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J.R.Coll.Edinb., 47, August 2002, 643-652
Audit of use of integrated care pathways within a District
General Hospital
S. DAS
Perth Royal Infirmary, Taymount Terrace, Perth, PH1 1NX
Introduction: The use of integrated care pathways (ICPs) in hospital medicine is becoming increasingly common. The aims include ensuring multidisciplinary teamwork, decreasing the length of hospital admissions and ease for further audit to improve the standard of care. I audited how efficiently the ICPs for fractured neck of femurs (NOF) and total hip replacements (THR) were being used. Patients and methods: I retrieved the case notes of 30 patients who had been discharged following surgery (15 NOF and 15 THR). I recorded whether initial assessments, peri-operative assessments and daily assessment records had been documented in the ICP and whether they where complete or incomplete. Finally, I recorded how many sheets of the ICP were completely unused. Results: Of the initial assessment, 31% of the medical clerk-ins were complete (3% were incomplete). 56% of the nursing clerk-ins were complete (26% were incomplete), 100% of the professions allied to medicine (PAMs) initial assessments were not completed and 3% of the peri-operative assessments were complete. Of the daily assessment records, none were completed by medical staff, 63% were completed by nursing staff, 23% were completed by the physiotherapists and 9% were completed by the occupational therapists; 32% of the pages were not used at all. Discussion: As expected nurses, who have long been using care pathways, are best at using the ICPs. Medical staff still have a tendency to document assessments in medical notes, especially for acute admissions. Although all professions within the multidisciplinary team are aware of the ICP it was a surprise to find none of the PAMs incorporated it during their initial assessment, each preferring to keep their own records, which seems to be the major problem in promoting the ICP.
Using management and audit tools to improve ENT
surgical audit-meeting performance quality
S.S. BACKHOUSE and S.T. BROWNING
Singleton Hospital, Sketty Lane, Swansea, Wales, UK, SA2
8QA
Introduction: The central role of audit to monitor and improve service provision within the NHS is now firmly established. However there is no benefit if audit studies are either inappropriate, not completed or outcomes not used to improve practice. Aim: The aim of our audit, therefore, was to measure objectively and improve the effectiveness of our Ear, Nose and Throat (ENT) surgical department’s auditmeetings as a conduit for aiding selection, completion and dissemination of audit topic information to meeting participants. Methods: Management tools of ‘meeting structures’, ‘theory of change’ and ‘project management’ were applied to overhaul our audit process and meeting format. Anonymous prospective-audit confidential interviews were used prior to and one year after these changes to objectively measure both completed audit projects and the knowledge of audit studies retained by meeting attendees. Results: The study produced statistically significant improvements (p=0.036) for both audit projects completed and the meeting-attendees recollection of these audit projects. Discussion: We discovered weaknesses in our processes of audit topic selection, execution and presentation which we amended through co-operative reasoning and the use of management and audit tools. Every department that undertakes audit, though not having the same profile of weaknesses that we identified, should be able to adapt our approach to help improve their own audit process format. Following analysis of this audit study outcome we have since embarked on a second audit loop, aiming to improve further our audit performance. Conclusion: Benefits of audit are dependent on project selection, completion, and dissemination of outcomes. We have shown that this process can be improved, both functionally and statistically, by managed ‘audit of audit.
An audit of an integrated care pathways for primary total
knee replacement
S. BALACHANDRAN, D. JENA, and S. CHUGH
New Cross Hospital, Wolverhampton, UK
Background: Clinical pathways are being frequently used to integrate the care of patients with specific illness or undergoing standard operative procedures. They are best practice tools, which display treatment goals and the sequence and timing of staff activity to achieve these goals. Clinical pathways aim to produce high quality outcome with increased patient care and decreased length of stay in hospital and related costs. Primary total knee replacement is one of the suitable procedures for clinical pathway as it is a common and the patient care process is relatively standardised. Following success with Integrated Care Pathway (ICP) for primary total hip replacement (THR), the ICP for primary total knee replacement (TKR) was introduced in March 2001 at New Cross Hospital, Wolverhampton. Objectives: The objectives of this study were (1) To determine any reduction in length of stay for patient undergoing Primary TKR during first 6 months of using ICP (2) To compare the quality documentation between ICP and pre-ICP groups, (3) To determine whether introduction of ICP for THR had any influence on Length of stay of patients undergoing TKR during that period and (4) To highlight any changes that need to be made in the patient care. Study Design: Data was collected retrospectively from 172 patients who underwent TKR 1 year before introduction of ICP for joint replacement, 97 patients who underwent TKR after introduction of ICP for THR and from 92 patients who underwent TKR during first 6months period of utilising the ICP for TKR. Results: Mean length of stay was reduced from 16.8 days (1 year before ICP) to 10.5 days mode length of stay from 12 days to 8 days. Introduction of ICP for THR had definite influence on mean LOS of TKR patients by bringing it down to 11.2 days. There was no difference in readmission rate between the study groups. There was definite improvement in quality of documentation by all disciplines. Some changes in ICP, as well as in the protocol, were suggested. Conclusion: The ICP is an effective method for streamlining care and reducing length of stay for patients undergoing primary TKR. It also improves quality of documentation.
Appropriateness of referrals to a specialist breast clinic
M.D. BARBER and J.S. O’NEIL
Department of Surgery, Borders General Hospital, Melrose
TD6 9BS, UK
Introduction: The emergence of specialist breast clinics and their associated infrastructure has allowed the prompt review of patients with breast problems. However, this also demands responsibility from general practitioners making the decision to refer and requesting specific urgency of review. Patients and Methods: Following dissemination of National Guidelines for referral of patients with breast problems to general practitioners, all patients attending the breast clinic at the Borders General Hospital have had an assessment made of the appropriateness of referral and the appropriateness of the requested urgency of referral made by the clinician seeing the patient. A total of 645 patients had this assessment made between October 1999 and December 2000. Results: 209 (32.4%) patients were referred urgently. A total of 110 (17.2%) patients had an ultimate diagnosis of cancer. Cancer patients were referred urgently on 71.8% (78 of 110) of occasions. Non-cancer patients were referred urgently on 24.2% (131 of 535) of occasions. Overall, the urgency of referral was deemed to be appropriate in 84.2% of cases, for cancer patients urgency was appropriate on 90% of occasions and for non-cancer patients 83.6%. Inappropriate referrals were made on 52 (8.1%) occasions. Discussion: General practitioners in the Borders region appear to be doing well in referring patients with appropriate problems and with appropriate urgency. Feedback to individual general practitioners with higher rates of inappropriate referral is planned.
