Correspondence her quality of life and that of some external assessor. be it a surgeon or carer. Second, it is clear that the frame of reference used by a person to evaluate their quality of life will itself be influenced by circumstances. A patient may see things quite differently following a major intervention. Aspects of life previously assigned little weight may assume increased importance after life-saving surgery. In this context, we are presently assessing the postoperative quality of life of patients presenting with ruptured aortic aneurysms.
C. OBoyle Di~purtt~ietit o/ P S J ~ U ) I ( J < J J . The RojwI C ~ l l e y eo / Surgeotis it1 Irelurid Mercer Street LOllW Duhliti 2 IrelNtld
Audit of general practitioner referrals t o an acute surgical unit Sir The recent paper by Dookeran et id. ( B r J Surg 1992; 79: 430-1 ) demonstrates not that general practitioners are falling down on their duties, but that inefficient organization of National Health Service resources results in an inefficient consumption of resources. The consultation level was selected to be the least experienced and therefore presumably the least able to provide detailed advice. To compound this, the person who assessed the arriving patients was also the least experienced member of the team, so it is hardly surprising that this resulted in inappropriate admission to hospital and undue consumption of resources. As the authors conclude, a great deal more efficiency could have been obtained had the general practitioner been able to speak to a surgeon with more surgical experience than himself, rather than less. In addition, there can be no doubt that clinical examination of a patient by an experienced surgeon is by far the most important method of assessment in patients referred to acute surgical units. I am surprised that the authors found it necessary to recourse to an audit of their activities to prove this.
P. D. Coleridge Smith Deportnierit of’ Suryerj, Uiiirersity College mid Midclleses Scliool The Middleses Hospital Loridori W I N 8 A A UK
Sir We read with interest the paper by Roxburgh ct erl. ( B r J Sury 1992; 79: 415- 18) concerning the attitudes of cardiothoracic surgeons in the UK to the human immunodeficiency virus type 1 (HIV-I ). We agree with their conclusions that HIV-I testing and the refusal of surgeons to operate o n such patients are not the answers to this problem. We also agree that changes in operative practice and the institution of additional precautions are needed if the risk of infection to health workers is to be minimized. The authors concluded, however, that these changes will take time and require considerable resources. The maintenance of an intact barrier between the hands of the surgical team and the tissues of a patient is an important factor in preventing the transmission of disease. The effectiveness of surgical gloves in providing this mechanical barrier has been questioned’.’. As Roxburgh et a/. point out, glove perforation may occur in up to 20 per cent of surgical procedures3, thus increasing the risk of cross-infection. Double gloving reduces the risk of cutaneous exposure to blood and body fluids4 by 60 per cent, but the associated loss of tactile sensitivity may make surgeons (particularly vascular ones ) reluctant to adopt this method of protection. In a study carried out in our department. nearly 70 per cent of all glove perforations detected during open heart surgery were shown to occur during sternotomy closure5. A subsequent prospective randomized trial showed that this incidence could be significantly reduced by the simple measures of either double gloving or wearing cotton gloves over a single pair of latex ones6. In open heart surgery we have therefore identified a specific stage of the operation (sternal closure) during which the potential for glove perforation is greatly increased, and have also shown that simple additional protective measures reduce this risk. As with all forms of additional protection, manual dexterity and comfort are reduced, but fortunately the stage of the operation at which the operating team is at most risk is also the stage requiring the least tactile sensation. We would suggest that more widespread use of these simple precautions during sternal closure in cardiac surgery would enhance the safety of operation for both the patient and surgical team. and that these methods would not, as the authors suggest, be time consuming or expensive to implement.
M. J. Underwood N. Weeresena T. R. Graham* J. S. Bailey R. K. Firmin
of’ Medicine
Authors’ reply Sir The practice of preregistration house officers accepting and arranging admission for acute surgical referrals from general practitioners is common in Leicester and in other hospitals in the Midlands (for example in Sheffield and Nottingham). The outcome of our audit of general practitioner referrals to an acute surgical unit is particularly useful because it demonstrates that inefficiencies exist in the acute surgical service and quantifies the cost of these inefficiencies. In this study the resultant cost was high approximately f25000. We believe that audit is an excellent method of determining the cost-effectiveness and utilization of acute surgical facilities, and would encourage all surgeons to use audit as a method of improving the efficiency of their acute service.
M. M. Thompson Leirester Royal Infirniary Leicester LEI 5 WW UK
Attitudes of cardiothoracic surgeons in the U K t o human immunodeficiency virus
K. A. Dookeran Glenfield General Hospital
Br. J. Surg., Vol. 79, No. 10, October 1992
Leirester LE3 9QP UK
The Curtliolkorucic Unit Grohy Roud Hospitul Leicester utid *The Curcliotliorucic Unit Tlie R o j d Loticlon Hospital Londori UK 1.
2. 3.
4. 5.
6.
Hussain SA, Latif ABA, Choudhary AAAA. Risk to surgeons: a survey of associated injuries during operations. Br J Sury 1988; 75: 314-16. Brough SA, Hunt T M , Barrie WW. Surgical glove perforations. Br J Sury 1988; 75: 317. Cole RP, Gault DT. Glove perforations during plastic surgery. Br J Plus/ Surg 1989; 42: 481-3. Gerberding J, Littel C , Tarkington A et ul. Risk of exposure of surgical personnel to patients’ blood during surgery at San Francisco General Hospital. N Engl J Med 1990; 322: 1788-93. Hosie KB, Dunning JB, Bailey JS, Firmin RK. Glove perforation during sternotomy closure. Lancer 1988; ii: 1500. Underwood MJ, Weeresena N, Graham TR rt al. The incidence and prevention of glove perforation during open heart surgery. J Tlioruc Curdioiaw Surg 1992 (in press).
