Clinical Audit

RE: Clinical Audit

Anthony Todd — Thu, 10 Sep 2015 10:47:20 GMT

[quote user="Martin Atkinson"] I think we already achieve their objectives without even thinking about it don't you Evelyn?[/quote]

Crikey, and I'm called a "dinovet". ....

All of the good dinovets I know would never admit to sharing that attitude, nor having it.

Mind you the only way they could monitor their results was by the patient's success or failure, not by an improving blood parameter, or not.

RE: Clinical Audit

Aine Seavers — Thu, 10 Sep 2015 01:03:05 GMT

We ran similar events here as clinical rounds with local practices- instead of making it a what did I do wrong- it starts off as collecting notes on what folks would have initially thought and why- ie what markers started triggering diagnostic thoughts. how or what would you do at each step, creates much discussion and very little criticism so more collegiate atmosphere. And don't always audit the bad ones, audit a good one too and see how you can improve even on that-we have enough negativity thrown at us, some times its nice to share the joy of getting it or seeing it be done correctly. Encourage not Discourage.

RE: Clinical Audit

Michael Woodhouse — Mon, 31 Aug 2015 21:19:41 GMT

http://www.bmj.com/content/351/bmj.h4662?sso=

http://www.journalslibrary.nihr.ac.uk/hta/volume-18/issue-43#hometab0

RE: Clinical Audit

Nhombokisheni — Mon, 31 Aug 2015 16:52:42 GMT

Following the exchanges I believe there is agreement on the need to continually reflect on one's practice and seek to improve. Martin does it solo, others do it as a "team". The team approach is good, especially when you consider standard of quality in service delivery at practice level. Most practice websites make sweeping "promises" on quality and so clients expect every vet in that practice to perform to that level...........so case discussions/presentations offer the opportunity to team members to not only learn, but to standardise. I have a problem with the word "audit". It brings a dimension of scrutiny that can hinder free flow of contributions in a team....never mind the pressure that it insinuates during actual clinical case mananegement where the vet is constantly thinking "what will the others say if I do this?", and instead of doing the "anecdotal" correct thing, they opt for the "safe" that can pass the audit. Sounds far fetched maybe, but I have come across a lot of so called "safe" professionals. I suggest sticking to normal clinical language eg case reviews/discussions/presentations etc.

RE: Clinical Audit

Luciano Nebiante PGCertSAS — Mon, 31 Aug 2015 15:44:13 GMT

We are doing during working hours, mainly to not affect our life outside work too much. We do Vets meeting after hours, and that is when we get pizza :-D

RE: Clinical Audit

Miriam Lodewyks — Wed, 26 Aug 2015 19:50:58 GMT

I think it's a super idea. We try do it too. My question is: do you do this during regular working hours, or after hours, perhaps with a pizza thrown in?

RE: Clinical Audit

Luciano Nebiante PGCertSAS — Mon, 24 Aug 2015 21:17:13 GMT

[quote user="Martin Atkinson"]

Luciano, it is not clear whether you are a practice owner/partner or an assistant although the tone of your OP suggests the former. If so It is a good idea to have meetings to brain-storm problems and allow exchange of ideas but if you then restrict what you do only to that which is proven by clinical studies I fear you will fall further into the trap of fear of litigation/disciplinary action and your patients will suffer.[/quote]

Oh Martin, I can guarantee you that I would never let my patients suffer. What I keep deep in my heart, is rather offer them the best according to the most recent reliable evidence based knowledge.

Where this is not available, then I tend to go to the next level, and where there isn't any study published then personal or communal experience will do.

Just as an example, we all use Sam-E for liver disease, and there are many products available on the market. But a recent study on the JSAP showed that only one product maintained a constant level of Sam-E in its formulation, thus giving supposedely a better absorption.

Let me also clarify that I am an assistant.

[quote user="Martin Atkinson"]

I give you an example. For years I have been pre-emptively treating animals with heart disease before they show symptoms of heart failure. I sub-consciously have been performing a current status assessment without using that actual phrase. Experts/specialists have consistently told me that there is no evidence to suggest that this is of any benefit but logic and my own anecdotal experience had convinced me it is. Low and behold the recent EPIC trial and before that the PROTECT trial have shown that I was correct.[/quote]

Yeah I see your point of view and experience. Although I probably would not medicate what I can't prove, now there is enough evidence for the use of Pimobendan in certain breeds, and its earlier use is justified. But I must say that I would not like to be administered a drug if there wasn't enough evidence to support its use. So I might offer it to the client if my experience would tell me otherwise, but I make them aware that it is my personal experience and some other vets might disagree or have a different experience.

[quote user="Martin Atkinson"]

I feel that you are over-thinking and over-complicating this and over-using management speak buzz words. That in itself may be a barrier - if I was in your meeting and you started speaking like this I would switch off.[/quote]

I instead think we could have a very interesting chat!

