rate and also about the most common complications they are experiencing. Ideally, this information is verified with a supervisor and training support is provided to surgeons as needed. Sometimes surgeon payments are linked to numbers of surgeries done. Post-surgical records. Follow up data on each patient is recorded at day 1, 7 to 14 days (if silk suture is used) and between 3 and 6 months after the operation.
PTT cases need to be referred to the most experienced trichiasis surgeon or eye specialist available for assessment and a management plan. Between diagnosis and review by that professional, epilation (which is repeated plucking of lashes) is encouraged. Epilation or electrolysis - the removal of trichiatic [eye]lash roots with the application of heat using electric current should be the first management approach when the patient has only a few peripheral eyelashes touching the eyeball, with no eyelashes touching the cornea and no entropion.
Surgery should be considered in patients with PTT in whom: trichiatic eyelashes present a threat to vision, or there is evidence of entropion. The potential risks and benefits of surgical and non-surgical approaches need to be discussed with the patient.
And on the presence or absence of: infection or discharge, granuloma - this is the feeling a foreign body, or a visible lump, on the inner-side of the eyelid, eyelid contour abnormality, over-correction.
It’s important for managers to share data from post-surgical follow up with the surgeon and team, and to reflect on any action required. For example, if at the 7-day visit it’s found that there’s a high percentage of cases with wound infection, then the sterilisation and intraoperative processes used by the surgical team should be reassessed. If a high percentage of overcorrection is being found then the surgeon may need refresher training.
Key reporting activities for managers: 1. Send data to local authorities and supervisors to verify. 2. Share feedback on results from data with the surgical team and with individuals in charge. 3. Take informed action to improve and enhance service delivery. Good data can also be used to reinforce support from funders. In practice, when reporting, trichiasis surgeons need to target a cumulative incidence (frequency)
of post-operative trachomatous trichiasis of: less than 10% by six months for cases that had minor trachomatous trichiasis, which is 5 or less [eye]lashes touching the eyeball, pre-operatively, and less than 20% by six months for cases that had major trachomatous trichiasis, which is 5 or more eyelashes touching the eyeball pre-operatively. In summary. Recordkeeping is an essential component of a trichiasis surgery team’s work. It should be done by a dedicated, trained person using pre-agreed, standardised data forms. The forms may be paper-based or electronic. Managers must analyse and verify the data to guide and improve service provision.
Data trends guide trachoma programme activities towards achieving the trachoma elimination target of a prevalence of trichiasis of less than 0.2% in adults aged 15 years and above.

To achieve high coverage and high quality in a trichiasis surgery service, we need to measure how we are doing.

Data collection and recordkeeping happen together:

  • Patient registration forms: Information to trace and locate each patient. Data collected include: name, age, sex, district, sub district, village, location, compound.
  • Facility summary register: Monthly data summary for each facility. Shows numbers of surgeries done, proportion given post-operative azithromycin, number of women and men that received surgery, and so on.
  • District summary register: Each district office collects monthly data from each facility and calculates the total number of surgeries done per month in the district.
  • Regional summary register: Each region records monthly totals from all constituent districts.
  • National summary register: Data from all regions are collated and used to report to funders and at global level.

The TT Case Manager assists with all of these functions (see the previous step).

Nurse working on statistics Realising for the first time what statistics mean. © Victoria Francis CC BY-NC (Click to expand)

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Eliminating Trachoma

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