Clinical governance

RE: Clinical governance

Vet2Vet — Fri, 02 Apr 2021 14:53:24 GMT

I’ve had a good look through .The materials involved are all variable . There’s a good sweep of different nurses in roughly even proportions . The surgeries are all under 35 minute surgical time . I think the problem may be technical .

RE: Clinical governance

James Dunne — Fri, 02 Apr 2021 12:50:02 GMT

I would approach this by discreet observation first. If something is clearly not being done correctly, then go down the road of direct discussion with the surgeon involved. If the spay looks well-executed, consider factors other than the surgeon (and statistical anomalies) as the reason for the complications. Seven surgeries in six months breaking down for one particular surgeon is certainly highly suspicious, but not impossible. You equally cannot wait years to see if the problem is going to even itself out among other people, given the potential risks to patients. And if you have a faulty batch of material in your surgery, it needs to be weeded out. Beware of bias also. People doing postgraduate qualifications in practice can sometimes be more under the microscope but are not immune to having problems with their cases developing.

RE: Clinical governance

Richard Carter — Thu, 01 Apr 2021 08:51:46 GMT

Continuous in itself is not a problem if the material going to hold for duration of healing- the issue is it’s a one failure disaster- either material or knot failure and the guts are on floor. At least interrupted spreads tension and if a local failure, then hopefully worst case is a small hernia

RE: Clinical governance

Arlo Guthrie — Thu, 01 Apr 2021 08:23:43 GMT

Vet2Vet HI - can I ask you to try and quote from posts you're replying to. Makes it easier for others to follow.

When you reply, highlight the specific text you are responding to, then you should see the word 'quote' flash up when you've highlighted. Press that and the quoted text is transposed into the reply box, for you to reply beneath.

I'm doing it retrospectively to your posts, and hope I get it right!

RE: Clinical governance

Vet2Vet — Sun, 28 Mar 2021 20:04:31 GMT

[quote userid="8858" url="~/001/veterinary-clinical/small-animal/soft-tissue-surgery/f/discussions/29744/clinical-governance/229483#229483"]I used to work with a vet who pulled all layers of sutures incredibly tight, and I was always amazed she didn't have many problems. The problem Minne highlights is how difficult it is to know what people do after they qualify (like driving) and her solution is fair, but a shame for all involved, as the person won't improve (and surely, deep down, we all want to be good?).[/quote]

An example of what happens if it's not a whole team approach

RE: Clinical governance

Vet2Vet — Sun, 28 Mar 2021 20:03:36 GMT

It's frustrating if good, helpful information doesn't filter through

RE: Clinical governance

Vet2Vet — Sun, 28 Mar 2021 20:02:42 GMT

[quote userid="2457" url="~/001/veterinary-clinical/small-animal/soft-tissue-surgery/f/discussions/29744/clinical-governance/229479#229479"]I do sometimes see surgeons grasping and tightening the suture material, as they go along, with their needle holders - something which is bad with an interrupted pattern but can be catastrophic with a continuous pattern. Other than that, I'm not aware it is more at risk of failure?[/quote]

Hi Gillian , agree this can weaken suture

RE: Clinical governance

Vet2Vet — Sun, 28 Mar 2021 20:02:06 GMT

Hi Richard , interesting point regarding anti-inflammatories . In the vet world , I believe we are very lucky generally with healing abilities of pet species but that's a valid tweak that could definitely be made with especially older or weaker patients .

RE: Clinical governance

Vet2Vet — Sun, 28 Mar 2021 19:59:26 GMT

Thanks for your input Jill . I am going to try to audit it out methodically .

RE: Clinical governance

Vet2Vet — Sun, 28 Mar 2021 19:58:05 GMT

Agree that a constructive , positive , ' learning culture ' route is the best and most humane approach for all concerned .

RE: Clinical governance

Vet2Vet — Sun, 28 Mar 2021 19:56:08 GMT

I agree surgery is in the hands as much as the brain and starting young and plenty of practice helps enormously , thanks for your thoughts

RE: Clinical governance

Vet2Vet — Sun, 28 Mar 2021 19:55:00 GMT

Thanks for all the thoughts . I agree on reflection that possession of a certificate may not equate with talent or proficiency . At the moment , the case load is pretty routine but spays although routine carry their own challenges as we all know

RE: Clinical governance

Vet2Vet — Sun, 28 Mar 2021 19:53:18 GMT

I'm going to audit this much deeper now . None of the other surgeons seem to have had any recent issues .

RE: Clinical governance

Neil Wheadon — Sun, 28 Mar 2021 19:17:28 GMT

[quote userid="8858" url="~/001/veterinary-clinical/small-animal/soft-tissue-surgery/f/discussions/29744/clinical-governance/229483#229483"]The problem Minne highlights is how difficult it is to know what people do after they qualify [/quote]

How many vets watch another vet operate?

