Clinical audit: A walk through

S Chockalingam

Senior Consultant – Orthopedician, Kauvery Hospital, Cantonment, Trichy

Background

Latin word audire meaning “to hear “. Started way back in Persia (522-486 BC), China, Egypt, Greece. Auditors in Britain in medieval times, used to hear the accounts read out to them and written records followed soon after. Audit is hence “hearing the data to” verify transactions to prevent fraud, to detect errors

Audit was thus used random method to check the data for errors. Audit in every industry has changed from finding faults to establishing some standards and audit compliance with

Audit is a standard practice in

Finance and accounts
Airline industry
Quality
Performance
Project
Energy
Information technology
Operations audit
Forensic audit

Health Care Audit

King Hammurabi, the sixth king of Babylon in 1750 BC! Instigated the audit for clinicians
Florence Nightingale, detailed statistical analysis in 1853 to 1855, reducing mortality from 40–2%
Ernest Codman from Harvard, in 1916, Ortho Surgeon, Surgical outcomes
Avedis Donabedian in 1966, conceptual model of clinical audit.

What is the difference between audit and research?

Audit	Research
Are we doing, what we should be doing	Are we doing, what we should be doing
Guidelines or standards already in place	Set the standards ( new knowledge)
Sometimes what is common sense	To discover better ways of doing

Are they completely different?

Often Audit is needed as first part of research
Sometimes one needs to research to get the data for audit
Audit is easier to complete and present and publish
Research is easier when one has experience of audits

Areas of Clinical Audit: Avedis Donabedian

Resources: Waiting times
Process: Infection prevention, bed sore prevention etc
Outcome: Most clinical studies

What is not clinical audit

Review of mortality of one patient in a meeting
Knee jerk reaction to mortality and morbidity and changing practice
Looking at the outcome in a non systematic manner.

Who should (Should not?)

Medical Audit to Clinical Audit

Audit was formally introduced into the NHS in 1989 via the Working for Patients White Paper, called Medical Audit

Nurses and other health care professionals started getting involved and hence the term changed to Clinical Audit

National clinical audits in UK are now mandatory.

Who should not?

If I audit my work, then I understand all the compounding factors
If I do not audit my work, someone else would audit and tell me what to do
Professional is someone who constantly strives to improve his work and takes accountability

Why doctor should do clinical audit?

Reasons to do clinical audit

Many ways to skin a cat, which method should I follow
Want to make the treatment better for my patient
Have to answer my patient questions and concerns
Should do it, otherwise someone else will tell me what to do

Need not do?

Follow standard guidelines and protocols
My patients are doing well in my practice
Base my practice on what learned seniors and peers advice
Can answer all the questions, patients and relatives ask

How to do Clinical audit

Method 1: Follow standard practice, Protocol approach and audit compliance
Method 2: Local Trigger initiating clinical Audit with a systematic approach

Method 1

Look out for protocols which are already accepted and implement them locally where we work
For example, Safe Surgery Check list, Use of Ultrasound for CVC, marking the site and side of the patient for surgery,
Audit compliance of the same regularly and change practice to ensure compliance.

Method 2

Use of triggers for audits locally

A Scenario 1

We saw failures at six weeks after a fracture surgery so we decided to look at all patients with this surgery over a period of time. Reviewed over 300 X rays, 33% of patients had problems with this particular technique.

It was decided to change our practice to different accepted surgical technique. Review of X rays of the different surgical technique showed 5% problems

A Scenario 2

82 year old lady with fracture neck of femur, Diabetic keto acidosis, Sepsis. Operated but died on the third post op day

Discussed in the audit meeting

Review all fracture neck of femur patients treated at kauvery hospital
Over 80 years of age I.e octogenarians
Our mortality rate was well below the reported incidence in the literature 5% as opposed to 6 to 9.6 %

Some practical example

1. The trigger: Valium given instead of Voveran for a patient

Action

Medical Council of India code of medical ethics says “Every physician should prescribe drugs with generic names legibly and preferably in capital letters”

A simple trigger

One of the patients presented with back pain
X rays and clinical exam was normal
He was treated with standard analgesia and physio
He returned with ongoing pain, and more importantly with night pain

A simple analysis of data

His investigations showed him to have secondaries from lung tumor
Do not want to miss any red flag signs
But we have limited time to take history in a busy clinic

Change in practice

Beta version

The current one

Change in practice saves time (and potentially Life). But needs re-analyzing the data for accuracy

2. The Trigger: Blood is being cross matched, but not used. Time and money cost

Group and save vs Cross matching

# neck of femur IT type	#neck of femur Intra capsular type
Blood loss was higher	Blood loss was lower
Post op Hb was lower	Post op Hb drop was not high
Transfusion need was higher	Transfusion need was lower
Transfusion index was used	Transfusion index was used
X matching done	Group and save done

*Cost and time savings achieved

3. The trigger

A female (Nurse) patient with back pain was sent for an X ray
Patient was not asked if she could be pregnant prior to these investigations

Action

Atomic Energy Regulatory Board of Government of India

A permanent radiation warning symbol and instructions for pregnant/likely to be pregnant women shall be pasted on the entrance door of the X-ray installation, illustrating that the equipment emitsx-radiation.

4. The trigger

We prescribe pain relief to be given as needed
Nurse mentions that the patient is comfortable after surgery, but patient had wept due to pain in the night

Action

KMC Speciality pain audit

Used Knowledge and attitude to pain questionnaire among health care professionals by using a standard validated questionnaire
Found out that there is general lack of understanding patients pain
Pain assessment score chart was introduced based on patients perception and rather than the perception of the health care professional.

