What is a "clinical audit"?

RE: What is a "clinical audit"?

Anthony Todd — Fri, 19 May 2017 17:49:55 GMT

[quote user="Phil Elkins"]

Unfortunately this is a slight misunderstanding of clinical audit. Before undertaking an audit you must determine the processes that should be being undertaken, not the outcomes. Post-op infection rate is not an auditable process in this context. The steps undertaken in pre-op preparation are. But before auditing them you must determine an acceptable level of expectation based on the evidence available.

[/quote]

I've never known such an obvious tool for measuring success, failure, good-vet, bad-vet, good practice, bad practice, crap practice etc being so obfuscated by a unnecessary argument over what it should be called!!

If any op. of mine came back with any sort of reaction I knew about it, wanted to know, and wondered why, and was pretty sure I'd done something wrong or badly.

Geez, the acceptable level of expectation in routine surgery is 0 , zero, nil, never. Anything else is bad and should be corrected.

A rose by any name is still a lovely thing!!

RE: What is a "clinical audit"?

Anthony Todd — Fri, 19 May 2017 17:41:43 GMT

Dunno what you'd call it but what about counting the number of clients who don't return for a needed revisit??

RE: What is a "clinical audit"?

Phil Elkins — Fri, 19 May 2017 14:07:15 GMT

[quote user="Kate Richardson"]I know it's only an example, but I don't think it is a good one, mainly because it doesn't take into account the owners wishes.[/quote]

A better example would be how many times it was offered and recommended. It is the processes to be audited not the outcomes.

RE: What is a "clinical audit"?

Phil Elkins — Fri, 19 May 2017 14:05:57 GMT

RE: What is a "clinical audit"?

Phil Elkins — Fri, 19 May 2017 14:01:52 GMT

Clinical audit is not just a case of collating outcomes and deciding if they are acceptable. It is a process whereby a number of steps take place in a circular fashion to ensure the service provided is as it should be.

Setting best practice, determining whether that best practice is being implemented, identifying restrictions to best practice, implementing change and then starting again. It is a really good way of determining if as a practice/group/business you are at the level you think you are, or are happy with.

We carry out 10-12 audits annually.

Phil

RE: What is a "clinical audit"?

Anthony Todd — Thu, 18 May 2017 20:23:03 GMT

[quote user="roland bulkyn-rackowe"]As far as procedures audits go,[/quote]

There's this:

http://www.vetaudit.co.uk/

which is worth more than a look and was previously mentioned, but not the link.

RE: What is a "clinical audit"?

Martin Atkinson — Thu, 18 May 2017 16:57:15 GMT

Well my proud record of not having lost an apparently healthy dog under GA for a routine surgery in so many years I can't remember went today. Four year old GSD in for ACL repair, all pre-op checks normal, and hour into surgery and just suturing the skin went into cardio-respiratory arrest. 15 minutes of CPR,intravenous and intracardiac adrenaline to no avail. Monitored throughout with pulse oximetry. respiratory monitor, blood pressure, oesophageal stethoscope, on IV drip, nurse updating anaesthetic chart every minute adjusting drip rate/ Iso in response to depth of GA and BP/pulse rate/sats.

Conclusion of audit: pulse oximetry is crap and its time to buy a capnograph.

RE: What is a "clinical audit"?

Roland Bulkyn-Rackowe — Wed, 17 May 2017 19:04:34 GMT

I think Sarah has described audit very well.

For me the limitations on audit have been the lack of evidence based best practice protocols and very few outcomes benchmarks. With our neutering audit we had the vetaudit benchmarks to compare ourselves to.

As far as procedures audits go, I think the IGF measurement of unstable diabetics is a good example. If the client refuses on the basis of cost this is not an audit failure! Note down that IGF blood testing has been offered and refused. The failure is if the test is not offered.

A example procedure audit I carried out was whether in house cytology was carried out for dog otitis externa cases where an antibiotic product was prescribed.

