Download MBBS Surgery Presentations 54 Surgical Audit Lecture Notes

Download MBBS (Bachelor of Medicine, Bachelor of Surgery) 1st Year, 2nd Year, 3rd Year and Final year Surgery 54 Surgical Audit PPT-Powerpoint Presentations and lecture notes


Surgical Audit and Research

Objectives

? Describe the principle of process and outcome audit.
? Use audit to the benefit of your patients.
? Develop soundly based audit projects.
? Introduction to the basics of surgical research.
Introduction

? We are continuously being scrutinized.
? Living in the era of evidence based medicine and accountability.
? Must show that our standard of practice is satisfactory.
? Research and audit are processes by which evidence is developed.
? Audit generates information related to performance- both individual

and collective.

Case 1

? You have discovered that over

? Key issues

the last year there has been a 2

? Patient scoring systems.

fold increase in the mortality of

patients operated in your unit.

? Case mix alterations process and

outcome audit

? Structure.
Audit has been divided:

vMedical audit :

An audit undertaken by doctors and consists of a review of

clinical events.

vClinical audit :

A review of all potential medical events surrounding the

treatment of a patient. This wil include nursing, physiotherapy,

social aspects, etc.

Surgical Audit ? What is it and why do it?

? The purpose of audit is to examine whether what you think is

happening really , and whether current performance meets existing

standards

? Critical study of all aspects of patient care.
? May address economy, efficiency and effectiveness.
? Covers structure, process and outcomes.
? Ultimate goal is improving the quality of care for patients.
? Stimulus and source of material for learning and quality improvement.
The aims of audit are:

? To identify ways of improving and maintaining the quality of care for

patients;

? To assist in the continuing education of surgeons;
? To help make the most of resources available for the provision of

surgical services.

Forms of Audit

? Total Practice or Workload Audit: covers all the surgical operations

performed.

? Selected Audit from Surgical Practice: covers all patients who

undergo a selected procedure.

? A Clinical Unit Audit: conducted by a clinical unit in which individual

surgeons may participate.

? Group or Specialty Audit: an audit conducted by or under the

auspices of a group or Specialty Society.

? A Focused Audit: : e.g. what is the wound infection rate after large

bowel surgery.
Surgical Audit and Continuing Professional

Development
? Regarded as a cornerstone of professional development.
? Only by looking objectively at our own practice of surgery will we be

able to compare our current proficiency and discover how to improve

on this for the sake of our patients.

? Audit can help identify the difference between what surgeons think

they are doing and what they actually do.

The Surgical Audit Cycle

? Surgical audit activities are based on a five-step cycle:

Make

changes and

Determine

monitor

scope

progress

Interpret

Select

results with

standards

peer review

Collect data
? Step 1 Determine scope:

? A thoughtful decision about which area(s) of surgical practice to review.

? Step 2 Select standards:

? A clear description of what is good practice in this area against which the results of the

audit wil be compared.

? Step 3 Col ect data:

? The collection of relevant data.

? Step 4 Present and interpret results with peer review:

? Comparison of results to standards , discussion with peers, decision about what changes

may lead to improvement e.g. learning new skil s, changes in practice, systems etc.

? Step 5 Make changes and monitor progress:

? Alteration of practice in accord with the results and then checking that improvement has

occurred.

Common topics for audit:

? 30 day mortality and significant morbidity;

? length of hospital stay;

? unplanned readmission or re-operation rates;

? positive and negative outcomes;

? operation-specific complications;

? process of care, such as pre-operative care;

? time on waiting list;

? numbers waiting for outpatient appointment;

? use of investigations;

? justification of management; and

? patient satisfaction.
How to select standards?

? use evidence-based research and guidelines;
? adapt existing local guidelines for local relevance;
? use an accessible library for evidence about effective practice and

develop new guidelines; and/or

? look to your specialty group to define standards.

Col ect Data

? what data you wil collect, and how you wil collect it.

? The most important principle here is to ensure that you collect quality data.

? Consider the following questions to help decide on the best quality assessment method:

? What information is necessary to answer the audit question(s)?

? From whom wil it be collected?

? Should it be collected prospectively or retrospectively?

? How wil it be collected?

? During or after the operation, on a PDA, on a computer, on a form, or by questionnaire,

and by whom?

? How wil follow up data be collected?

? By record review, by patient follow-up questionnaire, through the GP, by phone cal , or

by review of routine data, and by whom?
? How will the cases for review in a prospective project be identified or

selected?

? All patients, random selection, consecutive operations, all patients on

the same day each week, or checklist to determine eligibility?

? How will the cases in a retrospective review be identified or

selected?

? From a register, medical records data, review of referrals, or from

previous

? appointment schedules?

Present and Interpret Results with Peer

Review
? The results of your audit should be presented at a clinical meeting.
? Peer review is a learning exercise. It is not an opportunity to blame or

brag.

? Involves an evaluation of one's work by one's peers.
? Peers are other surgeons with comparable training and experience.
Make Changes and Monitor Progress

? The next step is to implement any changes that are recommended.
? Implementation involves not just making changes but ensuring that

everyone involved is educated/ informed as to what changes are

being made and why.

? The impact/ effects of the changes made then needs follow up action.

What Makes for Effective Audit?

? Promotion of a culture of audit
? Al ocate time and resources
? Oversee and verify data col ection
? Productive peer review
What Opportunities Arise from Surgical

Audit?
? Educational opportunities
? Systemic improvement opportunities

What Resources are Required for Surgical

Audit?
? Manual systems
? Computer systems
? Logbooks
Surgical research

What is Research ?

