Surgical Audit & Research

surguical audit

1. SURGICAL AUDIT & RESEARCH

2. “ … surgery without audit is like playing cricket without keeping the score.” (Hugh Brendon Devlin 1932-1998, Founding Director of the Surgical Epidemiology and Audit Unit, Royal College of Surgeons of England)

3. DEFINITION - AUDIT Clinical audit is a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the review of change. (NICE 2002) The word ‘auditing’ has been derived from Latin word “ audire ” which means “to hear”.

4. INTRODUCTION Clinical audit is a process used by clinicians who seek to improve patient care. The process involves comparing aspects of care (structure, process & outcome) against explicit criteria.

5. CARE ASPECTS STRUCTURE. PROCESS. OUTCOME .

6. Structure – what is in place The people, their training, their knowledge, the way they are led, the equipment, their organization, the way they are paid, etc.

7. Process – what you do How referrals are processed, what diagnostic tests are done, the antibiotics that are used, the use of intensive care, the policy of feeding & mobilization after surgery, the discharge policy, etc.

8. Outcome – the results you get Wound dehiscence rate, readmission rates, mortality, reduction in symptoms, improvement in quality of life, return to work, etc.

9. EXPLICIT CRITERIA If the care falls short of the criteria chosen, some change in the way that care is organized is proposed, it may be required at one of many levels : An individual who needs training An instrument that needs replacing

10. At team level e.g. nurses undertaking procedures instead of, or in addition to, doctors At institutional level e.g. new antibiotic policy At regional level e.g. provision of a tertiary referral centre At national level e.g. screening programmes & health

11. THE AUDIT CYCLE Problem or objective identified Criteria agreed and standards set Audit (Data collected) Identify areas fo r i mprovement Make necessary changes Re-audit

12. STAGE 1 : PREPARING FOR AUDIT Selecting a topic Defining the purpose Planning

13. STAGE 2: SELECTING CRITERIA Defining criteria Sources of evidence Appraising the evidence

14. STAGE 3: MEASURING LEVEL OF PERFORMANCE Planning data collection Methods of data collection Handling data

15. STAGE 4 : MAKING IMPROVEMENTS Identifying barriers to change Implementing change External relationships

16. STAGE 5: SUSTAINING IMPROVEMENT Monitoring and evaluation Re-audit Maintaining and reinforcing improvement

17. DEFINITION - RESEARCH A systematic investigation undertaken to discover facts or relationships and reach conclusions using scientifically sound methods.

18. TYPES OF RESEARCH STUDY Types Definition Observational – Retrospective Prospective - Evaluation of condition or trt in a defined population -Analysing past events -Collecting data contemporaneously 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 small similar group & expanding results

19. Definition Measurements are taken over a period of time, not looking at the whole population but selecting a small similar group and expanding results. Two or more treatments are compared. Allocation to treatment groups is under the control of the researcher. Two randomly allocated treatments. Includes a control group with standard Types Longitudinal Experimental Randomised Randomised controlled TYPES OF RESEARCH STUDY

20. RESEARCH – IDENTIFICATION Purpose – To provide new knowledge in order to set or change standards. Methods – Randomised Trials etc… Data Analysis – Extensive statistical analysis. Ethical & Trust Approval - Always required. Sample size – statistically powered calculation.

21. Significance –Statistical difference (hypothesis driven) Outcome – Improve knowledge Results, publications – Generalisable, publishable in peer reviewed journals

22. GRADE System: Meaning of the 4 Levels of Evidence. Quality levels Current definition Previous concept High High confidence in the correlation between true and estimated effect Confidence that the estimation of effect will not vary in subsequent studies. Moderate Moderate confidence in the estimated effect. It is possible that the true effect is very different from the estimated effect . Subsequent studies may have a significant impact on our confidence in the estimate of effect Low Limited confidence in the estimated effect. The true effect may be very different from the estimated effect It is very likely that subsequent studies change our confidence in the estimate of effect . Very low Very little confidence in the estimated effect. The true e ffect is very probably different from the estimated effect. Any estimate is very uncertain