[quote user="Martin Atkinson"]

While clearly there needs to be some correlated approach to what you might call quality control you can't over-formalise it. And just to complete my own sequence of horrible buzz phrases: perhaps you need to think outside the box a little more.[/quote]

I think outside the box already too much. My nurses think I am mad! Fortunately my madness helps me in delivering care to my little patients (or Soldiers as I call them, seen that they face a lot of battles!) :-D

Over all this has been a good discussion.

Cheers

RE: Clinical Audit

Martin Atkinson — Mon, 24 Aug 2015 14:02:10 GMT

[quote user="Michael Woodhouse"]Doing what logically seems like the right thing potentially can cause a lot of harm - however well meaning the actions.[/quote]Yes but I was/am using drugs that would be used to treat animals if they were in heart failure and so have been shown to be efficacious and safe so slightly different. There was some suggestion that using ACEi prior to cardiac failure could be counter-productive, although I'm not sure that is proven, but I switched to Pimobendam when it came out anyway.

Anyway we've hijacked the subject of the OP so we either go back to that or head off to a tangent.

RE: Clinical Audit

Michael Woodhouse — Mon, 24 Aug 2015 12:59:14 GMT

[quote user="Martin Atkinson"]I give you an example. For years I have been pre-emptively treating animals with heart disease before they show symptoms of heart failure. I sub-consciously have been performing a current status assessment without using that actual phrase. Experts/specialists have consistently told me that there is no evidence to suggest that this is of any benefit but logic and my own anecdotal experience had convinced me it is. Low and behold the recent EPIC trial and before that the PROTECT trial have shown that I was correct.[/quote]

Just going on what we think makes sense isn't always in our patients best interests. Allow me to quote Dr Ben Goldacre:

So in 1980, some researchers did a study on a drug called lorcainide, and this was an anti-arrhythmic drug, a drug that suppresses abnormal heart rhythms, and the idea was, after people have had a heart attack, they're quite likely to have abnormal heart rhythms, so if we give them a drug that suppresses abnormal heart rhythms, this will increase the chances of them surviving. Early on its development, they did a very small trial, just under a hundred patients. Fifty patients got lorcainide, and of those patients, 10 died. Another 50 patients got a dummy placebo sugar pill with no active ingredient, and only one of them died. So they rightly regarded this drug as a failure, and its commercial development was stopped, and because its commercial development was stopped, this trial was never published.

3:54 Unfortunately, over the course of the next five, 10 years, other companies had the same idea about drugs that would prevent arrhythmias in people who have had heart attacks. These drugs were brought to market. They were prescribed very widely because heart attacks are a very common thing, and it took so long for us to find out that these drugs also caused an increased rate of death that before we detected that safety signal, over 100,000 people died unnecessarily in America from the prescription of anti-arrhythmic drugs.

4:30 Now actually, in 1993, the researchers who did that 1980 study, that early study, published a mea culpa, an apology to the scientific community, in which they said, "When we carried out our study in 1980, we thought that the increased death rate that occurred in the lorcainide group was an effect of chance." The development of lorcainide was abandoned for commercial reasons, and this study was never published; it's now a good example of publication bias. That's the technical term for the phenomenon where unflattering data gets lost, gets unpublished, is left missing in action, and they say the results described here "might have provided an early warning of trouble ahead." https://www.ted.com/talks/ben_goldacre_what_doctors_don_t_know_about_the_drugs_they_prescribe/transcript?language=en

It's a TED talk transcription, but also in his book.

Doing what logically seems like the right thing potentially can cause a lot of harm - however well meaning the actions.

RE: Clinical Audit

Martin Atkinson — Mon, 24 Aug 2015 09:29:00 GMT

[quote user="Luciano Nebiante"]

My personal issue is that I as all of us must accept my limits to be able to overcome them.

And I grow professionally by also confronting with others and exchanging ideas. I appreciate some of us have different way of improving. Therefore I think more stress and effort should be put in gathering more evidence, and especially in first opinion practice. There is obviously many evidence coming from institution or referral practices, but obviously the population of studies is very different from that of first opinion practice, and one fundamental question of every study, is: does this result apply to a population in first opinion practice?

[/quote]Luciano, it is not clear whether you are a practice owner/partner or an assistant although the tone of your OP suggests the former. If so It is a good idea to have meetings to brain-storm problems and allow exchange of ideas but if you then restrict what you do only to that which is proven by clinical studies I fear you will fall further into the trap of fear of litigation/disciplinary action and your patients will suffer.

RE: Clinical Audit

Luciano Nebiante PGCertSAS — Sun, 23 Aug 2015 23:53:57 GMT

Thanks everyone.

My personal issue is that I as all of us must accept my limits to be able to overcome them.

And I grow professionally by also confronting with others and exchanging ideas. I appreciate some of us have different way of improving.

However I tend to agree with Michael when he says that many things we routinely do in practice have basically no evidence aside from some anecdotal reports.

Therefore I think more stress and effort should be put in gathering more evidence, and especially in first opinion practice. There is obviously many evidence coming from institution or referral practices, but obviously the population of studies is very different from that of first opinion practice, and one fundamental question of every study, is: does this result apply to a population in first opinion practice?

