It’s Clinical Audit Awareness Week from 23 to 27 November and we’re raising awareness about the audits that are carried out at our hospital.
In recent weeks we’ve been asking our clinicians to share some of their audit success stories and, on the final day of the week, all 14 of those submitted are now below.
Audits are important in health care to see how procedures can be improved. Clinical audits can help identify gaps in processes and highlight where changes can bring improvements, whether this be making things clearer or easier for our staff or enhancing the care, treatment and services we provide to our patients.
The Clinical Audit & Effectiveness Department said; “We really want to share the good work going on across the hospital, as our teams continue to care for patients in the midst of the Covid-19 pandemic. Despite everything that is going on this sends a strong message that improvements through audit can still be made, for the benefit of patients and our staff.”
Below are snapshots of some of the recent audits carried out. If any of our staff are interested in finding out more information please view the Clinical Audit & Effectiveness page on our Intranet, under the 'Departments' section.
Clinical Audit success story snapshots;
The Acute Kidney Injury (AKI) Recognition, Assessment, Management and Follow-Up Re-Audit looked at compliance with protocols for discharge and the provision of clear instructions for primary care (GP) follow up for patients with AKI.
It was recognised that improvements needed to be made and teaching sessions on AKI were held with junior doctors, with education on how to complete e-discharge letters correctly. Posters were circulated to all wards and there were screensavers on Trust computers to raise awareness.
The focus resulted in a significant improvement, with more specific instructions being given to GPs in 90% of AKI cases, up from 30%. The aim now is to sustain this positive change.
The Clinically Agreed Plan of Treatment (CAP) Audit, set up by our Resuscitation Service, aimed to improve completion of the Capacity Assessment form and to communicate this with patients next of kin more effectively.
Regular spot checks were carried out with any issues with the forms being discussed with doctors and the nurse in charge. Useful instructions were distributed via internal communications and steps were taken to include the form in both the staff induction process and mandatory training sessions.
Two monthly re-audits have demonstrated an improvement and audit results are now shared Trust-wide with information highlighting areas for improvement. The training is now available electronically too.
Auditing Compliance with WHO Surgical Safety Checklist. This audit looked at ensuring our hospital safety checklist included everything in the World Health Organisation Surgical Safety Checklist. The check found that two parameters needed to be added, to anticipate blood loss during the surgery and to anticipate the length of the surgery. These parameters are now included and are re-audited. The review also highlighted that the current intraoperative summary only included yes or no options when ‘not applicable’ might also be relevant to include as an option. It has been recommended that the checklist includes this option too.
The Lithotripsy Audit looked at processes around treatment for certain types of kidney stones and stones in other organs. The initial audit identified that it would be helpful to improve Surgical Discharge Notifications. The findings were presented to a Urology team meeting where it was recognised that existing documentation was not as user friendly or as fit-for-purpose as it could be, with poor completion an issue because of this.
A new document was designed which also could be a useful tool for other auditing purposes within Urology.
In a re-audit after the new documentation was adopted there was 100% compliance.
Post-Partum Haemorrhage Audit. This audit found that in incidents of post-partum haemorrhage (PPH) it was not clear if the PPH box had been requested as it was not documented as to whether it was requested or not. Several steps were taken to ensure there was proper documentation, including the education of staff involved in care delivery and monitoring of the documentation. This is now subject to regular audits and the team are working to embed this as standard practice in delivery suite activities.
Audit to Improve Surgical Ward Rounds with a Systematic Checklist. Analysis of data collected in this audit revealed that documentation quality declined in standard over the course of a general surgery patient stay, with a drop-off in checklist usage the longer the patient was in hospital . A new surgical ward round checklist was created, based on those from different surgical specialities. The team are currently looking at the data gathered from the re-audit in September 2020, to see how many days they were used and which sections were used the most. It is hoped it will lead to a greater standardisation of ward rounds and better organised and better documented rounds.
Audit of Abdominal X-Ray Requests. Abdominal X-Ray imaging (AXR) is often the first line of investigation but previous studies have suggested that it has no place in assessing acute abdominal pain because of its low diagnostic yield and limited contribution to direct clinical decision making. Out of 111 requests for the study period only 11 had led to a diagnosis.
