Clinical audit

RE: Clinical audit

Anthony Dennison — Thu, 05 Nov 2015 11:42:21 GMT

We have an operations log for each branch with an op theatre which details the procedure done, whether there was charity assistance (mainly for neuters), the vet and nurse involved, whether the animal was intubated, suture material used, post-op temp and length of procedure.

All are collated at the main hospital which is then discussed at a clinical meeting with the head vet and nurse once a month.

RE: Clinical audit

John Flynn — Tue, 03 Nov 2015 22:03:06 GMT

OK, Michael - I think I see what you are saying broadly.

Your premise is that I overestimate the success of approaches I take to clinical cases and the solution is something called "clinical audit"

I'm obviously in no position to comment as to the premise, however I'm not convinced on the solution assuming it is accepted. I've tried out http://www.clinicalaudittools.com/index.php?option=com_ariquiz&view=quiz&quizId=2&task=quiz&Itemid=104 which tells me whether something is a "clinical audit" or not and I'm still not convinced that I think this is a relevant "thing" for me.

Past success/failure is a poor predictor of future success/failure in my opinion. The reasons being that what I consider to be a good idea or the diligence with which I perform it vary with time and the small case numbers of differing clinical presentations with multiple complicating factors I encounter mean that trawling through to produce data that focuses on "quantitative (e.g. single responses, Yes/No) data" is unlikley to yield any meaningful conclusions that have contemporary validity for improved individual patient care (though may be useful from a management perspective). The sorts of things I can think to analyse of interest (e.g. average life expectancy of dogs that attend my clinic as a pup and then for their whole life and the average cost of veterinary care I deliver over that patient's life) are long-term, with no useful benchmark, retrospective in nature and not directly aimed at improving individual patient care so wouldn't count as clinical audit anyway?

If I decide to focus my clinical improvements by trying to do something called "clinical audit" I am looking specifically for something with a quantitatively measureable outcome just because that fits the definition of "clinical audit" rather than because I have concluded based on my observations that the best improvement in patient care I can offer will come from spending time reviewing some data on diabetic cats I have treated.

Furthermore, I will be limited to something which I can measure "against agreed best practice (e.g. national standards, local guidelines, etc)". That is a serious limitation and quite unrealistic I feel. What is "best practice" for diabetic cats? or for anesthetising rabbits? Am I even aiming for this "best practice"?

Finally, should the process not fall at the above hurdles, the focus on past cases and past performance can be detrimental also. I may extrapolate wrongly from a small number of cases that an approch I have been taking is either good/bad or indifferent. If I wish to improve rabbit anesthesia, looking at the records of the 2 rabbits I anesthetise a year is unlikley to yield as much benefit as reading an up-to-date article on current thinking on anesthetising rabbits! For instance, in the thread you refer to, there is reference to textbooks from 15 years ago if I remember correctly. There is a well recognised phenomenon whereby one pattern-recognizes based on recent cases managed also and the same no doubt is true when one spends a lot of time between consults reading cases of a specific presentation, so this isn't a totally benign process unaffecting your performance - perhaps having been well-rested and meditated on being positive and attentive for the next consult could have yielded greater individual patient benefits - who knows?

I have no problem with following up cases, performing post-mortems, reflecting on a case and making notes on what you might do differently in future - indeed I think all these things are useful learning - however I'm yet to see a place for me for this "clinical audit". The main thing suggested so far seems to be post-operative complication rates - I think simply trying to improve things when we can is better than keeping a running tally which is as likely to go with the phases of the moon than anything helpful that I am likely to identify from this tally.

I am willing to be convinced otherwise, and like so often on issues I originally don't get, I may find myself in a few years having reflected on this "conversation" with your "voice" ringing in my ears and me nodding sagely on the wisdoms of "clinical audit" even if I don't seem to grasp it just now.

RE: Clinical audit

Michael Woodhouse — Tue, 03 Nov 2015 21:24:36 GMT

John Flynn - the evidence is strong that we over estimate our successes and down play our failures. Go and look at some of the rabbit GA success rates in the recent thread - far higher than the published evidence.

Unless we objectively appraise our own practice then we don't know how good we are. If we don't objectively expose our weaknesses then how can we decide where to make changes for the better?

What is your post operative wound infection rate? How many of us have that figure to hand? (We don't!)

RE: Clinical audit

John Flynn — Tue, 03 Nov 2015 21:09:13 GMT

This one's rather new to me, but having been on wikipedia (that most reliable of sources) to swot up on what "clinical audit" actually is, I'm unconvinced that there's much of interest for a small animal general practitioner working in a small, perhaps even single-handed, clinic?

Perhaps I'm just not enlightened yet or have misunderstood what is being talked about, and my general dislike of management "buzzwords" doesn't help, but generally I find improvement occurs from spending time mainly on reading and sharing experiences from outside my limited clinic and selecting things to implement in the future rather than spending time collating and reviewing information from the past?

