SURGICAL AUDIT
SURGICAL AUDIT
"Every doctor cares more for his reputation than his efficiency and is tempted to spend his time in concealing his ignorance rather than increasing his knowledge" E.A. Codman.
Definition
The systematic critical analysis of the quality of medical care, including the procedures used for diagnosis and treatment, the use of resources, and the resulting outcome and the quality of life for the patient, carried out by those personally engaged in the activity concerned.
Introduction
There has been mounting concern about processes involved in surgical care, to examine outcome and determine how process and outcome interact. Also, influence of cost on medical care is an additional concern. Hence, balance of recent developments, finance, and practice is essential to improve patient care. A systematic review of untoward results with an emphasis upon connection is needed to improve the quality of surgical care.
History
John Graunt, called the father of medical statistics, in 1662 drew attention to the high infant mortality and showed that the overall mortality in towns and cities was higher than in country districts. Dr. William Farr, credited with the association of ascribing the major outbreak of cholera to contaminated water in London in 1854, made significant contributions to vital statistics. Florence Nightingale's revelations of the inadequacies of the British army's administrative and medical services during the Crimean war led to a new wave of inquiry and reform in Britain. The first serious attempts to introduce national audits of outcome were made in Britain by Ernest Hey Groves (1908) and in US by Ernest Amory Codman (1910).
Reasons for audit
| Time utilisation / cost effectiveness | A surgeon must know how he is spending his time and the resources of the hospital before attempting to improve on time utilisation |
| Mortality/morbidity assessment | In order to investigate the avoidable complications mortality/morbidity data must be available |
| Quality of diagnostic services - inefficient/misuse | Assessment of a patient's stay in the hospital might bring to light the misuse or inefficient use of diagnostic services |
| Monitoring performance | Monitoring the performance of the staff is an essential outcome of audit. |
| Assessment of newer technologies | Whether addition of newer diagnostic / therapeutic modalities has improved health care can be determined |
| Knowledge of patient satisfaction | The patient's view of health care delivery can be assessed |
| Legal implications | In case of accusation of malpractice, audit data can help to establish that the rate of complications compares favourably with that of the accepted standards |
| Research | The borderline between audit for improvement of clinical practice and audit for research is thin. Many surgeons start auditing their practices, find deficiencies which lead onto different ways of doing things i.e research Scientific Research asks "Are we doing the right operation ?" : Audit Research asks "Are we doing it the operation right ?" |
Components
To set objectives
To collect/ analyse information
Evaluate the process and outcome
Review objectivesTHE AUDIT CYCLE
Requirements
The Royal College of Physicians in 1989 suggested the following to common to all systems of audit.
| Purpose |
should be educational and relevant to patient care
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| Control |
should be by clinical peers with voluntary participation
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| Standards |
should be set locally by participating clinicians
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| Methods |
should be non threatening, interesting, objective and repeatable
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| Resources |
should be cheap, simple
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| Records |
should contain adequate clinical content and be easily retrieved.
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Audit of structure
The structure is the organisation, within which surgical practice is carried out, could be the hospital per se, the department or the Operating theatre. Standards, to change the working environment for the better, can be set to improve the patient care and encourage the staff to function to the best of their abilities.
Audit of the structure would include
Audit of process
Data collection
Data collection for audit depends on
Analysis
Some performance indicators
Most important of these from a surgeon's viewpoint concern the use of beds, of outpatient clinics and of operating theatres.
Actual length of stay = (Number of occupied beds) * (Number of days in study period)/(Number of patients discharged or dead during the study period)
Expected length of stay is the average of all hospitals in a particular district/country, corrected for age, gender and diagnostic category.
Turn over interval is a valuable indicator of the efficiency of bed management.
Turn over interval = (Number of available beds - Number of occupied beds) *( Number of days in study period )/ (Number of discharges in study period)
Actual throughput per year = (Number of days in the year)/(Length of stay + turn over interval)
Operation theatre usage concerns
If an effective algorithm is used in scheduling, norms of utilisation should be above 60%. Hence, efficient use of available theatre time is crucial in increasing the turn over of the treated patients.
An audit of operating theatre time utilisation in general surgery in this institute between April 1996-May 1997 revealed the following observations.
The study concluded that overall correction of these factors would increase the available time for surgery by nearly 20% without increase in the working hours.
Presentation
Audit data can be presented formally or informally but is essential to maintain the interest of the audience. Informal presentation could be made in weekly grand rounds, journal clubs, morbidity/mortality conferences. In addition, data can be presented formally at intervals eg. monthly/quarterly.