About 6 months ago I was chatting with a vet who was doing a dog castrate. After 29 years of doing them open, I now do them closed having watched him do the operation and can't quite believe I didn't do it sooner

Nurses watch us all, we should take note and ask them (I do)

Neil

RE: Clinical governance

Jill Butterworth — Sun, 28 Mar 2021 19:12:09 GMT

I used to work with a vet who pulled all layers of sutures incredibly tight, and I was always amazed she didn't have many problems. The problem Minne highlights is how difficult it is to know what people do after they qualify (like driving) and her solution is fair, but a shame for all involved, as the person won't improve (and surely, deep down, we all want to be good?).

RE: Clinical governance

Minnie — Sun, 28 Mar 2021 17:25:00 GMT

nurses point of view. Continuous linea alba pulled so tight you can barely see the suture finished with a totally ineffectual knot followed by another layer of continuous subcuticular suture perhaps not quite so tight this time, but still quite tight, again finished with an ineffectual knot and you just know there is an increased chance that dog is heading back to theatre before its 2nd post op check.

As a nurse you try to be tactful along the lines of ' that's interesting is that a new knot? I haven't come across that one before. You must show me how to do it. Have you seen this one? - this is the one I learnt at college' Which falls on deaf ears, so you drop a few more respectful but heavier hints

You flag a concern to management which isn't taken that seriously because you are reminded you are 'just a nurse' and not a qualified vet, get accused of being intolerant and unsupportive so as a nurse the only option left open to you is that you stop booking in certain surgeries for that particular vet.

RE: Clinical governance

Gillian Mostyn — Sun, 28 Mar 2021 09:55:22 GMT

[quote userid="2675" url="~/001/veterinary-clinical/small-animal/soft-tissue-surgery/f/discussions/29744/clinical-governance/229478#229478"]suture technique- if they have suddenly switched to continuous for eg[/quote]

There has been mention of continuous patterns a couple of times - is it seen as 'higher risk'?

I do sometimes see surgeons grasping and tightening the suture material, as they go along, with their needle holders - something which is bad with an interrupted pattern but can be catastrophic with a continuous pattern. Other than that, I'm not aware it is more at risk of failure?

RE: Clinical governance

Richard Carter — Sat, 27 Mar 2021 21:49:00 GMT

Something basic going wrong here - the linea alba should heal well - do you think is actual infection, reaction to material or just failure to have adequate inflammatory response?

think this is serious enough to not warrant a softly don’t upset anyone- the alternative is you take them off operations

things I would be checking with assistance of the vet and operating team- anything different being applied to skin or surgeons hands/ gloves before cut made? New disinfectant for eg

are they using cautery to open or feeling the need to attend to oozing? Or are they messing about with abdominal swabs, putting tension on cut edges?

Suture material- suitable and not contaminated

suture technique- if they have suddenly switched to continuous for eg

knot for suture material

length of surgeries

other contamination

last - the use of high dose and continuous anti inflammatory will retard healing hence the human shift to opioids and plain paracetamol for pain control post op

RE: Clinical governance

Jill Butterworth — Sat, 27 Mar 2021 19:19:32 GMT

Tough love here too. They absolutely need to know, if it had happened to me, I would be mortified and prefer to discuss it in private pretty soon: abdominal dehiscence is a surgical disaster and there is something they need to revise. One is possibly bad luck, but several with the same surgeon? Ask any OOH clinician, it's an occasional thing. No way that's random, imagine what would happen if this was your local hospital?

Just bring up the worst case first and ask what happened. Maybe be careful when you do it so they don't feel crappy going into theatre or consultations, as they may need to process things. It depends on your relationship and you need to tread carefully to get honesty on both sides without recriminations. If they are defensive, they won't listen. They may realise they are not great and this is why they want to learn more, or they are deluded, which is a big problem.

Asking nurses to watch what is happening is a good idea, but I would suggest it is only very experienced, tactful ones, so that they are not undermined. It means looking into every aspect, as it can be really difficult to pinpoint where an individual has a small but significant gap in their knowledge. My thoughts would be, in no particular order: suture material, incorrect knot tying combined with a continuous technique(they're tying slip knots), (suggest change to simple interrupted for now), infection, poor sterile technique combined with a carrier state, could even be MRSA: swab a few wounds and the staff. Look to see if there is a nurse correlation and breaks in sterility. Swab tables, surfaces, kennels if MRSA could be involved. Poor mask wearing, nose sticking out? Excessive slowness? Need new glasses? Suggest placing wound dressings over everything to keep things clean and rule out kennel/home contamination.

My suspicion is they've got into some bad habit (or possibly done it all along) and they are repeating their error.

I love this kind of detective work, do let us know what happens.

