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