RE: What is a "clinical audit"?

Martin Atkinson — Wed, 17 May 2017 08:51:56 GMT

[quote user="Bill Nolan"]For example: A clinical process audit could be assessing how many times serum IGF-1 concentrations are measured in poorly controlled diabetic cats in a given year. The number will be arbitrary, however it can lead the audit team to determine whether or not they need to increase their surveillance for hypersomatotrophism.[/quote] The answer to this is: they do. Sadly most members of the profession have not yet seen David Church's excellent work on this topic so are unaware of the high prevalence of pituitary hypersomatotrophism in diabetic cats.

Moral: time would be better spent on further education on useful things rather than (as Beats so succinctly put it) naval gazing.

RE: What is a "clinical audit"?

Sarah Keir — Tue, 16 May 2017 19:26:45 GMT

If you post as Anonymous then your remarks cannot be taken seriously! Arlo, this is one case where the anon posting is being misused.

RE: What is a "clinical audit"?

An On MRCVS — Tue, 16 May 2017 19:17:26 GMT

Who gives a fukk?

RE: What is a "clinical audit"?

Sarah Keir — Tue, 16 May 2017 18:32:40 GMT

For me the point of clinical audit and especially differentiates it from research is that it is circular process, i.e. decide what to measure, measure, assess and feedback, and that the 'control' is what you did up to the moment you instigated the audit and not a randomly allocated, double blinded group.

RE: What is a "clinical audit"?

Evelyn Barbour-Hill — Mon, 15 May 2017 01:02:03 GMT

When not sure what something means, it's not a bad idea to go back to the beginning and look in the dictionary.

Audit. n. Official examination of accounts; searching examination, esp. Day of Judgment; periodical settlement of accounts between landlord and tenants.

so, the "audit" in "clinical audit" has been borrowed from financial terminology as an analogy. That's fine. But you have to stick to the analogy. Auditing the accounts means checking they are all tickety-boo, that the rules have been followed, that nobody has their hand in the till, that the taxman is not being hoodwinked, that the shareholders are not being deceived. [Sotto voce aside: a company that failed its audit would be in for SSSS ( a military term) and if it failed the next year it would be in deep doodah and probably going out of business. How many years running, remind me, 22 I think, have the auditors refused to approve the accounts of the "European Union"? )

So, by analogy, the clinical audit would mean checking that all the instructions, protocols and rules were being followed and nobody was cheating. As Mariette said, but nobody took any notice. Rather like the stupid waste audit we're all supposed to do (you do all do it, don't you ), counting the waste bins and photographing them.....

So what's really being suggested is a "clinical outcomes assessment". Would that be of value? In itself, probably not. Suppose you always give a post-operative course of antibiotic. Suppose you recorded and looked at your incidence of post-operative infections. You find it very low, say 0.5%. That's nice, you say, we should continue to give post-operative antibiotic. The exercise has been pointless unless you try not giving the antibiotic. (As I did, 32 years ago, and waited to see what would happen. Of course, nothing happened.) Or you could compare your results with another practice that never gives post-op antibiotic.

In other words, looking at your outcomes is pointless unless you compare them with something. In other other words, clinical assessment ( or audit, if you incorrectly must) is useless without clinical research.

RE: What is a "clinical audit"?

Kate Richardson — Sun, 14 May 2017 21:57:11 GMT

I know it's only an example, but I don't think it is a good one, mainly because it doesn't take into account the owners wishes. Finances may limit testing, or the owner may have discussed what a positive result means for them and their cat and have decided it won't change what they do. Testing for something should only be done if it is going to change the outcome, so increasing your surveillance for a disease is interesting, but not necessarily clinically useful in the real world.

RE: What is a "clinical audit"?

Beats — Sun, 14 May 2017 21:24:53 GMT

[quote user="Malcolm Ness"]That, to me seems a waste of time[/quote]

Crucially, it is a waste of "Clinical Time"

I feel a Venn diagram is called for at this point:

RE: What is a "clinical audit"?

