Documenting Drain Output Following Intra-Operative Drain Insertion for Cholecystectomy at Whipps Cross University Hospital

Abstract

Aim: To assess the current practice of documenting drain output, amount and type and to identify methods to improve the documentation of the drain output following cholecystectomy. Method(s): Data and demographic details of all patients who have intra-operative drain insertion for cholecystectomy at Whipps Cross hospital between 01-01-2025 and 30-06-2025 were obtained from theatre electronic system. Retrospective review of patient notes was conducted to determine whether the drain output was documented. Result(s): A total of 29 patients were included in this audit. * Gender :15 female(51.72) and 14 male (48.28) * Median age: 62 years (range: 34-90 years) * 17 operations were performed as an Elective(58.6%) and 12 operations as an Emergency 41.4%) * 27 operations were performed as Laparoscopically, one operation as Robotic and one operation as open. * Most common indication for surgery is Acute cholecystitis(37%) and recurrent cholecystitis(31%) in addition to biliary colic and gallstone pancreatitis * Difficult dissection of the gallbladder being the most common indication for drain insertion(55%), followed by pericholecystic abscess formation (17%) and intra-operative bile leak and bleeding (10% each). * Drain output has been documented in 24 patients(83%) and in 5 patients the drain output has not been documented (17%). Heamoserous fluid being the most common type of fluid in the drain, 22 patients(76%) and only 2 patients has bile. Conclusion(s): Increase awareness among the general surgery team regarding the importance of drain output documentation. Incorporate automated prompts in electronic medical records to ensure drain output is included in post operative patient assessment.