In other words, does the study bring any advantage to the pet seen at the primary care vet?

So clinical audits might be the first step towards some more evidence based approach.

RE: Clinical Audit

Martin Atkinson — Fri, 21 Aug 2015 17:31:57 GMT

[quote user="Bob Russell"]It is difficult to do a formal clinical audit in a single vet practice but it does not mean there is no questioning of the way pets are treated. Hopefully this reduces the risk of becoming one of those practices that believe they have got it all right and don't need to change anything! [/quote]As I intimated it is not difficult to do a clinical audit in single handed practice indeed I am subconsciously performing one continuously every moment of the day it just doesn't need a name. I agree that it could be easy for solo-vet to mutate to dinovet but it needs more than a management buzz word to prevent that, it is a state of mind. There is no greater critic of my work than myself but I realise my limits and the limits of what being sole charge places upon me. That does not mean that I don't continually strive to improve, indeed the day I feel I don't want to is the day I will retire. My nurses would not let me fall into bad habits anyway.

RE: Clinical Audit

Michael Woodhouse — Fri, 21 Aug 2015 16:56:55 GMT

[quote user="Martin Atkinson"]Ditto. I think we already achieve their objectives without even thinking about it don't you Evelyn?[/quote]

Maybe you both do, but it is far from my experience of a LOT of vets in general practice.

There is a lot of evidence that our recollection of events is very selective, and we perhaps remember our outcomes in a misleading way. I am absolutely guilty of taking a paper at face value (how many of us read an abstract and assume everything is OK?) and only when digging find out it is meaningless due to many possible flaws. As a student or until we bought the current practice I had no access to journals in general practice, other than a dusty collection of maybe Vet Record, In Practice and Cattle Practice (there are so many more useful resources)!

I saw a lot of things looked up in (often old edition) books, or done in a way they had always done them. Sometimes completely ignorant of new or different procedures - a very dogmatic "this is how I treat problem X". The view that if something bad happened then "YOU missed something", rather than examining the case and seeing what lessons could be learnt.

The really nerdy bit - I actually think this is all great and hugely positive for the profession. We are lagging behind the medics by about 30 years but things seem to be gaining momentum in the last couple of years. Actively doing this has really improved our levels of clinical practice and we do a lot of things better than we used to. We are all better informed and having much more meaningful discussions with clients. We have a steady run of vet students and I'm yet to have one who has participated in a journal club at another practice.

There are some rudimentary knowledge summaries coming out of the RCVS knowledge:

http://knowledge.rcvs.org.uk/evidence-based-veterinary-medicine/knowledge-summaries/

There are some useful resources from the Nottingham 'Best Bets for Vets" project:

https://bestbetsforvets.org/

The biggest thing coming out of this is we all need to work better together and build the evidence base. We have the numbers of animals to spot these small effects, just not the coordination to pull off the work. Some of these significant areas of vet medicine (things we are doing everyday) have practically no evidence that we are working to best practice.

RE: Clinical Audit

Bob Russell — Fri, 21 Aug 2015 15:51:20 GMT

We regularly discuss clinical cases within the practice. Although single handed vet-wise some staff have seen years of cases so can and do contribute very usefully.

I suspect I am a bit of a pain for the referral centres and path lab as I regularly wish to discuss problem cases. I am insecure enough about my diagnostic abilities to readily ask for help even after all these years!

It is difficult to do a formal clinical audit in a single vet practice but it does not mean there is no questioning of the way pets are treated. Hopefully this reduces the risk of becoming one of those practices that believe they have got it all right and don't need to change anything!

RE: Clinical Audit

Martin Atkinson — Fri, 21 Aug 2015 15:23:46 GMT

[quote user="Luciano Nebiante"]Our aim is to improve the quality of clinical examination, diagnostics tests and possibly reach a final diagnosis with subsequent appropriate treatment according to the latest evidence in clinical research.[/quote] Is this a competition to see how many pseudo-scientific buzzwords can be crammed into one management speak statement?

[quote user="Evelyn Barbour-Hill"]I'm really glad I'm singlehanded [/quote] Ditto. I think we already achieve their objectives without even thinking about it don't you Evelyn?

RE: Clinical Audit

Evelyn Barbour-Hill — Thu, 20 Aug 2015 21:46:09 GMT

I'm really glad I'm singlehanded

RE: Clinical Audit

Michael Woodhouse — Thu, 20 Aug 2015 14:15:38 GMT

Yes, we do a similar thing. It takes a couple of sessions for people to relax into it, it's not entirely comfortable pulling cases apart as a group - but perversely satisfying at the same time (if that makes any sense?).

There are some good resources on the RCVS Knowledge site that can be useful:

http://knowledge.rcvs.org.uk/evidence-based-veterinary-medicine/ebvm-resources/tools-guidelines-and-checklists/

We don't use forms or paperwork. I think the part I enjoy the most are journal clubs. If we have a vet student then they have to present the paper on the Friday lunchtime. Generally I'll give them one to do, but happy for them to chose their own.

Don't expect a nice conclusion each time. Don't expect everyone to agree.