Audit of a telephone helpline service for arthroplasty
patients in Edinburgh
D.A. CAIRNS, M. HATHAWAY and C.R HOWIE
The Princess Margaret Rose Hospital, Frogston Road West,
Edinburgh, UK
Introduction: Telephone helpline services for patients have gained increasing popularity in recent years. Services such as NHS Direct have been established with the aims of enhancing patient knowledge and reduction of the workload in over subscribed areas. The Edinburgh arthroplasty helpline was introduced in 1998 to improve access to specialist advice for patients after routine hip and knee surgery. The aim of this audit was to identify the population using the service, common reasons for calling and action resulting from each call. Patients and Methods: 685 calls to the helpline over a 6 month period were analysed with respect to 1) identity of the caller 2) nature of the enquiry 3) time taken to respond to the call and 4) nature of action resulting from a call. Results: 80% of callers to the service were patients, the majority of whom were using the service for the first time (65%). A high number of calls were repeat enquiries (35%). Several other health professionals were identified as users of this service. Appointment queries were the commonest reason for a call (21%), followed by requests for general advice (19%). The majority of enquiries were resolved promptly with most requiring telephone advice only. Overall, 40% of calls were deemed inappropriate for the helpline service. Discussion: Previous research has validated the safety and effectiveness of helpline services in primary care. The arthroplasty helpline is a unique service in orthopaedic practice which facilitates fast and direct access to specialist advice. In this audit we have identified common patient concerns after elective surgery, with corresponding improvements in pre-discharge education protocol. The service has also been identified as a useful point of contact for other health professionals involved in the care of arthroplasty patients.
Audit of GPs referral policy and risk factor management
in patients with intermittent claudication
K. CASSAR, R. COULL, P. BACHOO, E. MACAULAY, and
J. BRITTENDEN
Vascular unit, ward 36 , Aberdeen Royal Infirmary, Aberdeen.
AB25 2ZN, UK
Introduction: Intermittent claudication (IC) is common and affects 1 in 20 of the population. Claudicants are at as high a risk of developing or dying from coronary heart disease as many patients surviving their first myocardial infarction. The aim of this audit was to determine General Practitioners (GPs) attitudes to referral, risk factor management and treatment in patients presenting with life-style limiting IC. Methods: Postal survey questionnaire of 334 GPs within the referral area of a regional vascular unit. Questions were asked about the following: smoking, exercise, antiplatelet therapy, diabetes and cholesterol. Results: 242 (73%) of GPs responded. At initial patient presentation 50% would undergo a period of risk factor management and reassessment prior to referral; 45% would treat risk factors and refer directly to the vascular clinic. 90% of GPs would prescribe aspirin, and 71% clopidogrel, if this was contra-indicated. Nearly all (99%) would advise the patient to stop smoking and had access to an anti-smoking clinic. GPs would advise patients to increase exercise in 89% of cases, 77% would check blood glucose and 85% cholesterol level. The cholesterol levels (mmol/l) that GPs would treat in claudicants were: <5, 5%; >5, 36%; >5.5, 18%, >6, 23% and 18% would consider the patients overall risk factor profile. First line management was diet alone in 70%, statin in 30% and 18% had an age limit for statin therapy. Discussion: Current data suggests that claudicants should be treated with a statin irrespective of their cholesterol level. Yet this survey has shown that 18% of GPs consider cholesterol lowering therapy to be primary rather than secondary prevention and the majority would treat levels above 5.5mmol/l. Patients with IC are currently being sub-optimally treated and there is an urgent need for national guidelines.
A national study of basic training in general surgery
I. CURRIE*, G. YOUNGSON**, G. MACBAIN°, M. LAVELLEJONES°° and S. PATERSON-BROWN^;
* University Department of Surgical and Clinical Sciences,
Royal Infirmary of Edinburgh ** University Department of
Paediatric Surgery, Royal Aberdeen Children’s Hospital,
Aberdeen ° Department of Vascular Surgery, Southern General
Hospital, Glasgow °° Department of Surgery, Ninewells
Hospital, Dundee ^ Department of Surgery, Royal Infirmary
of Edinburgh, UK
Background: Basic training in general surgery has been reduced as a result of the Calman report, requiring trainees to acquire experience and achieve competence more rapidly. The constitution of an appropriate or sufficient training in general surgery at SHO level has never been defined. Aims: To derive benchmarks for training, the four chairmen of basic surgical training rotations in Scotland agreed that a national study should be carried out. Methods: Two cohorts of BST SHOs in Aberdeen, Dundee, Edinburgh and Glasgow completed a questionnaire detailing ward responsibility, clinic experience and operating opportunities. They also reported their operating experience in six key procedures. Results: There were 70 SHOs in post; responses were obtained from 55 (79% response rate). First (54%) and second (46%) year SHOs worked mostly in University Teaching Hospital/Tertiary Referral Centres (54%) or in District General Hospitals (46%) in 1 in 3 (4%), 4 (36%), 5 (41%) or 6 (19%) rotas. When on call, SHOs did too few (4%), a sufficient number (78%) or too many (18%) nights and saw 0-9 (36%), 10-19 (55%), 20-29 (4%) or >30 (4%) patients. Some found it too quiet (8%) and some too busy (13.6%). SHOs attended 1 (4%), 2 (18%), 3 (55%) or 4 (23%) theatre sessions and 1 (4%), 2 (45%), 3 (31.2%), 4 (13.6%) or 5 (4%) clinics per week. 55% of SHOs were able to attend specific BST teaching sessions regularly, although 45% of SHOs could not, either because of clinical commitments (18%) or no teaching sessions (27%). At the end of six months’ general surgery, an SHO in Scotland would have carried out a median of 8.5 appendicectomies (range 5-36), 9 varicose vein operations (range 1-37), 12.5 inguinal hernia repairs (range 3-41), 31 lumps & bumps (range 8-111), 11 enteric anastomoses (range 2-40) and 6 upper GI endoscopies (range 0-159). Conclusion: This study established a national database of SHO experience and opportunities so as to provide benchmarks for SHO training. These data will facilitate the identification of excellent posts in which opportunities and experience exceed the national average. Similarly, those posts which require increased levels of support to achieve training targets can be identified and appropriate action taken. Overall, these data should help to improve SHO training in general surgery.
Theatre efficiency - audit of theatre time intervals in three
different settings for laparoscopic cholecystectomy
S. AGRAWAL, A. PULLEN, H.M. KOCHER, A.G. PATEL
King’s Centre for Surgery of the Liver, Bile duct and Pancreas,
King’s College Hospital, Denmark Hill, London SE5 9RS, UK
Background and aims: Operative times may vary, thus, affecting theatre efficiency. Theatre time intervals were audited to identify points of delay for an operation in three different settings - routine inpatient theatre (RIT), day surgery unit (DSU), and waiting list initiative (WLI). Methods: 60 consecutive patients underwent laparoscopic cholecystectomy with intra-operative cholangiogram between May and October’ 2001 of which 31 had as RIT, 20 in DSU and 9 on WLI. Nonparametric tests (Mann Whitney U test) were used for analysing time sequences to identify delays. Results: Pre-operative time (holding bay time and anaesthetic time) was significantly greater for RIT, as compared with DSU (P= 0.001) or WLI patients (P=0.05). Operative time was significantly more for RIT as compared with DSU (P=0.01), but no different from WLI (P=0.24). The turn-around time ( non-operative theatre activity) was significantly more for RIT as compared for DSU (P=0.001) or WLI (P=0.009) patients. Trainees took more time to perform the same procedure than the consultants (P=0.01). Conclusion: Co-morbidity of inpatients would explain longer pre-operative and operative times for inpatients, as compared with those operated in the DSU. However, the inherent efficiency of DSU and the financial and time initiatives of the WLI achieve theatre time efficiency.
