title: Implications of rigid adherence to a protocol of investigation for patients undergoing thyroidectomy.
abstract: OBJECTIVE
  Protocols may improve patient care by standardizing investigations performed. In pre-operative surgical patients this should ensure all patients undergo essential investigations while limiting unnecessary tests. Previous studies have shown poor protocol adherence within 6 weeks of implementation unless strictly enforced. With this in mind, we analysed clinical and financial implications of rigid adherence to a protocol of pre-operative investigation for patients undergoing thyroidectomy in a single centre.
  
  
  METHODS
  A protocol for investigation of patients undergoing thyroidectomy was introduced, with investigations being performed at the surgical out patient clinic. Where already performed by the referring doctor, they were not to be repeated. Protocol adherence was measured over a 6-month period and strictly enforced to try to ensure 100% compliance.
  
  
  RESULTS
  35 consecutive patients underwent thyroidectomy over the study period. Compliance with the protocol was obtained for between 86% and 100% of tests required by the protocol. In addition, numerous tests specified by the protocol were performed more than once, and additional tests outside the protocol were done, with an average excess cost per patient of 121.38 pounds sterling.
  
  
  CONCLUSIONS
  A protocol for pre-operative investigation of a common surgical procedure can be achieved. Rigid enforcement of the protocol can lead to over-investigation because of concerns about test omission, with associated financial implications. Furthermore, a rigid protocol does not always prevent performance of unnecessary investigations.
authors.affiliation: Department of Clinical and Surgical Sciences (Surgery), Royal Infirmary of Edinburgh, Edinburgh, UK. r.hardy@ed.ac.uk
authors.forename: Robert
authors.initials: R
authors.lastname: Hardy
authors.forename: Andrew
authors.initials: A
authors.lastname: Moss
authors.forename: David
authors.initials: D
authors.lastname: Lee
mesh_terms: D002985:Clinical Protocols; D003955:Diagnostic Tests, Routine / Q000191:economics*; D019983:Guideline Adherence; D006801:Humans; D013965:Thyroidectomy / Q000191:economics* / Q000592:standards*; D019564:Unnecessary Procedures