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Trial registered on ANZCTR
Registration number
ACTRN12624001128583
Ethics application status
Approved
Date submitted
27/08/2024
Date registered
18/09/2024
Date last updated
18/09/2024
Date data sharing statement initially provided
18/09/2024
Type of registration
Retrospectively registered
Titles & IDs
Public title
Lost in Transcription – How accurately are we documenting the surgical ward round?
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Scientific title
Lost in Transcription – How accurately are we documenting the surgical ward round in patients admitted to the Department of Surgery at The Queen Elizabeth Hospital?
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Secondary ID [1]
312821
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None
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Universal Trial Number (UTN)
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Trial acronym
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Linked study record
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Health condition
Health condition(s) or problem(s) studied:
Surgery
334907
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Condition category
Condition code
Surgery
331454
331454
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0
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Other surgery
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Intervention/exposure
Study type
Observational
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Patient registry
False
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Target follow-up duration
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Target follow-up type
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Description of intervention(s) / exposure
General Surgical Patients admitted to South 2 Ward of the Queen Elizabeth Hospital were enrolled in this study. Patients were audio-visually recorded using a small camera during ward rounds. The videos were then transcribed verbatim and compared to the patient case notes retrospectively to assess how accurately the notes captured the discussions had and decisions made. Observations that were being collected involved, number of times patient asked a question and duration of speaking time from the patient. Patients were note asked to complete any questionaries. The overall time of observation was for the duration of the surgical ward round which usually lasted between 2 and 10 minutes. The video recording started when the surgical team walked in, and was stopped as soon as the last member left.
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Intervention code [1]
329363
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Not applicable
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Comparator / control treatment
General Surgical Patients admitted to South 2 Ward of the Queen Elizabeth Hospital.
During this study, patients act as their own control as the audio-visual recording will be compared to the patient case notes.
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Control group
Active
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Outcomes
Primary outcome [1]
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Documentation accuracy of patient case notes
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Assessment method [1]
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Audio-visual recording of Surgical Ward round and comparison to patient case notes
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Timepoint [1]
339203
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The documentation accuracy was assessed once all video recordings were captured and all patients had left the hospital.
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Secondary outcome [1]
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Length of stay
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Assessment method [1]
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Retrieved from patient case notes
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Timepoint [1]
439064
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Patient length of stay was assessed at hospital discharge.
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Eligibility
Key inclusion criteria
Patients will be eligible and approached by study investigators if admitted to the South 2 ward of The Queen Elizabeth Hospital, over the age of 18 and under the care of clinician(s) enrolled in the study.
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Minimum age
18
Years
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Maximum age
No limit
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Sex
Both males and females
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Can healthy volunteers participate?
No
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Key exclusion criteria
The absence of informed consent, either by lack of capacity or rejection of participation. Non-English speaking patients will also be excluded
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Study design
Purpose
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Duration
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Selection
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Timing
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Statistical methods / analysis
To address the primary objective, of determining how accurate patient case notes were, the number of Major, Minor and Not significant points in each audio-visual recording were tallied. To address the secondary objective, to determine what factors affected the accuracy of case note documentation, two multivariable linear mixed-effect models were performed between outcomes which were determined on an a priori basis determined by the literature: Percentage of ‘Major’ and ‘Minor’ and the covariates: patient age, location (rural or metropolitan hospital), patient sex (male, female), day of the week of the encounter, length of stay at the time of the ward round, clinician experience, and clinician time spent on the unit. The implementation of the checklist intervention was also included as a covariate to measure its effect on case note documentation. An Intraclass Correlation Coefficient (ICC) was calculated, and clustering was adjusted for using a random effect on the group that produced the highest ICC.
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Recruitment
Recruitment status
Completed
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Date of first participant enrolment
Anticipated
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Actual
12/05/2020
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Date of last participant enrolment
Anticipated
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Actual
1/07/2023
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Date of last data collection
Anticipated
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Actual
12/05/2024
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Sample size
Target
140
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Accrual to date
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Final
135
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Recruitment in Australia
Recruitment state(s)
SA
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Recruitment hospital [1]
27006
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The Queen Elizabeth Hospital - Woodville
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Recruitment postcode(s) [1]
43080
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5011 - Woodville
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Funding & Sponsors
Funding source category [1]
317259
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Other
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Name [1]
317259
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Avant Foundation
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Address [1]
317259
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Country [1]
317259
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Australia
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Primary sponsor type
University
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Name
The University of Adelaide
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Address
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Country
Australia
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Secondary sponsor category [1]
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None
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Name [1]
319537
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Address [1]
319537
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Country [1]
319537
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Ethics approval
Ethics application status
Approved
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Ethics committee name [1]
315995
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Central Adelaide Local Health Network HREC
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Ethics committee address [1]
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https://www.rah.sa.gov.au/research/for-researchers/central-adelaide-local-health-network-human-research-ethics-committee
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Ethics committee country [1]
315995
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Australia
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Date submitted for ethics approval [1]
315995
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09/04/2020
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Approval date [1]
315995
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12/05/2020
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Ethics approval number [1]
315995
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12993
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Summary
Brief summary
The purpose of this study was to understand how accurately surgical ward round patient case notes are. This was achieved by comparing audio-visual recordings of the ward round, to patient case notes. The hypothesis of this study is that ward round case notes are accurate and capture what is discussed in the ward round.
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Trial website
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Trial related presentations / publications
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Public notes
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Contacts
Principal investigator
Name
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Prof Guy Maddern
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Address
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The University of Adelaide, The Queen Elizabeth Hospital, 28 Woodville Rd, Woodville South SA 5011
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Country
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Australia
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Phone
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+61 8 82226750
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Fax
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Email
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guy.maddern@adelaide.edu.au
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Contact person for public queries
Name
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Guy Maddern
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Address
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The University of Adelaide, The Queen Elizabeth Hospital, 28 Woodville Rd, Woodville South SA 5011
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Country
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Australia
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Phone
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+61 8 82226750
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Fax
136451
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Email
136451
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guy.maddern@adelaide.edu.au
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Contact person for scientific queries
Name
136452
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Guy Maddern
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Address
136452
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The University of Adelaide, The Queen Elizabeth Hospital, 28 Woodville Rd, Woodville South SA 5011
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Country
136452
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Australia
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Phone
136452
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+61 8 82226750
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Fax
136452
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Email
136452
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guy.maddern@adelaide.edu.au
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Data sharing statement
Will individual participant data (IPD) for this trial be available (including data dictionaries)?
No
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No/undecided IPD sharing reason/comment
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What supporting documents are/will be available?
No Supporting Document Provided
Doc. No.
Type
Citation
Link
Email
Other Details
Attachment
24182
Ethical approval
388348-(Uploaded-10-09-2024-09-05-38)-12993 Maddern CALHN Ethics and Governance Approval Letter.pdf
Results publications and other study-related documents
Documents added manually
No documents have been uploaded by study researchers.
Documents added automatically
No additional documents have been identified.
Download to PDF