Optimal management of splenic injuries in adults
M.M. ELAHI,1 C. ARCHDEACON2 and D.M.
HEMINGWAY;1
(1) Department of Surgery, Leicester Royal Infirmary, UK
and (2) Department of Clinical Effectiveness, Leicester Royal
Infirmary, UK.
Background: Non-operative management of blunt injury to the spleen in adults has been applied with increasing frequency over the past decade. However, the optimal treatment of splenic injury following blunt trauma is an area of considerable clinical controversy. We performed a retrospective review of 53 adults treated for splenic injury following blunt trauma. The study aimed to identify factors that may help surgeons, select the optimal management option as well as those predicting successful outcomes. Methods: Retrospective case note review of all adult patients was done, who were admitted with a query of splenic injury to the Leicester Royal Infirmary over a ten year period. Results: A total of 53 patients were identified and audited. The mean age was 40 years (range 17-96 years); 74% were male. A total of 6 (13.2%) patients went directly to the operating room; 46 (86.7%) patients were admitted with planned investigations and treatment. Patients who went directly to the operating theatre were more severely injured than those who did not. Of the patients admitted with planned observations and investigations, 14 (26%) were managed non-surgically, 3 (6%) underwent operations that conserved the spleen and 30 (56%) were treated using splenectomy. The severity score and transfusion requirements were lower among those managed non-surgically. 49% had a computerised tomography (CT) scan of the abdomen and 36% had ultrasound of the abdomen on admission and 15% had a diagnostic peritoneal lavage (DPL). However, the severity of splenic injury, using CT or ultrasound did not correlate well with intra-operative findings and the decision to perform a laparotomy was based on clinical evaluation. Non-surgical management failed in four patients. Two showed continued splenic bleeding, while two underwent surgery for grade III splenic rupture, which was missed earlier, on ultrasound scan and was detected on CT scan when the patient collapsed. Frequency of immediate operation correlated with AAST grades of splenic injury. Of the patients initially managed non-operatively, the failure rate increased significantly by AAST grade of splenic injury. There were no deaths in patients treated with non-surgical or splenic conservation. However, five of the splenectomy group died. Among these, 3 presented to Accident and Emergency in shock and were related to splenic surgery while 2 died of brain stem death and multiple organ failure, respectively. Mean length of in-patient hospital stay was 10 days (range 1-41days). Conclusion: Management of blunt splenic injury remains controversial. Our experience in the management of splenic injury demonstrates that either of the treatment can be performed with acceptable outcomes. Successful non-operative management was associated with higher haemodynamic stability, less severe injury score, grade of splenic injury and quantity of hemo-peritoneum. However, priorities at laporotomy should be governed by the patient’s haemodynamic status as well as systemic assessment of all potentially life threatening injuries.
Audit of the use of low molecular weight heparin (LMWH)
and antibiotic prophylaxis in patients with fractured neck
of femur at the North Middlesex Hospital.
R.T. FREEMAN and B. SHANKLAND
North Middlesex Hospital NHS Trust, UK
Introduction: There are protocols for the prescription of both Low Molecular Weight heparin (LMWH) and antibiotic prophylaxis in patients admitted to the North Middlesex Hospital with a fractured neck of femurs (#NOF). We audited the compliance with these protocols by retrospectively reviewing the notes of 48 consecutive patients with #NOF. We recorded the dose and antibiotic prescribed, whether it was given at induction, and the number of postoperative doses given. Similarly, we recorded whether the patients were prescribed LMWH on admission, if not the reason for this, and the length of time they remained on LMWH for and whether this was converted to unfractionated heparin (UH). Results: 81% of patients received antibiotics at induction but only 1 patient (5%) received antibiotics according to hospital guidelines. 90% of patients were started on LMWH, but of these only 16% were switched to UH after 7 days as, recommended in the guidelines with 10% continuing for greater than 3 months. Discussion: Local guidelines for both LMWH and antibiotic prophylaxis were not being adhered to. We presented the results at the local audit meeting and invited the microbiologists, pharmacist, and ward nurses. The guidelines were re-emphasised and, after discussion, minor adjustments were made to the protocol. As well as the cost implications of long term use of LMWH, clexane is not licensed for more than 10 days for DVT prophylaxis. A simple orthopaedic front sheet was drawn up to aid the correct prescription of LMWH and antibiotics, and enabled the ward nurses and pharmacists to alert the team to any deviation from the protocol. A repeat audit showed dramatically improved compliance with the protocol so closing the audit loop. Conclusion: Audit can be used to monitor and improve compliance-with local guidelines, as a focus to update guidelines, and encourage a multidisciplinary approach to patient care.
Management of spontaneous pneumothoraces by accident
and emergency doctors in the north of England.
S.C. GIBB and N. HALFORD
Newcastle General Hospital Accident and Emergency
Department, Newcastle Upon Tyne, UK
Introduction: Intercostal tube drainage has traditionally been standard treatment for spontaneous pneumothorax. In 1993 the British Thoracic Society (BTS) published national guidelines for management of the condition, which recognised that for many patients simple aspiration may be a safe, effective alternative and that some may require no intervention at all. Recent audits in Liverpool, Ulster and Wales found that these recommendations were often not followed. We set out to ascertain whether casualty doctors in the north of England managed spontaneous pneumothorax according to BTS guidelines. Methods: 200 questionnaires were posted to all grades of doctors working in casualty departments in the north of England. In the questionnaire, 4 cases of spontaneous pneumothorax were described (including sample x-rays), and each doctor was asked to briefly describe their management plan. The results were then compared with the BTS guidelines. Results: We received 66 replies (33% response rate), creating a total of 256 cases for which management plans were described. Of these less than half of the cases (44%) would have been managed correctly according to BTS recommendations. In general, most doctors tended towards aggressive first line management, particularly insertion of chest drains. The guidelines, however, advocate simple aspiration initially in all cases of spontaneous pneumothorax. Discussion: In their guidelines the BTS recognised that chest drains are frequently inserted by junior staff and often fit poorly, leak or become dislodged. There is often confusion regarding their management and patients find them uncomfortable. Aspiration is preferred by patients, and is safer and easier to perform by junior doctors. Evidence would also suggest that simple aspiration would save resources. Despite this, these findings would suggest that the BTS guidelines for management of spontaneous pneumothorax are not widely followed within casualty departments in the north of England and awareness of their recommendations needs to be increased.