If I found myself struggling to think of useful things I could do that fitted under the heading "clinical audit", I would be likely to conclude that it wasn't a good heading to be focusing on for spending constructive time.

RE: Clinical audit

Bradley Viner — Tue, 03 Nov 2015 17:41:01 GMT

Francisco said:

"Without wanting the RCVS to impose more red-tape and controlling measures in the PSS practice, I'd welcome more examples that would really help to improve practice."

The PSS already does include clinical governance, and the consideration of outcomes will be given more emphasis in the new scheme. But you are absolutely correct to say that the effort that goes in to clinical auditing should be channelled into common areas of practice where there is considered to be significant room for improvement rather than just to satisfy some external requirement. There can then be a real cost benefit to the process.

Examples that I have applied in my own practice have included the management of diabetic cats, of nephritic cats, of monitoring blood pressure and of concordance with weight control clinics (run by nurses), as well as post-operative complications of neutering.

I run modules for the RCVS CertAVP in conjunction with VetLearning on both clinical audit and clinical governance for anyone interesting in finding out more.

RE: Clinical audit

Francisco Gomez — Sun, 01 Nov 2015 18:33:38 GMT

[quote user="Bradley Viner"]

Clinical audit is a tool to encourage practices to continually improve at embedding best practice into their work.

[/quote]

Without wanting the RCVS to impose more red-tape and controlling meassures in the PSS practice, I'd welcome more examples that would really help to improve practice.

Knowing how many clients follow up advise during routine health check/vaccinations would be useful not only for the practice but also for our pet community, Thank u! On the other hand, finding out how many complications you get in orthopaedic operations might be useless if you only perform 10 ortho sxs/yr in non standarised patients, different vets and different procedures...

RE: Clinical audit

Bradley Viner — Sun, 01 Nov 2015 13:07:21 GMT

It's great to hear about all your experiences with using clinical audit as a tool to improve practice performance. There was a fantastic turnout at the session Pam Mosedale and I put on at the EBVM Skills Day last Friday. Clinical audit is not about generating statistically valid information to produce generalisable results - that is the job of clinical research - it is a tool to encourage practices to continually improve at embedding best practice into their work.

I would be very happy to supply more information on clinical audit to anyone interested off line via my email at b.viner@rcvs.org.uk and also encourage anyone interested to join the RCVS Knowledge group on the subject.

RE: Clinical audit

Stephen Courtney — Sat, 31 Oct 2015 21:39:12 GMT

We record every unexpected outcome for surgery,also vaccinations.

This can include clipper rash, or a seroma, or suture reactions post spay, also more serious events such as septic peritonitis after bowel surgery , also critical care cases that don't do well.

The overall numbers of complications are low compared with the total number of procedures/ events, but it allows for trends to be monitored, and this has helped change certain procedures eg being much more proactive when animals are not bouncing back after Fb removal - scan for effusions and if in any doubt re operate sooner than later

We have created a 'Client' on our PMS called 'Messrs Clinical Governance' and within that client is a 'pet' named for each branch, and each compllciation is recorded on clinical governance under the appropriate branch. Once every month they are summarised and sent to the head clinician who peruses the data, and we have M&M rounds every few months , sooner if need be.

RE: Clinical audit

mariette asselbergs — Sat, 31 Oct 2015 19:51:46 GMT

I did an audit where I started on 1st of January looking through the records on the computer for booster vaccinations to see how often a condition was picked up during the health check, and how often the owners did follow the advice given e.g. to do a dental, take bloods, do something about weight, treat for worms and fleas, do an FNA of a lump, have anal glands expressed or ears treated, so a schirmer test or book an eye appointment.

It was easily done, and gives very useful results.

I also did an audit on emergency patients about which of our "toys" were used in these cases (x rays, bloods, oxygen, endoscope, ultrasound).

I could easily collect the data during waiting times between patients or appointments, or at night during quiet times.

Mariette

RE: Clinical audit

Emily Rainbow — Sat, 31 Oct 2015 18:58:02 GMT

We've just started a small in house one looking at post-op complications after a short run of them to try and see if there is a trend. We have a book that the nurses are filling in when they do their post-op checks.

RE: Clinical audit

Phil Hyde — Sat, 31 Oct 2015 18:35:14 GMT

Interesting that you've had no replies to this. I think everyone is keeping their heads low...

For my part, I think actual auditing using numbers and statistics is doomed to fail considering the numbers that we deal with. Try reading some papers on it if you're having trouble sleeping.

On the other hand, sitting around with colleagues discussing cases is useful and, at a stretch, comes under the same banner. Just remember to minute it, then the rcvs may keep off your back.

Phil