? Branch of medical science that determines the safety and

effectiveness of medications, devices, diagnostic products and

treatment regimens intended for human use.

?used for prevention, relieving symptoms of a disease.


Quantitative vs. Qualitative research

Quantitative:

Qualitative:

Designed to test a hypothesis.

Identifies themes following established

methodology.

May involve evaluating or comparing

Usual y involves studying how

interventions, particularly new ones.

interventions and relationships are

experienced.

Study design may involve al ocating

Uses a clearly defined sampling

patients to intervention groups.

framework underpinned by conceptual

or theoretical justifications.

Research vs. Clincal Audit

Research:

Clinical audit:

? May involve experiments on human Never involves experiments, whether

subjects, whether patients, patients on healthy volunteers, or patients as
as volunteers, or healthy volunteers. volunteers

? Is a systematic investigation which ? Is a systematic approach to the peer

aims to increase the sum of

review of medical care in order to

knowledge

identify opportunities for
improvement.

? May involve allocating patients

? Never involves allocating patients

randomly to different treatment

randomly to different treatment

groups.

groups


Research:

Clinical audit:

? May involve a completely new

? Never involves a completely new

treatment.

treatment

? May involve extra disturbance or work ? Never involves disturbance to the

beyond that required for normal

patients beyond that required for

clinical management.

normal clinical management

? Usually involves an attempt to test a

? May involve patients with the same

hypothesis.

problem being given different
treatments, but only after full
discussion of the known advantages
and disadvantages of each treatment.

? May involve the application of strict

? The patients are allowed to choose

selection criteria to patients with the

freely which treatment they get.

same problem before they are entered
into the research study.

? Scientific Research asks

Are we doing the right operation ?

?Audit Research asks

Are we doing the operation right ?


Types of study:

1) Observational
2) Case-control
3) Cross-sectional
4) Longitudinal
5) Experimental
6) Randomized
7) Randomized controlled

1) Observational study:

? Evaluating results of condition or treatment in a defined

population.

?Retrospective: analyzing past events
?Prospective: collecting data contemporaneously.


2) Case-control study:

?Series of patients with a particular disease or condition
contrasted with matched control patients.

3) Cross-sectional study:

?Measurements mode on a single occasion, not looking
at whole population but selecting small similar group &
expanding results.


4) longitudinal study:

?Measurements are taken over a period of time, not
looking at whole population but selecting small similar
group & expanding results.

5) Expermintal study:

?Two or more treatments are compared. Allocation to
treatment groups is under the control of the researcher.

6) Randomised study:

?Two randomly allocated treatments.


7) Randomised control ed study:

?control group with No treatment.
?GOLD STANDARD.

Types of study

Type of study

Definition

Observational

Evaluation of condition or treatment in a

defined population

Case - control

Series of patients with a particular

disease or condition compared with

matched control patients .

Cross ? sectional

Measurements made on a single occasion

, not looking at the whole population but

selecting a smal similar group and

expanding results

Longitudinal

Measurements are taken over a period of

time , not looking at the whole

population but selecting a smal similar

group and expanding results

Experimental

2 or more treatment are compared

Randomised

2 randomly al ocated treatment

Randomised contrlolled

Include a control group with standard

treatment Gold standard


Sample size

?Calculating the number of patient required to perform a

satisfactory investigation is a very important prerequisite to the
study.

?An incorrect sample size is probably the most frequent reason

for research to be invalid.

?Never forget that more patients wil need to be randomized than the final sample size to

take into account patients who die, drop out or are lost to fol ow up.

Types of error:

vType I:
Benefit is perceived when really there is none (false
positive).

vType II:
Benefit is missed because the study has small numbers
(false negative).


v The Eliminating bias:

?Blinded observer:

? The observers or recorders who do not know which treatment

has been used.

?Single blind:

? The patient is unaware of the treatment allocation.

?Double blind:

? Neither patient nor researcher is aware of which therapy has

been used until after study has finished, & these are the best
randomized studies.

Confidence Interval "CI"

?Confidence intervals are used to indicate the reliability of an

estimate.

?Depends on p value.


P value:

?The probability that results (difference between groups) of
this magnitude would be observed if the null hypothesis is
true .

?The lower the p-value the more strongly you can reject the
hypothesis .

? If p value is small (<5%) probability of obtaining observed

difference by chance alone is low ? HO rejected.

? If p value is large it is conceivable that data are consistent with

HO ,which cannot be rejected.


Evidence based surgery:

?Surgical practice has been considered an art, ask 50
surgeon how to manage a patient and one will get 50 different
answers .

?is a move to find the best ways of managing patients using
clinical evidence from collected studies.

v Levels of evidence:

?Evidence grade I:

? (High)The described effect is plausible, precisely quantified and

not vulnerable to bias.

?Evidence grade II:

? (Intermediate) the described effect is plausible but is

not quantified precisely or may be vulnerable to bias.


?Evidence grade III:

? (Low): concerns about plausibility or vulnerability to

bias severely limit the value of the effect being

described and quantified.

The Cochrane Col aboration:

vAn international not-for-profit and independent organization, of

over 27,000 contributors from more than 100 countries .

vIt produces and disseminates systematic reviews of healthcare

interventions and promotes the search for evidence in the form
of clinical trials and other studies of interventions.

vThe Cochrane Collaboration was founded in 1993 and named

after the British epidemiologist, Archie Cochrane.

This post was last modified on 08 April 2022