Bill Nolan — Sun, 14 May 2017 20:50:12 GMT

[quote user="Anthony Todd"]Could it be better called "Clinical Outcome Audit" eg. number of C/Ss with any sort of complications.[/quote]

Not a bad idea. However, as I understand it, clinical audits can be used to evaluate 'outcomes' or 'processes'.

For example: A clinical process audit could be assessing how many times serum IGF-1 concentrations are measured in poorly controlled diabetic cats in a given year. The number will be arbitrary, however it can lead the audit team to determine whether or not they need to increase their surveillance for hypersomatotrophism.

A clinical outcome audit would be, as you say, looking at the number of post-operative complications for routine surgery in a the last year. If the number is high, you can look deeper into the details of each case to determine a possible cause. A practice I recently visited performed a clinical outcome audit as I just described, and determined that the majority (~80%) of post-operative complications seen in neutering surgeries were associated with subcutaneous polyfilament suture materials. They have now adjusted their practice guidelines such that subcutaneous/skin closing sutures be made with monofilament suture material.

On the whole, I believe that clinical audits can be used as tools to ensure that practice guidelines are continually reviewed and improved.

RE: What is a "clinical audit"?

Malcolm Ness — Sun, 14 May 2017 19:35:34 GMT

[quote user="Beats"]What you are not doing is determining whether washing your hands between patients is a beneficial exercise with meaningful clinical benefits to your patients - that would be "clinical research".[/quote]

This chimes with what others have suggested when trying to explain Clinical Audit to me. My problem is that this implies that as soon as there might be some tangible benefit arising from the exercise, then it defines itself as clinical research while for the endeavour to be considered 'Clinical Audit' there must be no risk of any benefit and any advantage accruing to the exercise must remain purely speculative. That, to me seems a waste of time: something about which Kafka might write a novel.

RE: What is a "clinical audit"?

Seadna — Sun, 14 May 2017 19:26:02 GMT

[quote user="Beats"]If you work in a sole charge veterinary clinic, then an example might be to ask the work experience student to keep a log of how many times in a day you didn't wash your hands between patients (assuming you accept this to be a valid ideal), then have a think about what might encourage you to wash them more (prefarably wihtout being detrimental to your overall clinical care), impleemnt those measures and then ask the next work experience student to do the same. If you are being fancy, then you can use stats to develop a confidence interval to see with what level of confidence versus random variation it is likely that you have improved/failed-to-improve versus this accepted standard, and determine what level of sampling is required (one consult session, one day, whole week etc). What you are not doing is determining whether washing your hands between patients is a beneficial exercise with meaningful clinical benefits to your patients - that would be "clinical research"[/quote]

That's a really good example, thanks.

RE: What is a "clinical audit"?

Anthony Todd — Sun, 14 May 2017 11:20:22 GMT

Drop "clinical" and just call it "outcome audit" or, if you insist "clinical outcome audit" which is what it is!

Important thing is to measure what we all know needs to be measured.

My COA with cat spays was always 100%......[just an example....]

RE: What is a "clinical audit"?

David Mills — Sat, 13 May 2017 23:33:02 GMT

[quote user="Beats"]meaningful clinical benefits to your patients - that would be "clinical research".[/quote]

I think the problem I have is that the techniques of data assimilation are the same.

As Malcolm says, nicely illustrated by your example, what is the point if you can't point to an improvement in outcome? It seems like a silly halfway house, designed by NHS middle managers.

RE: What is a "clinical audit"?

Beats — Sat, 13 May 2017 21:16:45 GMT

[quote user="David Mills"]I cannot see the difference between audit and clinical research. People talk of auditing outcomes or prevalence but it seems indistinguishable to me from a retrospective study. May be wrong. [/quote]

I really shouldn't try to defend the term at all, but as I understand it (which isn't very much and I've clearly given up trying), the idea is that "clinical research" informs topics and opinions on ideals, and then hospital performance is measured against this by means of "clinical audit".