Change in the way pain is monitored

5. The trigger

Patient was quite depressed in the ward
Psychiatrist opined Post trauma stress syndrome

Action

Literature review

Post-Traumatic stress disorder: An under-diagnosed and under-treated entity. January 2013”

Audit: Analysis of all patients with major trauma identified many with PTSS with a standard questionnaire, this was administered by a social worker

Findings: Significant number of major trauma patients were found to be depressed.

Change in practice

Psychiatrist advice is sought for major trauma and poly trauma patients
This will also is a starting point of research in this area

6. The Trigger: Not all patients who had undergone partial hip replacement were happy with their hip replacement

Action

Literature and guidelines

Total hip replacement gives better functional results than partial hip replacement
But there is a risk of postoperative dislocation as a complication

Change in practice

Total hip replacements were introduced at Kauvery hospitals, Trichy
The case cohort were studied for complications and satisfaction
Over 110 patients who had total hip replacements were reviewed
Their mortality, morbidity especially the dislocation rate were reviewed
It was found out that the total hip was safe even in the elderly population.
It is routinely offered for our patients

7. The trigger

Quite a few patients and the relatives do not consent for total knee replacement

Even though this would make their quality of life better
They mention the age in particular for not undergoing the procedure

Action

Literature review and audit

Quite a number of papers in the literature to support this surgery in the elderly population
Outcome Audit: We reviewed 50 patients over the age of 70 who had undergone TKR and shown that the mortality was nil and morbidity noted could be managed by other departments effectively

Change in practice

We are able to counsel patients accordingly
We seek opinion of other consultants promptly to ensure optimal outcome

8. The Trigger

Quite a few patients were supplemented with Vitamin D for Musculo skeletal pain
This practice was questionable when there was a different diagnosis for many patients which needed a definitive treatment

Action

Literature review

Vitamin D deficiency can give symptoms of non specific body and bone pain
Vitamin D deficiency leads to muscle weakness which makes function of joints difficult

Audit

Vitamin D testing was performed on a case cohort of patients who had presented with non specific pain, difficulty in getting up from sitting posture, weakness, tiredness with body pain
It was found quite a significant number of patients were deficient and insufficient, a small percentage with hypervitaminosis D
These patients were treated with vitamin D replacement only and patients showed noticeable improvement

Change in practice

Vitamin D testing more commonly used
Vitamin D is now used for treatment more often
Sit to stand test is now routinely used in Orthopaedic clinical examination as it detects proximal myopathy

9. The trigger

Aunt of a doctor who had total knee replacement, In post op pain, felt that she should not have undergone this procedure
Was on epidural analgesia for pain relief, but still!

Action

Literature review and Audit

Peri articular injection of analgesia was practiced in US and Australia
There were many papers to justify this
An audit was performed studying epidural group and showed unsatisfied patients with inadequate pain relief.

Change of practice

PIA is routinely used instead of epidural analgesia
Consistent pain relief and satisfaction is noted
The audit cycle was completed.

10. Trigger: Frozen shoulder is a common problem

Physiotherapy does not help all the patients shoulder arthroscopy is quite interventional and poor acceptance by patients. MUA and injection helps and audit of all patients with good results.

Action

How to audit deaths

Mortality

Mortality review for individual deaths has limited learning value
Mortality is a crude outcome indicator
Has multiple compounding factors in most cases
Individual patient mortality is best done as a confidential enquiry, Eg CEPOD

Change in practice

All patients with fracture neck of femur are offered surgery
Pre-op optimisation and early surgery
Immediate post op mobilization
Not kept in ICU unless warranted

Certainly Audit can change practice for betterment of patients

At all our kauvery units clinical audit meeting was started way back in 2009 and should continue
Change is the constant Mantra
But with systematic analysis, which is what is Clinical Audit and that is how it should be done

When should I do clinical audit

As a medical student
As an intern
As a practicing doctor
As a health care professional

We are in the business of treating patients

All Clinical Audits should start with patients in mind
what does the patient want?
Ideas, Concerns and Expectations of the patient is a start
I don’t want to die
I don’t want to stay in ICU
I do not want any complications
Will there be lot of pain
will I walk normally like I used to.

Where should I do clinical audit

Outpatients
In patients
Operating Theatres
Emergency department
Treatment rooms
Para clinical areas
Non clinical areas which will impact on clinical satisfaction.

Summary

Use Triggers to start clinical audit in your area of responsibility and practice

The trigger

Children with fracture lower limbs, stayed in the hospital longer, cost and family difficulties noted
Though children were treated in plaster casts, traction and major surgery when they had fractured thigh bones
Newer techniques were standard in major institutions to
1. Reduce the hospital stay,
2. Reduce the cost to the hospital and the family and
3. Improve the outcome

Change in practice

The thigh bone fractures were stabilized with Minimally invasive surgery resulting in better outcome
This was shown by comparing the traditional methods of treatment with a different technique of acceptable treatment
This changed our practice locally.

Audit can change practice across a country

Elderly patients with fracture neck of femur were developing bed sores
The patients with fracture neck of femur patients were waiting in trolleys for a long period in Emergency department
Time delay for admission from emergency department to hospital bed was stipulated to less than 4 hr across the country.

Kauverian Bookshelf

Applied Medical Statistics

Clinical audit: A walk through