Audit of codes entered for surgical procedures by different
personnel - improving the quality of audit
S. GIBSON*, Q. COX and R. SMITH
Department of Orthopaedics, Raigmore Hospital, Perth Road,
Inverness IV2 3UJ *corresponding author
Background: Office of Population Censuses and Surveys (OPCS) codes are used to record all surgical procedures. This information is then used in audit at local hospital level and for national statistics and planning. The accurate use of OPCS codes is essential to audit quality. Objective: To assess the accuracy of use of OPCS codes within the Orthopaedic Department of a district general hospital. Patients and Methods: 163 consecutive orthopaedic procedures were studied. Codes were applied to each procedure by the trained hospital coders (2 people), the orthopaedic audit nurse (1 person) or operating department personnel (numerous people) as per current practice. For our study, the operating surgeons (8 people) were asked to code the procedure without any patientidentifying details. The accuracy of codes applied was initially assessed by looking at consistency of coding for the same procedure by each group of coders. A scoring system was then devised to assess the accuracy for each procedure. The different groups of coders were then compared. Results: The group with the highest internal consistency of coding was the audit nurse (99.6%), followed by the hospital coders (96.2%). The audit nurse also had the highest accuracy for procedure coding of all groups (92.0%), given the level of agreement with the operating surgeons. Discussion: Inaccurate use of codes for surgical procedures leads to difficulties in estimation for service provision at a local and national level. Accurate coding is essential for departmental and individual case-mix audit and research. To assure quality of audit, accurate information must be recorded for each case. Conclusion: A single trained individual coding all procedures performed in one department can improve accuracy in coding. This individual need not be part of the surgical team.
The 2-week wait target for suspected colorectal cancer
- audit of the first year of implementation
K. GRANT, D. WHITELAW, J. LIVINGSTONE, B.
MACFARLANE and J. MEYRICK-THOMAS
Watford General Hospital, Vicarage Road, Watford, Hertfordshire. WD18 0HB , UK
Background: The 1997 white paper “The New NHS” stated that by December 2000, every patient suspected of having colorectal cancer, should be able to see a specialist within two weeks of referral by their General Practitioner (GP). Our hospital introduced a 2-week target on 1st June 2000, following distribution of guidelines to local GPs, who were invited to fax referrals on specific proformas. Aims: To assess our ability to meet the 2-week target and its impact on the detection of colorectal cancers. Patients and Methods: A retrospective case-note review of patients referred between 1/6/2000 and 31/5/2001 was undertaken. Patients fell into three groups; i) Those referred under the 2-week initiative, ii) Those referred outside the 2-week initiative but designated to be seen within 2 weeks, iii) All colorectal cancer cases referred during the study period (64). Results: 222 patients were referred, or designated as “two week waiters” during the study period, of whom 100 were seen in outpatients and 122 underwent primary colonoscopy. From referral receipt, median wait was 25 days (interquartile range 14-37 days); Median time to colonoscopy was 35 days (interquartile range 23-43 days), compared with 15 days (interquartile range 11-22 days) for clinic referrals. Of the 100 specific 2-week wait referrals, 21% were not faxed, leading to a mean delay of 6.95 days. Of the 222 patients, 16(7.2%) had colorectal cancer, representing 25% of cancers detected during the study period. Discussion: The 2-week target was not achieved, predominantly due to pressure on endoscopy services. Additional delay was caused by the failure of GP’s to use and fax the referral proforma. The appointment of 2 new consultants and re-education of GP’s should address this. The current 2-week wait scheme is not an effective method of detecting colorectal cancers as the majority are diagnosed via other routes.
Audit of the management of acute oesophageal food bolus
obstruction.
O.J. HILMI, A. CAIN, M. RANTA, E. SOH PING, M.
THAHA and P.S. WHITE
Department of Otolaryngology, Ninewells hospital and
medical school, Dundee DD1 9SJ, UK
Introduction: Oesophageal food bolus obstruction is a common surgical emergency necessitating admission for approximately 200 patients/year in Scotland. The management of this condition is both medical and surgical but there are no guidelines describing an overall management plan. The aim of this project was to identify potential areas for improvement in the management of these patients and assess the impact of these changes on the patient care pathway. Patients and methods: A retrospective review of patients admitted by the department of otolaryngology to Ninewells hospital between July 1996 and June 1998 was undertaken looking into the patients previous history, management and follow up. As a result of this review, it was identified that some patients were being operated either without a trial of non surgical treatment or had no obstructive bolus found at operation. A review of the literature failed to identify a gold standard for the treatment of this problem. Guidelines where, therefore, set down recommending a period of at least 12 hours medical treatment after admission prior to surgical intervention unless there were complicating factors. An ongoing prospective study was then performed from November 1999 looking into the same factors as the original review. Results: Subsequent to the guidelines being accepted the operative rate for oesophageal food bolus obstruction has fallen from 24/37 (64%) in the original study to 17/41(41.5%). This represents a reduction of 20% (95% CI: 0-40%). Discussion: We conclude that by the introduction of local guidelines for the management of oesophageal food bolus obstruction the operative rate has reduced, thus, reducing patient morbidity and health costs.
Audit of DVT prophylaxis in surgery at a District General
Hospital
C.L. IVES
North Tyneside General Hospital, Rake Lane, North Shields,
UK
Introduction: (deep vein thrombosis) DVT and pulmonary embolism (PE) are common causes of death and morbidity in hospitalised patients, and are preventable. This audit looks at whether patients on surgical wards are receiving adequate DVT prophylaxis. The prevalence of DVT and PE is included in the audit. Patients and methods: All patients on the surgical wards were included. Guidelines currently in use were examined, and views on local preferences were discussed with senior staff members. A ‘snapshot’ view of all patients on wards was taken, recording adequacy of prescribed prophylaxis (TEDS [thromboembolic deterrent stockings] +tinzaparin). No staff were aware this was happening. Medical staff were then educated on prescribing DVT prophylaxis, and re-audited two months later. Results: The THRIFT guidelines¹ are those currently used. Most staff (Consultants and Ward Sisters) felt that all patients should receive prophylaxis unless mobile, young or contraindicated. Of 42 patients in the first audit, 30 (71%) had adequate DVT prophylaxis according to guidelines, 10 (24%) had inadequate prophylaxis and 2 (5%) had insufficient data. Discussion: There was an increase in DVT prophylaxis after simple education. Interestingly, most patients now had TEDS prescribed, showing the increased doctor awareness. It is impossible to tell if the improvement is due to the education or increased competence after months in the job. However, I feel that any new intake of medical staff should be educated on DVT prophylaxis prior to commencement of a new job. The sample sizes are very small; this audit needs to be repeated with a larger population.