So, for hypothetical example, if "clinical research" has helped to inform an opinion that giving intravenous antibacterials an hour before first cut for patients receiving antibacterial prophylaxis, then the purpose of "clinical audit" is to determine firstly if your hospital is doing this, secondly if not why not, thirdly can you change anything to make this happen more reliably, and fourthly to see that it has happened. There is not necessarily a fifthly to see if that has decreased post-operative infection rates as I understand it - or at least not in this specific clinical audit exercise which is merely an exercise in auditing your compliance with an already accepted standard.

If you work in a sole charge veterinary clinic, then an example might be to ask the work experience student to keep a log of how many times in a day you didn't wash your hands between patients (assuming you accept this to be a valid ideal), then have a think about what might encourage you to wash them more (prefarably wihtout being detrimental to your overall clinical care), impleemnt those measures and then ask the next work experience student to do the same. If you are being fancy, then you can use stats to develop a confidence interval to see with what level of confidence versus random variation it is likely that you have improved/failed-to-improve versus this accepted standard, and determine what level of sampling is required (one consult session, one day, whole week etc). What you are not doing is determining whether washing your hands between patients is a beneficial exercise with meaningful clinical benefits to your patients - that would be "clinical research".

RE: What is a "clinical audit"?

David Mills — Sat, 13 May 2017 20:58:39 GMT

There's a ex pres who's big on audits. Not sure how to do the link thingy but he may wish to contribute.

I cannot see the difference between audit and clinical research. People talk of auditing outcomes or prevalence but it seems indistinguishable to me from a retrospective study. May be wrong.

RE: What is a "clinical audit"?

Beats — Sat, 13 May 2017 19:50:28 GMT

[quote user="Anthony Todd"]OK let's agree on a definition of "clinical audit" for a start!![/quote]

What is the definition? That's easy:

Clinical audit can be defined as : “A quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change. Aspects of the structure, processes and outcomes of care are selected and systematically evaluated against specific criteria. Where indicated, changes are implemented at an individual, team or service level and further monitoring is used to confirm improvement in healthcare delivery.”

Which of course means nothing to simple me. Is it a useful task for the average vet to spend "clinical time" on, or another attempt to hoist irrelevant NHS jargon/bureaucracy on the average vet? You decide:

http://www.clinicalauditsupport.com/what_is_clinical_audit.html

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

http://www.vetaudit.co.uk/Vet%20Rec%20clinical%20audit%20article.doc

For me, I glaze over when I hear phrases like this. If I can't see the point quite quickly, I just give up and move on.

This week I got to tutor my nursing student on "Nursing models", yes, that's academic models of nursing care as in for people in hospitals. I tried to stay positive up until the point where there was a box to fill in on the patient's ability, restrictions and aims regarding their ability to express their sexuality... I can't remember if that was the Roper, Logan and Tierney, Orems or the other one, but I think I'd seen enough to confine "Nursing models" to the same mental compartment as "clinical audit".

RE: What is a "clinical audit"?

Anthony Todd — Sat, 13 May 2017 19:14:19 GMT

OK let's agree on a definition of "clinical audit" for a start!!

Could it be better called "Clinical Outcome Audit" eg. number of C/Ss with any sort of complications.

Number of otitis externa not "cured" in X visits etc.

Number of acute abdomens fixed in under 5 Xrays [joking but that's why we need a definition]

RE: What is a "clinical audit"?

Malcolm Ness — Sat, 13 May 2017 18:40:18 GMT

[quote user="mariette asselbergs"]but it is a clinical management tool.[/quote]

Absolutely not. In the NHS it is a tool to manage clinicians and that is a very different thing. It is yet to be usefully defined in the veterinary world: the evaluation of compliance by clinicians with an arbitrarily decided 'standard' is at best pointless and at worst, counterproductive.