1111
C. OBoyle Di~purtt~ietit o/ P S J ~ U ) I ( J < J J . The RojwI C ~ l l e y eo / Surgeotis it1 Irelurid Mercer Street LOllW Duhliti 2 IrelNtld
Audit of general practitioner referrals t o an acute surgical unit Sir The recent paper by Dookeran et id. ( B r J Surg 1992; 79: 430-1 ) demonstrates not that general practitioners are falling down on their duties, but that inefficient organization of National Health Service resources results in an inefficient consumption of resources. The consultation level was selected to be the least experienced and therefore presumably the least able to provide detailed advice. To compound this, the person who assessed the arriving patients was also the least experienced member of the team, so it is hardly surprising that this resulted in inappropriate admission to hospital and undue consumption of resources. As the authors conclude, a great deal more efficiency could have been obtained had the general practitioner been able to speak to a surgeon with more surgical experience than himself, rather than less. In addition, there can be no doubt that clinical examination of a patient by an experienced surgeon is by far the most important method of assessment in patients referred to acute surgical units. I am surprised that the authors found it necessary to recourse to an audit of their activities to prove this.
P. D. Coleridge Smith Deportnierit of’ Suryerj, Uiiirersity College mid Midclleses Scliool The Middleses Hospital Loridori W I N 8 A A UK
Sir We read with interest the paper by Roxburgh ct erl. ( B r J Sury 1992; 79: 415- 18) concerning the attitudes of cardiothoracic surgeons in the UK to the human immunodeficiency virus type 1 (HIV-I ). We agree with their conclusions that HIV-I testing and the refusal of surgeons to operate o n such patients are not the answers to this problem. We also agree that changes in operative practice and the institution of additional precautions are needed if the risk of infection to health workers is to be minimized. The authors concluded, however, that these changes will take time and require considerable resources. The maintenance of an intact barrier between the hands of the surgical team and the tissues of a patient is an important factor in preventing the transmission of disease. The effectiveness of surgical gloves in providing this mechanical barrier has been questioned’.’. As Roxburgh et a/. point out, glove perforation may occur in up to 20 per cent of surgical procedures3, thus increasing the risk of cross-infection. Double gloving reduces the risk of cutaneous exposure to blood and body fluids4 by 60 per cent, but the associated loss of tactile sensitivity may make surgeons (particularly vascular ones ) reluctant to adopt this method of protection. In a study carried out in our department. nearly 70 per cent of all glove perforations detected during open heart surgery were shown to occur during sternotomy closure5. A subsequent prospective randomized trial showed that this incidence could be significantly reduced by the simple measures of either double gloving or wearing cotton gloves over a single pair of latex ones6. In open heart surgery we have therefore identified a specific stage of the operation (sternal closure) during which the potential for glove perforation is greatly increased, and have also shown that simple additional protective measures reduce this risk. As with all forms of additional protection, manual dexterity and comfort are reduced, but fortunately the stage of the operation at which the operating team is at most risk is also the stage requiring the least tactile sensation. We would suggest that more widespread use of these simple precautions during sternal closure in cardiac surgery would enhance the safety of operation for both the patient and surgical team. and that these methods would not, as the authors suggest, be time consuming or expensive to implement.
M. J. Underwood N. Weeresena T. R. Graham* J. S. Bailey R. K. Firmin
of’ Medicine
Authors’ reply Sir The practice of preregistration house officers accepting and arranging admission for acute surgical referrals from general practitioners is common in Leicester and in other hospitals in the Midlands (for example in Sheffield and Nottingham). The outcome of our audit of general practitioner referrals to an acute surgical unit is particularly useful because it demonstrates that inefficiencies exist in the acute surgical service and quantifies the cost of these inefficiencies. In this study the resultant cost was high approximately f25000. We believe that audit is an excellent method of determining the cost-effectiveness and utilization of acute surgical facilities, and would encourage all surgeons to use audit as a method of improving the efficiency of their acute service.
M. M. Thompson Leirester Royal Infirniary Leicester LEI 5 WW UK
Attitudes of cardiothoracic surgeons in the U K t o human immunodeficiency virus
K. A. Dookeran Glenfield General Hospital
Br. J. Surg., Vol. 79, No. 10, October 1992
Leirester LE3 9QP UK
The Curtliolkorucic Unit Grohy Roud Hospitul Leicester utid *The Curcliotliorucic Unit Tlie R o j d Loticlon Hospital Londori UK 1.
2. 3.
4. 5.
6.
Hussain SA, Latif ABA, Choudhary AAAA. Risk to surgeons: a survey of associated injuries during operations. Br J Sury 1988; 75: 314-16. Brough SA, Hunt T M , Barrie WW. Surgical glove perforations. Br J Sury 1988; 75: 317. Cole RP, Gault DT. Glove perforations during plastic surgery. Br J Plus/ Surg 1989; 42: 481-3. Gerberding J, Littel C , Tarkington A et ul. Risk of exposure of surgical personnel to patients’ blood during surgery at San Francisco General Hospital. N Engl J Med 1990; 322: 1788-93. Hosie KB, Dunning JB, Bailey JS, Firmin RK. Glove perforation during sternotomy closure. Lancer 1988; ii: 1500. Underwood MJ, Weeresena N, Graham TR rt al. The incidence and prevention of glove perforation during open heart surgery. J Tlioruc Curdioiaw Surg 1992 (in press).
1111