Audit of outcome
Quality of life after surgery - 'what matters is how the patient feels, rather than what the doctor thinks he ought to feel'.
Visual analog score - To evaluate post op pain
Karnofsky scale - To evaluate quality of life after an intervention
- Moribund
- Very ill
- Severely disabled
- Disabled
- Needs assistance
- Needs occasional help
- Can care for self but can't carry on normal activities
- Has some symptoms, normal activity is an effort
- Has some symptoms, but can carry on normal activities
- No complaints
This was used originally to assess the outcome of treatment of cancer with chemotherapy.
Visick score - To assess quality of life after gastric operations
I - only fullness after extra large meals
II - mild occasional symptoms easily controlled
III - mild symptoms, not controlled
IV - not improvedBarthel index - measures physical activities in post op patients in institutions
Feeding } Ability to get from bed to chair } 0 - Totally dependent Ability to wash or shave } | Ability to get on and off to toilet } | Ability to take bath } | Ability to walk on level surface } | Ability to walk up and down stairs } | Ability to dress } 100 - Fully independent Continence } Quality of life index: Devised by Spitzer et al, originally applied to patients with cancer.
· ability to work
· ability to take self care
· ability to interact with friends/family
· ability to perceive health
· Patient's mood
Patient satisfaction
It is essential to have a honest and comprehensible communication with the doctor, taking time to listen to the patient's story and then to explain the disease and treatment options. Ovretveit et al underlined ten features for assuring patient's satisfaction.
Morbidity/Mortality assessment
The following are examples used in the assessment of post op morbidity
Technical factors
Enormous problems occur in assessing the professional competence of doctors in terms of the outcome of their care, as the purpose of raising the sub-standard surgeon is to achieve better skills may be misinterpreted. Improvements in operative skills are more important in determining post-op outcome than attention to pre-op nutritional care.
Eg: accepted rate of in patient complications for elective herniorrhaphy is less than 2%. To say that the outcome is poor the rate of complications should be more than 4%.
Nosocomial infections - surveillance
Prospective surveillance has four elements
It was found that the regular feedback regarding the nosocomial infection to the surgeon kept the wound infection rate low.
National Confidential Enquiry into Perioperative Deaths(NCEPOD) started in 1986
The objective of CEPOD was to identify any deficiencies in the care offered, so that corrective measures can be adopted later on.
Patients who die within 30 days of surgery are studied. Two independent assessors (one surgeon, one anesthetist) are involved. Confidentiality is maintained by removing identity of patient, hospital and surgeon. Details of the case with an assessment form sent to the assessors and the report given to the surgeon.
Assessment is based on
- appropriateness of the operation
- appropriateness of preoperative preparation
- appropriateness of grade of surgeon
- soundness of the organisation
- equipment failure
- adverse drug reaction
- human failure
- lack of knowledge
- failure to apply
- lack of experience
- lack of care
- fatigue
- physical/mental impairment
- inadequate supervision
- others
NCEPOD found that disaster arose frequently when surgeons attempted procedures for which they possessed insufficient skills and training.
A study of NCEPOD in 1987 in London found that
Techniques in audit
Basic clinical audit
Analysis of throughput, broad analysis of case type, complications, mortality and morbidity. To be undertaken once three monthly.
Incident review
Discussion of strategies to be adopted in certain clinical scenarios which would result in the production of guidelines for a given scenario. Eg :- uncontrolled variceal bleed.
Clinical record review
Clinical records to be audited by a member of same speciality from another hospital in the presence of a third person to avoid too much concentration on quality of record keeping than on patient care.
Criterion audit
Retrospective analysis of case records is made to judge against a set of chosen criteria like assessment of
Adverse occurrence screening
Details of adverse occurrences such as wound infections, unplanned readmissions, delay/error in diagnosis are reviewed to identify trends and perform comparative analysis.
Focussed audit studies
Outcome from any area of audit may dictate the need for a more closely focussed area of research. Such a study assumes academic
Global audit
The entire process of health care delivery during a patient's stay in hospital including the spectrum of administration, nursing staff, para clinical staff and doctors, is assessed as outcome which is an important measure of the quality of care.
National studies
These are vital to study the overall health trends in the country.
For the audit to be meaningful, it should satisfy the following
Examples of areas of Surgical Audit
Death from potentially remediable conditions
Problems with drugs
Problems with infusions
Problems with transfusions
Abnormal results of investigation
Pressure sores
Unnecessary investigations
Inappropriate admission/surgery/discharge
Delay in treatment