RE: Clinical governance

Dinu Catilina — Sat, 27 Mar 2021 15:56:51 GMT

[quote userid="7542" url="~/001/veterinary-clinical/small-animal/soft-tissue-surgery/f/discussions/29744/clinical-governance/229447#229447"]Cert AVP in surgery[/quote]

In my opinion the CertAVP(GSAS) is not a suitable way to improve basic skills or even to gain new skills. There is limited to zero practical teaching and it's more to develop a certain mindset and approach to cases. If someone wants to be better then they need to learn, shadow and try. Can you offer them 2 days a month, fully paid to shadow an excellent surgeon in a different practice?

[quote userid="8991" url="~/001/veterinary-clinical/small-animal/soft-tissue-surgery/f/discussions/29744/clinical-governance/229466#229466"]Is this perception or reality? Clinical audit is your friend, straightforward to document surgical complications, and take into account patient status. Most wound failures are due to excessive tension, which is a technique issue. Rarely it is due to defective suture material, though can be due to inappropriate material usage. Linea albas rarely fail due to patient interference. Beware of random clustering effect too.[/quote]

This. I would also add knot failure.

I believe that calling them out is counter productive. If we have an issue in practice I will do a staff meeting and discuss about how I want things done. Isolate the issue and rather than criticise the mistake reiterate how it should be done correctly. General advices of be better, be more careful, make less mistakes are meaningless and will not achieve anything.

RE: Clinical governance

jane alexander — Sat, 27 Mar 2021 12:21:07 GMT

We had a similar issue with one Cert-enrolled vet, did a clinical audit (to avoid a bit of a witch-hunt) and eradicated a new (cheaper) suture from our shelf, problem left us at same time. Still not sure if that was the reason or if everyone improved their skills after a discussion at M&M meeting!

RE: Clinical governance

Neil Wheadon — Sat, 27 Mar 2021 11:34:30 GMT

I'm going to be more direct, you simply have to tell them, but that's hard.

I've seen lots of surgeons at work and there are vets out there who aren't good at surgery, you see the results. I spoke to a nurse once and they are the ones who truly see what a surgeon does. My comment was 'well he/she has a surgical certificate, they must be competent' her reply was that they weren't.

I worked somewhere once in a practice where the vet called themselves a surgeon, not a vet, a surgeon. However to have to start to explain to multiple clients why their cat spays were going wrong was tough. My heart absolutely sank when I walked in one day to see that they were going to attempt a TTA

There is a feeling in the human field that the days of a good surgeon may be limited as it takes training with manual dexterity from an early age and those days are gone when you play with meccano, though acknowlege that keyhole surgery is closer to a video game in regards hands eye co-ordination. In conclusion, just because you can pass a vet exam doesn't mean you can operate, however it's also true as David has said that a minority won't recognize this fact

Neil

RE: Clinical governance

David Mills — Fri, 26 Mar 2021 21:53:21 GMT

Some thoughts you might find useful.

Is this perception or reality? Clinical audit is your friend, straightforward to document surgical complications, and take into account patient status. Most wound failures are due to excessive tension, which is a technique issue. Rarely it is due to defective suture material, though can be due to inappropriate material usage. Linea albas rarely fail due to patient interference. Beware of random clustering effect too.

A surgery certificate won't address this unless they are made aware of the problem (if there is one). Certificates tend to go one of two ways - a person revisiting the basics and working on these to do everything better or it distracts people wanting to do sexy surgeries. Some of the most careless surgeries I've seen are from certificate hopefuls doing routine work who don't see the value in every single surgery and get distracted or 'above' things. Every surgery is a learning opportunity and a chance to practice and develop.

Be careful how you address this (I don't know how much experience you have in management so this may be grannies and eggs). My approach would be as part of general feedback - normally start as a group (M and M meetings are good with anonymised surgeon data (say, presenting the audit results), followed up by individual meetings to give individuals their scores). There is benchmark data for routine neutering on VetAudit (RCVS, google it) from a wide range of practices. You need to establish a) if they perceive a problem; b) a shared way forward to improve. You can be strict here and outline that the complication rates are too high and you need to work together to find a solution. Most surgeons would be horrified (they may be defensive at first and diversionary) and want to improve. A minority would be resistant, in which case you may need to up the ante and enforce a plan on them (e.g. having someone (you most likely) scrubbed in with them and performance managing). Ensure, more than anything, you do a follow up audit at a time point in the future - it will reassure all involved and also make the individual feel like they haven't been singled out.

It sounds like a relatively straightforward fix, will take a bit of work, but most people are glad of it in the end. Good luck.

RE: Clinical governance

Bob Russell — Fri, 26 Mar 2021 09:39:00 GMT

What suture material is being used? We had three in a week many years ago and found that the Bondek used could be broken by hand. We learned a lot of lessons in a short time.

Does the practice discuss cases? We do all the time and try to work out ways to do better. I consider myself a surgeon of little brain so take all constructive assistance with enthusiasm!

RE: Clinical governance

Vet2Vet — Fri, 26 Mar 2021 09:17:58 GMT

Seven here in six months