Clinical audit

General introduction

There is a growing reliance on evidence-based medicine and increasing pressure to improve the quality of healthcare delivery, to increasing numbers of patients and within increasingly constrained budgets.  The Government is encouraging this trend towards evidence-based medicine and in a 1997 White Paper ^[1] recommended clinical audit as a way of improving health care provision.  This affects all areas of medicine.

As discussed in other areas of this resource, nausea and vomiting can have medical, practical and financial implications in post-operative care, palliative care and in other areas of medicine.   Therefore all healthcare professionals will want to reduce the incidence of nausea and vomiting, and to treat it effectively if it does occur.

The route towards achieving these objectives for nausea and vomiting is to understand the risk factors in different medical settings, the cost and efficacy of the various treatment options that are available, and to combine this information with an audit of current clinical practice.   This will enable informed decisions to be made about the current quality of care and enable changes to policies and practices to be implemented if appropriate.

What is an audit?

A medical audit is a formal examination of the quality of practice in a particular area of medicine, and involves the benchmarking this against best practice.

Why undertake an audit?

An audit is the first step of a process that provides an understanding of the current status quo.  The results of the audit can be compared to best practice and can be used as the basis of informed decision making and if necessary changes in clinical practice that can improve the clinical outcome.

Some of the steps in undertaking an audit

The steps involved with undertaking an audit include the following:

• Definition of the aims of the audit, researching the background to the area of medicine and clearly identifying the relevant issues
• Creation of an audit team, with clear identification of responsibilities
• Clear definition of the appropriate indicators, with an understanding of the reliability of the chosen measures, and how the data will be collated and analysed
• A clear definition of the level that the chosen indicator should reach

Typically a series of forms will be used to collect the data, and the audit will be carried out by one individual over a fixed period of time, or number of medical procedures.  When the audit has been completed the results should be analysed and presented back to the rest of the team, and other interested stakeholders including medical, nursing, pharmacy and financial personnel.

If the audit indicates that the desired quality of the clinical outcomes is not being achieved, the team needs to identify the reasons, and to implement a process to change current policy and practice in order to achieve the desired outcomes.  Many hospitals and trusts have found that the introduction of formalised protocols or procedures aids in this process, but it is important that these are adequately communicated to all staff involved, explaining the rationale for the change.  It is also important to regularly monitor whether the desired outcomes are being achieved, and take corrective measures if appropriate.  It is also important to revisit the audit when new clinical data become available.

The Health Services Management Centre at the University of Birmingham has developed a useful information pack "The clinical audit assessment framework: improving the effectiveness of clinical audit" for the NHS Executive.  This can be downloaded from the University of Birmingham website as follows: http://www.hsmc3.bham.ac.uk/hsmc/ (follow the publications link).

Audit of Post-Operative Nausea and Vomiting

The Royal College of Anaesthetists has prepared useful guidelines on the audit of PONV, which can be found in their publication "Raising the Standard - a compendium of audit recipes for continuous quality improvement in anaesthesia".  This can be downloaded from their website.

http://www.rcoa.ac.uk/

In these guidelines audit of PONV is covered in each of the following sections:

• post-operative care
• day care services
• acute pain services

The following is a summary of some of the points covered in these guidelines

Best practice: research evidence or authoritative opinion

The following background information should be collected in the planning of an audit of PONV:

• Consider procedural risk factors - general anaesthesia, type of surgery (abdominal, gynaecological, middle ear or strabismus surgery), use of N₂O and systemic post-operative opioids.
• Consider patient risk factors - female gender, past history of PONV or motion sickness.
• Distinguish between prophylaxis and treatment of emesis.
• Consider whether the appropriate emetic drugs are currently used, by the appropriate route, dose and interval. 
• Consider whether emetic problems are adequately charted, and whether the drugs are prescribed or actually administered. 
• Consider the financial impact, both the cost of the increased length of stay and the cost of correcting medical problems, balancing this against the cost of anti-emetic drug treatment.

Suggested indicators

A number of different approaches for the choice of indicators have been suggested by the RCA as follows:

• Use of a scoring system for PONV - either a simple scoring system (0 - none; 1- mild nausea on enquiry; 2 - nausea without enquiry; 3 - vomiting occasionally; 4 - severe or repeated vomiting) or a 10cm Visual Analogue Scale.
• % of patients with an acceptable nausea score during the whole postoperative period (on the unit, during the journey home and at home).
• % of patients who vomited during this period.
• % of high-risk and low-risk patients who receive prophylactic antiemetic.
• % of high-risk patients who receive a post-operative pain regime that minimises the need for opiates (regional or local anaesthetic, use of NSAIDs and simple analgesia).
• % of patients with established PONV who are treated promptly and effectively in the opinion of the auditor (eg receives a first line antiemetic within one hour of the start of repeated vomiting or persisting nausea and a second line antiemetic if symptoms persist within a further hour).

Proposed standard or target for best practice

It is recognised by the RCA that there are no published standards for best practice for PONV, so this will need to be determined locally. However, some examples proposed include the following:

• Different standards could be set for different procedures.  For example for laparoscopic sterilisations a 5% nausea rate and a 1% vomiting rate in the post recovery period might be ambitious, but this might be appropriate for inguinal hernia repairs.  The target should apply to the whole postoperative period, including the journey home.
• 100% of patients assessed for PONV on the unit and, by telephone, at 24/48 hours after discharge.
• Less than 25% of all patients undergoing surgery should suffer from PONV.  With change in practice from initial audits this figure should fall to less than 10%. 
• 100% of post-operative patients should be prescribed an anti-emetic and 100% of patients with PONV should receive an anti-emetic.

Suggested data to be collected

It is suggested that the following are some of the types of data that should be collected:

• Anti-emetic prescribed
• Antiemetic actually administered
• Nausea and vomiting episodes
• Risk factors for PONV
• Existence of local PONV protocols
• Operation, surgeon, anaesthetist
• Time to discharge and days to discharge
• Time of worst symptoms
• Whether the patient ate/drank before discharge

Common reasons for failure to reach standards

The authors of the RCA guidelines suggest some of the following as common reasons for failing to reach the required standard:

• Ignorance of the risk factors or prophylaxis versus therapy
• Failure to choose appropriate anaesthesia or analgesia
• Underestimate of cost or side effects of drugs
• Overestimate of the efficacy of antiemetics
• Patients not knowing to ask for treatment
• Delays in administering treatment
• Reluctance to modify techniques
• Poor compliance with agreed protocols eg in pre-emptive use of antiemetics
• Inexperienced anaesthetist
• Premature discharge with symptoms on the way home
• Inadequate ward nurse staffing to identify and attend to the problem
• Lack of understanding by ward nurses in identifying the problem and taking appropriate action

What to do after the audit is complete

If the audit indicates that the desired quality of the clinical outcomes is not being achieved, the team needs to identify the reasons, and to implement a process to change current policy and practice in order to achieve the desired outcomes.

Many hospitals and trusts have found that the introduction of formalised protocols or procedures aids in this process, as does the provision of information for patients on nausea and vomiting.  Some hospitals have also found it useful to use pre-printed prescribing labels that comply with the agreed protocol.  These are attached to patient charts and only need the physician's signature to be implemented.

Some of the UK's hospitals have already undertaken audits and based on informed decisions they have produced protocols, patient information leaflets and prescribing labels for PONV and other types of nausea and vomiting.  The hospitals have agreed that these can be made available for other healthcare professionals, to be adapted for local use. 

Reference