Audit of somnoplasty for snoring
P.K.D. KAPOOR, S. RAO, M. IZZAT and B.N. KUMAR;
Department of Otolaryngology and Head & Neck Surgery,
Royal Albert Edward Infirmary, Wigan, WN2 1NN, UK
Introduction: We audited the results of outpatient treatment for snoring by application of radiofrequency energy to the soft palate (somnoplasty) under local anaesthesia, to see how it compares with traditional surgical procedures such as laser palatoplasty (LAUP) and uvulopalatopharyngoplasty (UPPP), that have been shown to reduce snoring by 60-65% in the short term. Patients and methods: 46 snorers underwent somnoplasty in 2 cycles during the period between 01-03-2000 and 31-3-2001. At the start of the audit, inclusion criteria was a pre-operative VAS score of >7 (Visual Analogue Snoring scale: 0-10) and exclusion criteria were history suggestive of sleep apnoea and ESS (Epworth Sleepiness Score) of >10. The patients completed a snoring questionnaire including history, height, weight, Body Mass Index (BMI), VAS for snoring, ESS and underwent a full ENT examination including flexible nasoendoscopy. Results: 1st cycle: 20 snorers who underwent somnoplasty initially were assessed 3 months post-operatively. Of these, 14 patients (70%) had significant reduction in snoring (VAS<5). Of the 6 failures, 4 patients had a BMI >35 and 2 patients had significant nasal obstruction. Exclusion criteria were expanded to exclude patients with BMI>32 and nasal obstruction for the 2nd cycle. 2nd cycle: 26 non-apnoeic snorers who underwent somnoplasty in the 2nd phase of the audit were evaluated 3 months post-operatively. Snoring improved markedly in 21 patients (80%). (Preoperative VAS 9.65 vs. postoperative VAS 4.34; Wilcoxon ranked sum matched pairs test, p<0.0001). Discussion: Somnoplasty is a successful local anaesthetic outpatient surgical procedure to reduce snoring in the short-term. With proper patient selection, snoring can be improved in up to 80% of patients. Long-term results need to be evaluated.
An audit of the investigation of tachypnoeic patients on the
surgical wards
A.T. KING, P.G. POCKNEY, B.A. MOORE, K. DE SOUSA
and I.S. BAILEY
University Department of Surgery, Mailpoint 816,
Southampton General Hospital, Tremona Road, Southampton,
SO16 6YD, UK
Introduction: There is evidence that patients who become critically unwell on the ward are managed sub-optimally. Deterioration is heralded by deranged physiology, particularly tachypnoea. It is important, therefore, that patients with tachypnoea are evaluated thoroughly. We audited the investigation by house officers of acutely unwell surgical ward patients who had tachypnoea. Patients and methods: An Early Warning Score (EWS) system is used in this hospital. Ward staff score six observations, greater deviation from the normal range attracting higher scores. House Officers are required to assess patients who score greater than a threshold score (an “ activation”). The results of their assessment were prospectively audited for 6 weeks. The notes of patients with a respiratory rate of >20 were examined for record of an examination of the respiratory system, performance of blood gases and a chest Xray. Results were reviewed at a directorate audit meeting and staff were encouraged to assess these patients fully. The audit was then repeated. Results: In the first audit there were 214 recorded activations of the EWS. 113 of the activations had a respiratory rate of >20. Of these tachypnoeic episodes 8% had no record of respiratory examination, 36% had an arterial blood gas performed, 31% had a chest x-ray performed. In the second audit there were 161 recorded activations, 76 of which involved tachypnoea. 13% of the tachypnoeic episodes had no record of respiratory examination, 18.4% were investigated with an arterial blood gas and 21% had a chest x-ray. Discussion: Tachypnoea, especially in association with other physiological disturbances, is a significant sign of deterioration. Despite identification of this at-risk patient group and compulsory attendance by the house officer these patients are under-investigated. This assessment did not improve after formal review at a directorate audit meeting. We are now introducing a structured assessment proforma for these patients.
Do we really need to routinely cross-match blood before
primary total knee or hip arthroplasty?
G.M. MUNDY, R.A. POWER and S.J. BIRTWISTLE;
Glenfield General Hospital, Groby Road, Leicester, UK
Introduction: The use of a maximum surgical blood ordering schedule (MSBOS) is widespread in elective surgery. This practice may however lead to wastage of valuable resources due to over ordering of blood and/or under utilisation. We audited the results of a Group and Save (G+S) policy for routine primary hip (THR) and knee (TKR) arthroplasty to evaluate its safety and practicality in comparison with pre-operative cross matching. Patients and Methods: A retrospective review was conducted of all consecutive patients attending for a THR (179) or TKR (137) from 1/01/2000 to 31/08/2000 (Phase 1) Data was collected from the medical records/haematology computer. Two consultants introduced a G+S policy on 1/1/2001 for their patients undergoing THR or TKR. All consecutive patients attending from 01/01/2001 to 31/08/2001, for THR (205) and TKR (147) were prospectively reviewed (Phase 2) The two groups were comparable for age, gender, length of in-hospital stay, operating surgeon, pre- and lowest post operative haemoglobin, reason and timing of transfusion. The number of units of blood requested pre and post operatively, transfused and returned to blood bank, were also recorded. Results: 78% and 63% of blood requested for THR and TKR, respectively, in phase 1 was not utilised. 60% of patients undergoing THR in phase 2 underwent preoperative G+S. 92% of subsequent blood requested for these was transfused. Overall blood returning to the blood bank was reduced by 26%.Transfusion rates fell by 5%. 20 % of patients undergoing TKR in phase 2 underwent preoperative G+S, 100% of subsequent blood requested was transfused. Blood not utilised overall was reduced by only 2% but transfusion rates fell by 9%. No adverse events were recorded awaiting blood from a G+S sample. Conclusion: A G+S policy for routine primary THR/TKR is a safe procedure. Reduction in non-utilisation of blood has obvious economic and cost-saving implications.
Audit of time interval between emergency admission and
operative intervention in an orthopaedic and trauma unit
A. OLIVER, M.O. MATHEW, G.R. TAIT
Crosshouse Hospital, Kilmarnock, Ayrshire, Scotland
Introduction: It is well recognised that postponement of operations occurs in trauma management. This audit was performed over a 12-month period in a District General Hospital Orthopaedic Unit. Its purpose was to detect the frequency, length, distribution and causes of delays in operative intervention following emergency admission. Patients and methods: All emergency admission and operative lists were examined for patients whose operations were >24 hours from admission. The exception was open fractures which were deemed to be delayed if >6 hours from admission. The case notes of all identified patients were reviewed. Results: The Orthopaedic department had 1386 emergency admissions over the 12 month period. Of these, 1091 (78.7%) had operations; 145 (13.3%) cases of postponement were identified. There were 98 (67.6%) females and the most frequent length of delay was 2 days. In 46 (31.7%) the cause for delay was unclear as it was not documented in any notes. Those that were recorded were lack of theatre time in 22 (15.2%), followed by a change of treatment plan in 16 (11%). In addition, 61 (42%) were operated on outwith designated trauma list times. Discussion: Documentation of changes in patient management is highlighted as inadequate in 31.7% of cases. Lack of theatre time was the most documented cause for delay, which suggests the allocation of more dedicated sessions for trauma management may be beneficial. The age distribution and greater female component reflects the fact that 76 (52.4%) were patients with a fractured neck of femur who are very vulnerable patients. Recommendations have been made for improved documentation of decisions affecting patient care and to examine the possibility of more dedicated trauma lists to cope with the demand.