To move forward the team began educating colleagues around CT scanning for patients with acute abdominal presentations and that requests should be discussed with senior colleagues if in any doubt. There are plans to re-audit to measure the effect of this intervention on patient flow and patient outcome.
Audit to review the new BOAST (British Orthopaedic Association Standards for Trauma and Orthopaedics) guideline for the care of the older or frail orthopaedic trauma patient. This audit found there wasn’t sufficient documentation around pain control in A&E for patients, particularly those who came in with neck of femur fractures (often sustained as a result of a fall in older people). Although guidelines were followed, there was a lack of documentation to support this. As a result it is now highlighted in admission booklets as being important to document what pain control is used and, if it is not given, the reason why. This will be re-audited as pain control is important to patient recovery.
Ward Round Audit. This audit was carried out to see how ward rounds could be enhanced. It identified a number of points, including that times for rounds were not consistent and that there may need to be additional personnel involved, as well as a lack of some documentation that would be useful for patients and staff.
As a result a new policy was introduced, with consultants leading board rounds, and daily reviews and cross checking taking place. A re-audit showed significant improvements had been made with 100% adherence to guidelines, improved patient flow, better patient outcome and faster discharge processes.
Management of Distal Radius Fractures as per British Orthopaedic Association Standards for Trauma and Orthopaedics (BOASTs). This audit relates to the documentation of patients neurovascular status. In the initial audit this was documented in 57% of cases (41 out of 72) but this needed to increase. Posters were display in fracture clinic rooms, there was a presentation of the audit findings at an orthopaedics departmental meeting and an email communication regarding audit findings we sent to consultants and registrars. As a result a re-audit found that 90% of patients (35 of 39) now had their status documented.
An audit of JPUH practice against NICE (the National Institute for Health and Care Excellence) guidelines for the management of Idiopathic Constipation in Children and Young People. NICE recommendations state that AXR (Abdominal X-Ray imaging) should not be used to make a diagnosis of idiopathic constipation, however the audit found 38 AXRs were performed on 32 children and young people presenting with the signs and symptoms of idiopathic constipation. The audit findings were shared widely with relevant teams, including GPs, the paediatric team and radiology governance and a dedicated slot in the nurse-led constipation clinic was established for children undergoing faecal disimpaction to facilitate early review of cases. A checklist has also been devised for use with patients. A re-audit will be held next year to see what improvements this may bring and it is hoped it will reduce social, psychological and educational consequences for children and reduce costs.
An audit of Antibiotic prophylaxis in septic patients undergoing emergency laparotomies. This audit looked at patients in this area identified as septic over a period from July 2018 to May 2020. The audit found 47 patients did not receive antibiotics within the golden hour. An Emergency Laparotomy pathway checklist has been implemented to give a clear guide as to what has been done when a patient is deemed to need an emergency laparotomy. These are often poorly and septic patients so following the checklist and noting whether and when antibiotics were given will allow better tracking. This will be re-audited in due course.
Pre-Birth Safeguarding Audit. This audit identified that only 33% of Child Protection Conferences were attended by a midwife or appropriate representative. As a result there was a change in process where Children Services automatically sent conference invitations to the Safeguarding Midwife. Contact was then made with the community midwife to see if they could attend, with the aim of sending another representative if not. The community midwife was expected to provide a report in all cases.
The re-audit showed an improvement – 75% of conferences were attended – but further changes were made and all conferences are now attended by the Eden Team (the safeguarding maternity team). In two further re-audits 100% of conferences were attended.
Venous Thromboembolism (VTE) Risk Assessment and Prophylaxis in Day Surgery Patients. This identified ambiguity in guidelines around the definition of major surgery and the categorisation of patients as high risk and set out to reach a consensus, and identify other methods of risk assessment, to see what may be better suited to assess a patient risk. This will be re-audited to ensure patients are receiving appropriate VTE prophylaxis on discharge, and to ensure all clinicians are aware of the previous issues and the new guidelines.