The standard of informed consent (surgeon vs. physician)
S.M. ONG, *J. RAVENSCROFT and G.J.S. TAYLOR;
Glenfield Hospital, Groby Road, Leicester, LE3 9QP and *
Queen’s Medical Centre, Nottingham, UK
Introduction: The GMC, BMA and DoH have recently published recommendations for consent. We audited a surgical and medical specialty from two hospitals to determine if these recommendations were met when consenting patients. Patients and Methods: Orthopaedic pre-assessment clinic patients in Leicester and dermatology day unit patients in Nottingham were recruited. A questionnaire was given to the Leicester patients after signing a consent form and to the Nottingham patients after minor local anaesthetic surgery.Results: 97 orthopaedic patients and 76 dermatology patients completed the questionnaires. The common recommendations of the three professional bodies are (1)100% of patients should know their diagnosis.[Result: Orthopaedic 92%’ Dermatology 92%]; (2) 100% of patients should understand the purpose of the procedure.[Orthopaedic 100%, Dermatology 99%]; (3) 100% of patients should have alternatives treatments discussed.[Orthopaedic 23%, Dermatology 41%]; (4) 100% of patients should receive information about common comp lications.[Orthopaedic 58%, Dermatology 67%]; (5) 100% of patients should know the name of the consultant in overall charge of their care. [Orthopaedic 95%, Dermatology 82%]; (6) 100% of patients should be informed that a trainee doctor might be present during the operation.[Orthopaedic 11%, Dermatology 49%]; (7) 100% of patients should be aware of their right to withdraw consent at anytime.[Orthopaedic 68%, Dermatology 63%]; and (8) 100% of patients should know their right to a second opinion. [Orthopaedic 66%, Dermatology 57%]. Disscussion: This audit showed similar areas of weakness in taking consent in both specialties. This may due to doctors’ ignorance on the present guidelines. Doctors should be made more aware of the present recommendations possibly by running specific obligatory teaching courses. Alternative methods of improving consent should also be considered such as formatted consent forms.
Who knows, who does and how can we do better? An audit
of the National Guidelines and endocrine surgery in South-East of Scotland.
O. QUABA, L. MARSDON, D. LEE
and all the thyroid
surgeons of South-East Scotland
Department of Surgery, Ward 10, Royal Infirmary,
Edinburgh,UK
Background: In November 2000, the British Association of Endocrine Surgeons (BAES) published “Guidelines for the Surgical Management of Endocrine Disease”. Aims: The aim of this audit is to determine how many surgeons performing endocrine surgery in South-East Scotland are aware of the guidelines and how closely their practice conforms to the recommendations in the year after publication. Methods: Questionnaires were circulated to all surgeons performing thyroid surgery and data was presented at a regional meeting with an external contributor Results: 12 surgeons from 8 hospitals performed thyroidectomy in the year 2001 and all contributed. Only 6 are members of the BAES and these have a copy of the guidelines. Although 3 others are aware of the existence of the guidelines, only 1 had a copy. 196 thyroidectomies were performed, 30 of these for primary thyroid malignancy. Specific key guideline recommendations were compared with existing practice and results expressed as a percentage comparing (a) surgeons with a copy of the guidelines and (b) those without. (1.)”Pre-operative serum calcium” 73%:39% (2.) “Fine needle aspiration” 52.5%:33% (3.) “Recurrent laryngeal nerve visualisation” 87%:67% (4.) “Post-operative calcium” 93%: 100% (5.) “Cancer referral to a multidisciplinary team” 87%: 75%. Discussion: Not all surgeons performing thyroid surgery in this region have a copy of the BAES guidelines (7/12) or are members of the BAES (6/12). This study has demonstrated a variation in surgical practice which correlates with a knowledge of the guidelines. This information has been fed back to the surgeons at a regional meeting. Conclusion: All surgeons performing thyroid surgery should have a copy of the BAES guidelines and be encouraged to join the Association. An audit for 2002 is now required to demonstrate closer adherence to the guidelines and whether this will produce improvement in post-operative results. There is a need for a combined cancer unit for thyroid malignancy in this region.
Audit of compliance of operative records to R.C.S.Eng
guidelines
G. ROBERTSON, M. RANTA and K.W. AH-SEE
Department of Otolaryngology - Head and Neck Surgery,
Aberdeen Royal Infirmary, Aberdeen, AB25 2ZQ, UK
Introduction: The document ‘Guidelines for Clinicians on medical records and notes’ was produced by the RCSEng in 1990 and describes eleven essential components for the operative record. We have audited our departments compliance to these recommendations. Patients and methods : 100 consecutive operative records were examined by the two investigators. The eleven parameters in the R.C.S.Eng guidelines were assessed and graded as follows: present and legible, illegible, absent or not applicable. The data from the first limb of the audit project was presented at a departmental audit meeting and deficiencies in our departments compliance were discussed. Each surgeon was given a copy of the RCS Eng Guidelines, a reminder sheet and a copy of the results of the first audit. Reminder sheets were posted prominently in the operating theatre. After one month the audit was repeated and a further 100 operative records were reviewed. Results: There was a significant improvement in the quality and legibility of the operative records. The diagnosis was recorded legibly in 89% of records in the second limb as opposed to 36% in the first. There was a similar improvement in the recording of post operative instructions (66% 1st limb, 93% 2nd limb). In the first limb 20% of records were identified by name only without date of birth or hospital number. By the time the second limb was carried out this figure had fallen to 7 %. We conclude that education and reminder sheets have been effective in improving our compliance with the RC S Eng guidelines.
Scaphoid fracture - audit on diagnosis and conservative
treatment.
S. SHARMA and E.R. GARDNER
Victoria Infirmary, Langside road, Glasgow, G42 9TY, UK.
Introduction: It is important to diagnose and treat scaphoid fractures within the 1st week to prevent complications such as non-union. We audited our patient population to elucidate the outcome of conservatively treated scaphoid fractures. Patients and methods: 125 consecutive patients with clinically suspected scaphoid fractures (July 2000 to December 2000) were audited following which changes in the treatment protocol were introduced. The effect of this change in protocol was assessed in another audit on another 100 consecutive patients (June 2001 to October 2001). Results of first audit: The type of immobilisation included 78 scaphoid casts, 27 Colles’ casts, 18 wrist splints and 2 dorsal slabs. Only 25 (20 %) of the 125 patients had a scaphoid fracture. Union was achieved in 22 cases with conservative treatment; 3 fractures involving the proximal pole required surgery. Incidentally, 2 of these cases were immobilised in a splint for the first 2 weeks. In the 100 cases where no fracture was found, 18 cases were immobilised for more that 2 weeks, 15 of these cases had stiff wrists at 6 weeks. In order to bring some uniformity to the management of scaphoid fractures it was proposed that all clinically suspected scaphoid fractures should be treated in a Colles’- type plaster with 20 degrees dorsiflexion of the wrist. We also proposed using MRI or bone scanning at 2 weeks in case there was a high clinical suspicion of scaphoid fracture in the absence of any radiological evidence. Results of second audit: 23 of the 100 audited patients had a scaphoid fracture, 22 of which healed with the Colles’- type cast immobilisation. Of the remaining 77 patients only 4 had cast immobilisation for longer than 2 weeks. Conclusion: Our audit establishes the need of preventing unnecessary immobilisation and disability for patients who do not have a scaphoid fracture. The Colles’- type plaster immobilisation with 20 degrees of immobilisation was found to be an effective method of immobilisation for scaphoid fractures. This audit has led to an improvement in the quality of management of scaphoid fractures in our unit.
Upper gastrointestinal bleeding in patients having hip
replacements - an audit
S. SHARMA and P.D.R. SCOTT
Victoria Infirmary, Langside road, Glasgow, G42 9TY, UK.
Introduction: Use of non steroidal anti-inflammatory drugs (NSAIDs) and additional factors such as advanced age, anticoagulants and co-morbid diseases, commonly found in patients with arthritis, increases the risk of upper gastrointestinal (UGI) bleeding. Our aim was to assess the incidence of perioperative UGI bleeding in patients having hip replacements for arthritis. Methods: A retrospective case note review of 100 hip replacements was performed at Victoria Infirmary, Glasgow, between 1999 and 2000. Results: The mean age group was 74 (41 - 86); 63 % of our patients were female. 34 % of the patients had a previous history of UGI problems and were on ulcer medication. 59 patients were on NSAIDs pre- and intraoperatively and all the patients received anticoagulants (39 aspirin, 61 clexane) perioperatively. Four patients had haemetemesis and melena while on the orthopaedic unit. One patient was admitted within 6 weeks of being discharged from the orthopaedic unit, to the surgical unit with haemetemesis and melena. These 5 patients had endoscopies, which revealed bleeding from gastric ulcers (3), duodenal ulcer (1) and Barretts oesophagus (1). A further 4 patients had one episode of UGI bleeding in the postoperative period but did not have endoscopies. Discussion: All the 9 patients with UGI bleeding were patients who had been on NSAIDs and anticoagulants (6 clexane, 3 aspirin). These 9 patients were from the group of patients who were not on any ulcer medication. There was significant morbidity with 5 of these patients requiring a hospital stay of more than 2 weeks. Based on this audit we believe that the incidence of UGI bleeding in patients undergoing hip replacements is underestimated and, therefore, we propose ulcer prophylaxis in all our patients.
Fine needle aspiration cytology (FNAC): Does it still have
a role in the evaluation of a symptomatic breast lump?
S. BALACHANDRA, R. PILLARISETTI and W.R.G.
THOMAS
West Wales Hospital, Carmarthen, South Wales
Introduction and Aim: Fine needle aspiration cytology (FNAC) still forms an important component of triple assessment of a patient presenting with a palpable breast lump. This study aimed to audit the accuracy of FNAC in the evaluation of a symptomatic breast lump in our Unit and to compare the outcome with BASO Guidelines. Patients and Methods: This was a retrospective analysis of all patients who had FNAC performed for a symptomatic breast lump over a period of three years from June 1998 to May 2001. The sensitivity, specificity and positive predictive value of FNAC in detecting breast cancer was analysed and the results were correlated with the corresponding histopathology reports. Results: Some 418 patients were retrieved from our databank. The overall inadequate cytology (C1) rate was 27.03% (BASO Standard - < 20%). The sensitivity and positive predictive value of FNAC in detecting breast cancer was 79.08% and 98.61% respectively. The Specificity was 50.94%. Only 46.4% of patients subsequently proven to have Breast cancer had a preoperative C5 FNAC (BASO Standard - > 90%). The benign: malignant operation rate was 1:1.21 (BASO Standard - 1:10). Conclusion: This audit has revealed a high inadequate rate, a low sensitivity and consequently a high benign: malignant diagnostic open biopsy rate. We conclude that FNAC is no longer viable as a first option in the diagnosis of a symptomatic breast lump. Moreover, FNAC is less effective in the diagnosis of benign conditions. We have, therefore, changed our current practice to performing needle core biopsy on all patients presenting to our clinic with a symptomatic breast lump.
Quality assurance audit in axillary surgery
R. PILLARISETTI, N. SOOKHAN, D. MCCARTHY and C.J. DAVIES
Glan Clwyd Hospital, Bodelwyddan, Rhyl, North Wales
Introduction and Aims: Breast Test Wales (BTW) was asked by the National Assembly for Wales to conduct an All Wales Audit in 1998 to assess if >90% of patients with operable breast cancer had sampling/clearance of at least four axillary lymph nodes (BASO Standard). The results of BTW Audit, circulated to Consultants in May 2001, has shown that sampling/clearance of > four lymph nodes was not achieved in four out of the seventeen Trusts in Wales, of which ours was one. This study aimed to assess the accuracy of BTW audit in our Firm and to find out if our results were in keeping with the BASO guidelines. Patients and Methods: The records of all patients operated for symptomatic breast cancers during the calendar year 1998 were retrospectively reviewed. Results: Eighty-two patients underwent surgery for invasive breast cancer over a twelve-month period from January to December 1998. Forty-nine (60%) patients underwent axillary sampling, whilst thirty-three (40%) underwent axillary clearance. Sixty-five patients (79%) underwent sampling/clearance of > 4 lymph nodes (BASO Standard - >90%). Discussion: The results were in keeping with BTW audit. We were disappointed-that our current practice of axillary sampling fell short of the BASO Guidelines. We examined the reasons for the poor performance. It has been our surgical policy to remove fat and lymph nodes en block from the Level 1 region. We rely on the pathologist to find lymph nodes from this block of tissue. We have now changed to a more secure policy, i.e. dissecting out at least four lymph nodes from the axilla and presenting them to the pathologist. Conclusion: It would be important to re-audit our results prospectively to see if alteration of surgical policy has enabled us to achieve the quality assurance outcome measure in axillary surgery.
Audit of waiting times of ND:YAG laser capsulotomy:
potential for quality improvement
C.J. STYLES, W. SMITH, K. SWA and B. DHILLON
The Princess Alexandra Eye Pavilion, Chalmers Street,
Edinburgh, EH3 9YW, UK
Background: Nd:YAG laser posterior capsulotomy is the second most common surgical procedure in the UK. It is required as a complication of cataract surgery when the posterior capsule supporting the intraocular lens becomes cloudy. Aims: We audited this to obtain further information about the patient’s ‘journey’ from referral until discharge to determine potential for quality improvement in our service. Our standards were set as a 4 month waiting time for the procedure from referral and a maximum of 3 appointments. Patients and Methods: The sample was collected from consecutive patients with appointments for a YAG laser posterior capsulotomy. Results: About half of our patients are referred from the GP with visual problems after cataract surgery and a second group is already being seen in the out-patient clinic for other eye conditions. The first group has a mean waiting time from the date of the GP referral letter to treatment of 122 days. 9 patients (16%) were listed for laser treatment from the GP letter and did not have an out-patient appointment in between. The mean waiting time for these patients is 55 days. The second group had a mean waiting time of 47 days. 75% of patients wait less than 4 months for treatment.81% of patients were given a follow up appointment. The majority of patients, therefore, attend the Eye Pavilion 3 times. Discussion: Our audit shows that it should be possible for about 50% of patients to only have 2 visits to have this laser procedure. This should reduce waiting time from referral to treatment by about 70 days. We are now directly listing patients for a Nd:YAG capsulotomy when the GP letter mentions posterior capsule thickening. This audit should result in an improvement in the quality of our service.
Audit of arthroscopic still images of the knee--current
practice and guidelines.
R. VADIVELU, A. CHANDRATEY and T.J. SPALDING
University Hospitals Coventry and Warwickshire NHS Trust
Introduction: Arthroscopy of the knee is a common surgical procedure. The literature shows that still images produced during arthroscopy are more reliable and convenient when compared with video recording. However, there are no guidelines on how these pictures should be taken. We audited our current surgical practice to determine the quality of the still images, their documentation and illustration of the pathology and normal anatomy during knee arthroscopy and also cost implication to the trust. Patients and methods: A preliminary questionnaire survey of the current practice was carried out in our University Teaching hospital. A further retrospective review of 100 consecutive patients undergoing knee arthroscopy was undertaken. Surprising results from this audit led the Knee Unit to formulate guidelines regarding the appropriate way of image capture and documentation during routine knee arthroscopy. A further prospective audit was carried out 2 months after the issue of guidelines and the audit loop completed. Results: Preliminary audit results revealed that 50% of the practicing surgeons perform at least 1 knee scope per week and take multiple pictures (on a single sheet). Only 50% of the surgeons said that they could not identify lesions in their own pictures. 20% of the surgeons said that they cannot identify the lesion in the pictures taken by others and the rest agreed that they could identify the lesion “only sometimes”. Patients notes revealed that nearly 30% did not have any photographic records and in about 40 % the pictures were either of poor quality or did not reveal the pathology. Single large image format was found only in 25%. Prospective audit results following the issue of guidelines showed a statistically significant result. Good quality, clear images and correct documentation were seen in more than 80% and single large images were taken in more then 65% of the cases. Conclusion: Inadequate images, poor labeling and inconsistent documentation is common in arthroscopic records and have cost the trust. Proper guidelines improved the surgical practice in our hospital. We feel that correct guidelines improve the quality of the still images and also provide excellent records to aid in further management of the patient. We believe that such guidelines issued nationally will improve the practice throughout the country.
Audit of the patient information process through cataract
journey
A.C. WADOOD, A. LAING , J. ROBERTSON , and B.
DHILLON
Princess Alexandra Eye Pavilion, Royal Infirmary Edinburgh,
EH3 9HA, UK
Background: Informed consent is the key to successful cataract surgery outcome. In light of this, we audited our patient information process. Objectives: Our aim was firstly, to find out whether patients receive adequate information about the concerned surgical procedure in our department. Secondly, to learn from patients of their first-hand experiences before, during and after surgery in order to improve the service provided to the future cataract patients. Methods: 50 consecutive patients were requested to fill-in a questionnaire pre-operatively and one after they had the cataract surgery. Questions asked were about the different sources of information and level of adequacy of information given about the procedure. Results: The main sources of information were patient information leaflet (PIL) for 27 (60%) patients, cataract pre-assessment clinic 26 (58%), optometrist 13 (29%) and friends or family for 11 (24%) patients. The PIL was considered to provide adequate information on the events leading up to the cataract surgery by 21 (84%) patients, about the actual procedure in 18 (72%) patients and in the post-operative period in 19 (76%) patients. Similar figures for the cataract pre-assessment clinic were 22 (88%), 19 (76%) and 22 (88%), respectively. The level of understanding of the information given ranged from
84.6% (by optometrist) to 100% (PIL and clinic). Discussion: The current audit shows that about 40% of the patients did not receive the PIL or any information about the cataract by their optometrist. Measures undertaken on recommendations of this audit include revision of the PIL text, inclusion of PIL in the information package at the pre-operative assessment clinic and its distribution to the local general practitioners. A course, Lothian Optometrist Cataract Initiative (LOCI), comprising of a series of lectures, pre-assessment clinics and observing live cataract surgery was organised for the local optometrists. All these measures were aimed at providing accurate and similar information at all stages to the prospective patients.
An audit of the implementation of a national guidelines for
the assessment of microscopic haematuria
S.M. YONG, J. VAN DE RIET and S.A. MCNEILL;
Department of Urology, Western General Hospital, Edinburgh,
UK
Introduction: The Scottish Intercollegiate Guidelines Network (SIGN) published an evidence-based guideline for the investigation of asymptomatic microscopic haematuria in adults in 1997. Prior to referral to a specialist it is recommended that a proper history, physical examination, urine culture and measurement of the renal function be undertaken by the general practitioner. We conducted an audit to assess how well these recommendations are being implemented by referring general practitioners. Materials and Methods: A prospective audit of all referrals of patients with microscopic haematuria was performed. By examining the information provided in the referral letters we assessed how well the SIGN guidelines, which are widely available to all registered physicians, had been followed. Results: One hundred referral letters for patients with microscopic haematuria were received from general practitioners within the study period. Forty-two patients had associated urinary symptoms, whilst 58 patients were asymptomatic. In 95 cases a history was taken and provided in the referral letter, whilst only 11 referral letters contained information on the findings of physical examination. In 75 cases results of a urine culture were documented and in 26 the renal function had been assessed by measurement of the serum urea and electrolytes. Radiological assessment had been arranged by the general practitioner in 28 of the patients. Conclusion: This audit illustrates that despite availability of well-constructed, evidence-based, national guidelines on investigation of microscopic haematuria it would appear that many practitioners are failing to implement them fully. As the primary purpose of a guideline is to assure a minimum standard of care, further efforts are required to ensure more consistent application of such guidelines.
For details of the 2003 Audit Symposium, e-mail education@rcsed.ac.uk